Every finding on record at Aperion Care Chicago Heights

Based on observation interviews and record reviews, the facility failed to follow a physician order for enhanced barrier precaution (EBP) for one resident and failed to follow their enhanced barrier precaution policy by failing to ensure that staff wear appropriate personal protective equipment (PPE) while providing wound care. This failure affected one (R4) of seven residents reviewed for infection control. Findings include:R4 is [AGE] years old and has resided at the facility since 2025, face sheet listed the following past medical history cellulitis of right lower limb, bipolar disorder mixed with psychotic features, type 2 diabetes, hypokalemia, hyperlipidemia, anxiety disorder, essential primary hypertension, etc.Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score of 15, indicating that R4 is cognitively intact, section GG (functional status) of the same assessment revealed that R4 requires supervision or touching assistance for all activities of daily living (ADL) care needs, including ambulation.On 7/27/2026 at 10:30AM, R4 was observed in her room, awake and alert and stated that she is doing okay. Surveyor observed some blood stained Kerlix dressing on resident's right lower leg and asked her what happened, R4 said that she bumped her leg on a bed frame in her room, she gets dressing change every day, but it has not been done yet.On 7/27/2026 at 2:00PM, observed wound care for R4 with V5 (LPN/wound care) and V6 (RN). Upon entering resident's room, there was no sign on the door indicating any type of isolation precaution, or any PPE set up anywhere near the resident's room. V5 performed hand hygiene, gathered her supplies, donned gloves and proceeded to remove the dressing on resident's right lower leg. V5 cleaned the wound, applied betadine and wrapped the wound with kerlix wrap dressing. V6 assisted by helping to hold resident's leg while 5 was applying dressing. V5 and V6 failed to put a gown on before initiating this high contact patientcare activity (wound care).Review of medical record for R4 revealed an order for enhanced barrier precaution dated 6/18/2026. Wound culture dated 7/16/2026 revealed a positive result for proteus Mirabilis and gram-positive cocci.Office visit record dated 6/5/2026 documented in part: progress notes-Surgery post operative visit. Surgery: Incision and drainage of right leg hematoma.Subjective: [AGE] year-old female present to office for her post op visit after undergoing incision and drainage of right leg hematoma on 5/25/2026. Objective: Wounds: right lower extremity anterior/lateral wound, area of eschar in center of the wound bed, approximate 10cm X7cm in size, 4 sutures were removed. Assessment/plan: Patient should follow up with us in our general surgery office in another 2 weeks for another wound check, call the office with any questions.Review of facility enhanced barrier precaution policy revised 5/7/2024 documented in part: Purpose: To reduce risk of transmitting multidrug-resistant organisms (MDRO) and targeted MDRO when contact precautions do not apply for residents identified as higher risk. Guidelines: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact care activities.EBP are used in conjunction with standard precautions and expands the use of PPE to donning of gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP are indicated for residents with any of the following: chronic wounds and/or indwelling medical devices. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities, especially when care is being bundled: Dressing, bathing/showering, device care or use, wound care: any chronic skin opening requiring a dressing. On 7/28/2026 at 11:50AM, V5 (LPN) said that the facility does not have anyone on isolation or enhanced barrier precautions. Surveyor asked V5 what enhanced barrier precaution is used for and she said for someone with wounds or G-tube, V5 was asked if R4 is on enhanced barrier precaution and V5 said that she was supposed to, V5 was asked what staff should do for a resident on enhanced barrier precaution and she said wear personal protective equipment (PPE). Surveyor asked V5 if she wore any PPE when she changed wound dressing for R4 and she said no. Surveyor asked V4 why not and she said, I guess because it is not available.On 7/28/2026 at 12:02PM, V2 (DON) said that she is the one handling infection prevention, facility does not have anyone on isolation or enhanced barrier precaution. Surveyor asked V2 what enhanced barrier precaution is used for and she said for residents with G-tube or wounds. V2 was asked if any resident has wounds and she said one, R4. Surveyor asked V2 why R4 is not on EBP and she said, I don't know why, maybe the nurse from the hospital forgot to put it in. V2 was asked what the implication of R4 not being on EBP when she was supposed to and she said, it could prevent resident from getting a wound infection. V2 added that her expectation is for staff to take proper precautions when changing residents' wounds and to follow physician orders. On 7/29/2025 at 9:12AM V10 (Attending Physician) said that he is familiar with R4 and aware of the positive wound culture, R4 is in the care of a wound specialist, and the facility follows their recommendation. V10 have not seen the wound but saw pictures from the staff a couple of days ago. V10 said that if the resident has an order for enhanced barrier precaution, staff are supposed to be following the order, V10 cannot recall if he gave the order but stated that if the order is active, it should be followed until it is discontinued.

Based on interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency for one out of three residents reviewed for abuse reporting in a total sample of nine. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia and bipolar type schizoaffective disorder. R2 is a [AGE] year old with the following diagnosis: major depressive disorder, post-traumatic stress disorder and nonsuicidal self-harm. On 3/10/26 at 1:58PM, R2 was lying in bed and agreed to talk with the surveyor. R2 stated he got into a physical altercation with another resident (R1) about one to two weeks after R2 was admitted . R2 denied remembering the exact date of the altercation. R2 stated a heavy set black man hit R2 in the head and face more than once in the dining room. R2 denied remembering what led to the altercation but stated the other resident said words,' to R2 before hitting R2. R2 denied having any injuries. On 3/10/26 at 2:12PM, R1 was lying in bed and invited the surveyor into the room. When asked about an altercation at the end of January, R1 stated R1 hit R2 in the head because R1 thought R2 was making fun of the way R1 laughed. R1 reported R2 said something about R1's laugh so R1 hit R2 with a closed fist in the head. R1 stated R1 is aware that R1 should not be hitting anyone but was really mad at that time. R1 reported R1 was sent to the hospital and now feels better. On 3/11/26 at 10:40AM, V7 (PRSC) stated R1 became agitated to another resident in the dining room. V7 reported V7 was told this by another staff member but couldn't not remember who. V7 stated there was a back and forth between the residents which was verbal. V7 denied being informed any resident had gotten physical with each other. V7 reported if a resident hits another resident, then it is considered physical abuse. V7 denied speaking with R2 about the incident. On 3/11/26 at 12:30PM, V10 (LPN) stated V10 was told by other staff members that R1 was aggressive towards R2. V10 reported being told that R1 tried to hit R2. V10 stated R1 was sent to the hospital per physician orders after R1 was not able to be redirected. V2 denied speaking with R2. V10 reported V10 did not ask staff if the residents made contact with each other. V10 denied asking R1 if R1 hit R2. V10 stated V10 went off what V10 was told by other staff. V10 stated if residents touch or hit each other then it is considered abuse. On 3/11/26 at 2:35PM, the surveyor showed R2 the signed statement from V18 (Administrator) R2 allegedly made about the altercation with R1. R2 denied making the statement that is on the paper and denied signing the paper. R2 confirmed R1 hit R2 in the face a head and got multiple hits in before staff intervened. R2 said, There was definitely physical contact. R2 denied any staff members asking R2 about the incident the days after. R2 stated R1 hitting R2 was unwanted touching. R2 stated R2 did not think R1 was playing around because R1 was yelling. On 3/11/26 at 3:06PM, V16 (Behavior Aide) stated V16 did not physically see what happened at the beginning between R1 and R2 because others were in the way blocking V16's view. V16 reported heard a bunch of commotion and went to the area. V16 stated V16 saw R1 give R2 a couple taps but did not know if R1 was playing or not. V16 reported R1 hit R2 slower but with a closed fist. V16 stated this would be considered physical abuse because R1 hit R2. V16 reported all altercations have to be reported to a supervisor or administrator. V16 stated V16 told V18 (Administrator) about the incident and described the altercation to V18 exactly as it was explained to the surveyor. V16 reported staff receive abuse training every other month where staff are told what is abuse, what the kinds of abuse are, and how to report it. On 3/12/26 at 2:41PM, V18 (Administrator) stated V18 did an internal investigation about the incident between R1 and R2. V18 reported R1 claimed R1 didn't do anything and R2, along with other staff, described the incident as horse playing. V18 stated R1 did admit to tapping R2 in the shoulder area. V18 reported that according to the policy there was no need to report the incident. A Social Service note for R1 dated 1/29/26 documents social services were notified that R1 exhibited increased agitation toward a peer due to responding to internal stimuli. Social service educated R1 on impulse control, reality orientation, healthy emotional regulation, and appropriate boundaries. Despite interventions, R1 was unable to be re-directed and denied a PRN medication. R1 was placed on 1:1 monitoring until the ambulance arrived. A Nursing note for R1 dated 1/29/26 documents R1 was responding to internal stimuli and had increased agitation towards a peer. Staff intervened. R1 was escorted to the sensory room and placed on 1:1 monitoring. No injuries were noted. R1 denied complaints of pain. A PRN medication was offered and R1 denied. The DON and physician were made aware. The physician ordered to send R1 to the hospital for a psych evaluation. A Nursing note for R1 dated 1/29/26 at 11:30PM documents per the hospital, R1 did meet requirements for a psych evaluation. The nurse practitioner was called and a voicemail was left.A Nursing note for R1 dated 1/30/26 documents the psych nurse practitioner ordered for R1 to go to a different psych hospital for an evaluation. The other hospital accepted R1's admission and admitted R1 around 12PM. The Illinois State Police Criminal History Record dated 10/8/18 documents R1 was convicted of aggravated battery with great bodily harm and attempted murder on 12/8/05. The Petition for Involuntary admission dated 1/29/26 documents R1 needs an emergency inpatient admission due to increased agitation towards a peer while responding to internal stimuli. R1 was threatening others and refused a PRN medication.The Behavior Management Team Review Meeting note dated 1/30/26 documents R1 displayed an increase in agitation towards a peer. Precipitating factors include poor impulse control, poor coping methods, delusions, and poor emotional regulation. R1 was referred to the hospital for a psychiatric evaluation. R1 will be re-evaluated upon return from the hospital for further recommendations.The Hospital Record dated 1/30/26 documents R1 physically assaulted a peer at the nursing facility and is unpredictable due to acute psychosis.The Care Plan dated 12/9/19 documents R1 has a criminal behavior that fits the criteria for an identified offender. R1 has an offense of aggravated battery with great bodily harm and attempted murder. R1 appears stable and is deemed a moderate risk.The Care Plan dated 9/5/22 documents R1 has the potential to be physically/verbally aggressive towards others related to anger and poor impulse control.R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score at 15 (no cognitive impairment).A Social Service note for R2 dated 1/29/26 documents a wellness check was conducted on R2. R2 was observed in the dining room and presented with a stable mood. No behavioral changes were noted. R2 reported feeling safe.A Social Service note for R2 dated 1/30/26 documents a wellness check was performed on R2. R2 was in a stable mood with no changes to behavior. R2 reported feeling safe in the facility. R2 was encouraged to seek out staff to express feelings or concerns.There is no documentation about the altercation in R2's notes. The Abuse/Neglect Screening dated 1/15/26 documents a score of four indicating R2 is at moderate risk for abuse/neglect due to history of substance abuse, history of depression, psychiatric history, and R2's vulnerability. R2's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15 (no cognitive impairment).The Care Plan dated 3/10/26 documents R2 is at risk for abuse/neglect related to major depressive disorder. V18 provided an alleged statement from R2 about the incident with R1. There is a signature on the paper but no date. R2 denied ever seeing or signing the paper. R2 then signed the paper and showed the surveyor how R2 normally signs documents. The two signatures do not match. All Abuse Reportables were reviewed for the last three months and there was no documentation of an incident report that was sent to IDPH regional office. The policy titled, Abuse Prevention and Reporting-Illinois, dated 10/24/22 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, on reasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. the term willful and the definition of abuse means the individual must have acted deliberately, not that individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment .Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hereabout, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on interview and record review, the facility failed to ensure a resident (R2) was free of physical abuse by another resident (R1) for two out of three residents reviewed for abuse in a total sample of nine. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia and bipolar type schizoaffective disorder. R2 is a [AGE] year old with the following diagnosis: major depressive disorder, post-traumatic stress disorder and nonsuicidal self-harm. On 3/10/26 at 1:58PM, R2 was lying in bed and agreed to talk with the surveyor. R2 stated he got into a physical altercation with another resident (R1) about one to two weeks after R2 was admitted . R2 denied remembering the exact date of the altercation. R2 stated a heavy set black man hit R2 in the head and face more than once in the dining room. R2 denied remembering what led to the altercation but stated the other resident said words,' to R2 before hitting R2. R2 denied having any injuries. On 3/10/26 at 2:12PM, R1 was lying in bed and invited the surveyor into the room. When asked about an altercation at the end of January, R1 stated R1 hit R2 in the head because R1 thought R2 was making fun of the way R1 laughed. R1 reported R2 said something about R1's laugh so R1 hit R2 with a closed fist in the head. R1 stated R1 is aware that R1 should not be hitting anyone but was really mad at that time. R1 reported R1 was sent to the hospital and now feels better. On 3/11/26 at 10:40AM, V7 (PRSC) stated R1 became agitated to another resident in the dining room. V7 reported V7 was told this by another staff member but couldn't not remember who. V7 stated there was a back and forth between the residents which was verbal. V7 denied being informed any resident had gotten physical with each other. V7 reported if a resident hits another resident, then it is considered physical abuse. V7 denied speaking with R2 about the incident. On 3/11/26 at 12:30PM, V10 (LPN) stated V10 was told by other staff members that R1 was aggressive towards R2. V10 reported being told that R1 tried to hit R2. V10 stated R1 was sent to the hospital per physician orders after R1 was not able to be redirected. V2 denied speaking with R2. V10 reported V10 did not ask staff if the residents made contact with each other. V10 denied asking R1 if R1 hit R2. V10 stated V10 went off what V10 was told by other staff. V10 stated if residents touch or hit each other then it is considered abuse. On 3/11/26 at 2:35PM, the surveyor showed R2 the signed statement from V18 (Administrator) R2 allegedly made about the altercation with R1. R2 denied making the statement that is on the paper and denied signing the paper. R2 confirmed R1 hit R2 in the face a head and got multiple hits in before staff intervened. R2 said, There was definitely physical contact. R2 denied any staff members asking R2 about the incident the days after. R2 stated R1 hitting R2 was unwanted touching. R2 stated R2 did not think R1 was playing around because R1 was yelling. On 3/11/26 at 3:06PM, V16 (Behavior Aide) stated V16 did not physically see what happened at the beginning between R1 and R2 because others were in the way blocking V16's view. V16 reported heard a bunch of commotion and went to the area. V16 stated V16 saw R1 give R2 a couple taps but did not know if R1 was playing or not. V16 reported R1 hit R2 slower but with a closed fist. V16 stated this would be considered physical abuse because R1 hit R2. A Social Service note for R1 dated 1/29/26 documents social services were notified that R1 exhibited increased agitation toward a peer due to responding to internal stimuli. Social service educated R1 on impulse control, reality orientation, healthy emotional regulation, and appropriate boundaries. Despite interventions, R1 was unable to be re-directed and denied a PRN medication. R1 was placed on 1:1 monitoring until the ambulance arrived. A Nursing note for R1 dated 1/29/26 documents R1 was responding to internal stimuli and had increased agitation towards a peer. Staff intervened. R1 was escorted to the sensory room and placed on 1:1 monitoring. No injuries were noted. R1 denied complaints of pain. A PRN medication was offered and R1 denied. The DON and physician were made aware. The physician ordered to send R1 to the hospital for a psych evaluation. A Nursing note for R1 dated 1/29/26 at 11:30PM documents per the hospital, R1 did meet requirements for a psych evaluation. The nurse practitioner was called and a voicemail was left.A Nursing note for R1 dated 1/30/26 documents the psych nurse practitioner ordered for R1 to go to a different psych hospital for an evaluation. The other hospital accepted R1's admission and admitted R1 around 12PM. The Illinois State Police Criminal History Record dated 10/8/18 documents R1 was convicted of aggravated battery with great bodily harm and attempted murder on 12/8/05. The Petition for Involuntary admission dated 1/29/26 documents R1 needs an emergency inpatient admission due to increased agitation towards a peer while responding to internal stimuli. R1 was threatening others and refused a PRN medication.The Behavior Management Team Review Meeting note dated 1/30/26 documents R1 displayed an increase in agitation towards a peer. Precipitating factors include poor impulse control, poor coping methods, delusions, and poor emotional regulation. R1 was referred to the hospital for a psychiatric evaluation. R1 will be re-evaluated upon return from the hospital for further recommendations.The Hospital Record dated 1/30/26 documents R1 physically assaulted a peer at the nursing facility and is unpredictable due to acute psychosis.The Care Plan dated 12/9/19 documents R1 has a criminal behavior that fits the criteria for an identified offender. R1 has an offense of aggravated battery with great bodily harm and attempted murder. R1 appears stable and is deemed a moderate risk.The Care Plan dated 9/5/22 documents R1 has the potential to be physically/verbally aggressive towards others related to anger and poor impulse control.R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score at 15 (no cognitive impairment).A Social Service note for R2 dated 1/29/26 documents a wellness check was conducted on R2. R2 was observed in the dining room and presented with a stable mood. No behavioral changes were noted. R2 reported feeling safe.A Social Service note for R2 dated 1/30/26 documents a wellness check was performed on R2. R2 was in a stable mood with no changes to behavior. R2 reported feeling safe in the facility. R2 was encouraged to seek out staff to express feelings or concerns.There is no documentation about the altercation in R2's notes. The Abuse/Neglect Screening dated 1/15/26 documents a score of four indicating R2 is at moderate risk for abuse/neglect due to history of substance abuse, history of depression, psychiatric history, and R2's vulnerability. R2's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15 (no cognitive impairment).The Care Plan dated 3/10/26 documents R2 is at risk for abuse/neglect related to major depressive disorder. V18 provided an alleged statement from R2 about the incident with R1. There is a signature on the paper but no date. R2 denied ever seeing or signing the paper. R2 then signed the paper and showed the surveyor how R2 normally signs documents. The two signatures do not match. The policy titled, Abuse Prevention and Reporting-Illinois, dated 10/24/22 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, on reasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. the term willful and the definition of abuse means the individual must have acted deliberately, not that individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observation, interview and record review, the facility failed to secure handrails to the corridor walls. This failure has the potential to affect all 139 residents that reside within the facility.Findings include:Facility census (1/26/2026) documents in part that 139 residents reside within the facility.On 1/26/2026 at 10:25 AM, observed the handrail next to room [ROOM NUMBER] loose and able to be displaced 4-5 inches on the wall and unsecured to the wall. V1 (Administrator) observed the handrail and confirmed the findings. V1 stated the purpose of handrails is for safety and to prevent falls.On 1/26/2026 at 10:28, observed V1 testing other handrails down the corridor to check if they were firmly secured and observed walking with a cane down the hallway with an abnormal gait. V1 grabbed the handrail outside of the master shower room, near 143 and the rail fully detached from the wall and hit the floor. R19 was visibly startled and told V1, Wow that really could have hurt me.R19's care plan documents R19 has activity of daily living self-care deficits, R19 uses a cane/split to the left lower extremity during ambulation and requires supervision/touching assistance while ambulating.On 1/26/2026 at 10:35 AM, observed the handrail hanging from the wall by the nurse's station/room [ROOM NUMBER] with holes in the wall approximately 3-4 inches in diameter where the side rail was affixed to the wall. V15 (Licensed Practical Nurse) observed the handrail hanging from the wall and stated, yeah, that is not secured. That's a hazard. Maintenance should be coming to fix it.On 1/26/2026 at 10:37 AM, V8 (Maintenance Director) observed the handrail hanging from the wall by the nurse's station/room [ROOM NUMBER] with holes in the wall and confirmed the observation. V8 stated, I'm working on it now, and I'll have those holes patched up today. V8 explained that the purpose of the handrails is for the safety of the residents. V8 stated, we have a lot of residents here that don't walk right so it helps them to keep their balance, so they don't fall. The handrails come loose a lot because the residents who can do for themselves lean on them. V8 affirmed that the facility expectation is that handrails are checked every day to ensure they are firmly secured to the wall.Facility policy titled, Handrails and Grab Bars (1/20/2025) documents, Purpose To reduce the risk of slips, trips, and falls by ensuring that handrails and grab bars are properly installed, maintained, and used in accordance with applicable healthcare regulations and safety standards. Handrails must be installed on both sides of corridors in patient care areas and on stairways and ramps. Handrails and grab bars shall be inspected routinely during monthly rounds and repaired promptly by maintenance staff.

Based on observation, interview, and record review, the facility failed to follow policy and procedure and failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 139 residents at the facility.Findings include:Facility census dated 1/26/26, documents 139 residents residing in the facility.On 1/27/26 at 11:36am, accompanied by V10 (EVS/Environmental Services Supervisor), a tour of the facility's laundry room was conducted. V10 opened the lint compartment for dryer #3 and the lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. V10 said, Uh oh. Looks like they (laundry staff) didn't clean the lint out today. V10 removed the lint from the lint screen and the bottom of the compartment floor and disposed of the lint in the trash. V10 stated, We (laundry staff) clean the lint compartments out every Monday, Wednesday, and Friday because we (facility) launder out most of the laundry. The facility dryers are used for rags and maybe a few other things. The lint is cleaned out for safety and so a fire doesn't start.Facility presented document, untitled, dated 12/31/25 through 1/30/2026, shows that the dryer lint compartments were cleaned on Mondays, Wednesdays, and Fridays. There is no indication that the dryer lint compartments were cleaned more frequently. Record review of facility policy titled, Section: Laundry Services/Maintenance; Subject: Safety Procedures or Dryers in Laundry Department, dated 1/20/2025, documents, in part, Purpose: Preventative maintenance is very important for safety in the laundry department. Safety can be maintained if the following steps are practiced: 1. Clean lint screens can be maintained at least every 3 loads or every 2 hours by the laundry personnel. (Whichever comes first). Daily/Weekly Preventative maintenance, if not followed, will restrict the motor internal air flow causing overheating and irreparable motor damage. Laundry personnel can assist with the safety rules by: 2. Cleaning lint screens according to schedule.Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, . 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 provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on observation, interview and record review, the facility failed to ensure that staff sanitize the tables in the dining area in between residents and failed to ensure that residents were assisted with hand hygiene before eating. This failure has the potential to affect all 139 residents currently residing at the facility. Findings include:Resident census provided by V1 (Administrator) upon entrance- 139.On 1/26/2026 at 12:18PM during lunch observation, surveyor observed that the facility is using one dining room for all the residents. Some residents were already eating, while others were observed lined up in the hallway, waiting to be called. The residents who finished their food were noted leaving the dining area with their tray, while other residents will come in and sit on the same spot just vacated by another resident. Some of the tables were noted with food crumbs and garbage left by residents who have finished eating and the one coming in will just sit and eat on the dirty table. There is no organization as to who sits where, or the number of residents eating at a particular time before others comes in.Surveyor also noted many staff members in the dining area assisting with trays, others just standing around, but no one was observed assisting residents with hand hygiene before they eat or cleaning / sanitizing the tables between residents.On 01/26/2026 at 1:45 PM, Surveyor presented this observation to V1 (Administrator) who said that staff are supposed to sanitize the tables after each resident, before another resident sits on the same spot.On 1/27/2026 at 10:07AM, V4 (Infection Control Nurse) said that during dining, residents are called 5 at a time, after they eat, the table will be sanitized by staff before another set of 5 residents comes in to sit and eat. This process is to enhance infection control during dining. Facility was not following this process.Hand hygiene/handwashing policy revised 7/30/2024 provided by V1 (Administrator) sates: hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water) antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel).Examples of when to perform hand hygiene (either alcohol-based hand sanitizer or handwashing listed in part: At room entry, before exiting room, before eating.Surveyor requested for facility policy on hand hygiene and sanitizing the dining area during meals, but none was provided.A document titled cleaning instructions, tables and chairs (undated) provided by V1 (Administrator) stated that dining room table and chairs will be cleaned and sanitized on a regular basis. Under procedure #4 stated that dining room chairs will be wiped down after each meal, or as needed using a clean cloth and hot, soapy water. Chairs covered in cloth may be brushed or vacuumed instead.

Based on observation, interview and record review, the facility failed to ensure that the outside dumpster garbage disposal was covered with the lids and failed to ensure that the floor around the dumpsters were free of bags of trash and spilled trash, thus creating an unsanitary environment. These failures have the potential to cause harboring of rodents which can affect all 139 residents in the facility.Findings include:On 1/26/26 after the entrance conference, V1(Administrator) presented the facility census as 139.On 1/26/26 at 9:52am, after kitchen observation with V7(Dietary Manager), the outside dumpster was observed to be open without lids, with bags of trash and spilled trash on the floor around the dumpster. V7 stated that the garbage truck should have come on Friday, and because of the weekend, the garbage was overflowing. Again on 1/26/26 at 11:20am, the surveyor observed the same dumpster still in the same condition without covers and with trash on the floor. On 1/27 26 at 10:20am, V7 stated that leaving dumpsters open could cause rodents to come around the building, and that she(V7) would notify maintenance to call the garbage truck. Facility's policy titled Garbage and Rubbish Disposal dated 2020 states: Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents. All outside dumpsters will be maintained in clean and sanitary condition. #1: All garbage or rubbish is to be put into waste containers which are emptied as often as necessary to prevent overfilling. This will assist in the prevention of odors, pests, and possible contamination. #4: All containers will be provided with tight-fitting lids or covers and will be leak proof and waterproof. All garbage and rubbish containing food waste are covered when not in immediate use so as to be inaccessible to vermin. #8: Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter.

Based on observation, interview, and record review, the facility failed to ensure that: food carts were free of dried food spills; the floor of the dry storage room was kept clean and free of visible dirt, and the wall air vent return was free of accumulated dust. These failures have the potential to affect all 139 residents that receive oral foods from the facility's kitchen. Findings include:On 1/26/26 after the entrance conference, V1(Administrator) presented the facility's census as 139. No residents have NPO status (receive nothing by mouth).On 1/12/26 between 9:35am and 10:00am during observation of the kitchen with V7(Dietary Manager), the floor of the Dry Storage Area of the kitchen was observed with visible accumulated dust, and visible dirt. V7 stated that the floor of the whole kitchen is supposed to be cleaned on supply days by the utility staff. Also, one kitchen cart was observed with dried food spills and visible dirt; V7 stated that the carts should be cleaned daily. In addition, the wall air return vent had a lot of accumulated dust. V7 stated that the vent would be cleaned.Facility's Dietary Policy titled OnTray Dietary Policies and Procedures- Ceiling Vents states: Purpose- To ensure food safety; The Ceiling Vents should be cleaned quarterly or more often, if needed, by Maintenance, with support from kitchen staff. It is recommended that Maintenance assists in removing and replacing the vents monthly. Dietary staff can wash the removable parts.Facility's undated Kitchen Cleaning Schedule Daily Cleaning Schedule states in part: Sweep and mop kitchen floor, Clean Food carts, Sweep and Mop Storeroom.

Based on observation, interview, and record review, the facility failed to follow policy by not matching residents' diet orders to food trays during meal service, and failed to have a system in place to ensure that the prescribed diet was served and ensured tray accuracy (that each resident receives food that is prepared in a form designed to avoid allergies and meet each individual's needs and preferences). These failures have the potential to result in residents receiving the wrong diet and can affect all 139 residents in the facility. Findings include: On 1/26/26 after the entrance conference, V1(Administrator) presented the facility census as 139. On 1/27/26 at 10:56am, V1 stated that all 139 residents receive oral foods from the kitchen.On 1/26/26 between 12:15pm and 12:45pm during lunch service, surveyors observed meal service to residents in the dining room. Dietary staff were observed dishing foods into each tray without tray cards and without any communication from the staff (V13/CNA/Certified Nurse Assistant) who was holding the Diet Order Report. Residents received the food trays, ate, and left the dining room. The surveyor asked V13 about how the kitchen staff that was dishing the foods into the plates knows what kind of diet order a particular resident has; V13 showed the Diet Type Report in his hand to the surveyor; this was not called or used to alert staff that a certain resident should get a certain diet type. V2(Director of Nursing), who was also present in the dining room was notified of this issue and V2 stated that V13 was supposed to call the diet so each resident will get the correct diet as ordered by the physician.V14(RN/Registered Nurse) who was also helping in the dining room was asked about tray tickets or tray cards that should show the diet order/preference/allergies for each resident; V14 stated that there are no tray tickets, but that staff should call the diet for each resident before handing them the tray.On 1/27/26 at 11:40am, V7(Dietary Manager) stated that that she(V7) cannot say that the dietary staff knows each resident's diet order by heart because there are different diets, and there 4 residents on mechanical soft diet. V7 added I don't know why they did not call the diets yesterday. Today, I will make sure they do it. V7 added that she(V7) has worked in other facilities before and they used tray cards, but they don't use tray cards here. At this time, V7 presented the Diet Type Report was reviewed and shows different residents with different diet orders as follows: Mechanical Soft Diet (for residents with swallowing difficulties)- 4 residents. No Concentrated sweets diet - 4 Residents.Low Concentrated Sweets No Added Salt diet - 7 Residents.No Added Salt Diet - 4 Residents.The Diet Type Report shows a few residents on No Added Salt/Low fat/Low Cholesterol diet, and other residents are on General Diet.This Diet Type Report also shows other residents with different allergies, food preferences and orders for large portion sizes.On 1/27/26 at 10:05am, V1 presented an alphabetically arranged Diet Type Report that shows the different diets for each resident. V1 stated that when she(V1) started working at this facility a few years ago, the facility was not using tray cards, but she(V1) would look into it. V1 explained that all dietary staff and CNAs were given in-service about Name Call with Meals. V1 presented the In-service sign in sheet dated 1/26/26 that states: Call Meal per Call Sheet; All Diets are not the same; Follow Diet per MD Order; Record percentages accurately. V1 also presented a policy titled Guideline & Procedure Manual dated 2020 - Meal Identification, Resident Meal Card. This policy states: All residents shall have a tray card on file indicating significant food preferences, including any for religious or cultural preferences, diet orders, food allergies, and any other nutritional needs. Resident trade cards shall be utilized by dining services staff to identify and provide accurate mail service for the individual while honoring their dining needs and preferences. #2: A temporary male card containing the residence name, room number, and diet order may be used for the first several meals, until the resident information is entered into the mail card program or a laminated three card is prepared. #3: Resident Evil cast will include residence name, room number, diets order, significant food preferences or dislikes, and any other specific diets or care plan initiatives. Food allergies will be clearly noted. #4: Resident male cats will be used during meal service to ensure proper diets are served and food preferences and care plan initiatives are offered and encouraged.

Based on observation, interview, and record review, the facility failed to ensure that five residents (R52, R64, R93, R119 and R136) had a clean and sanitary bathroom. This failure affected a total of five residents reviewed for resident's rights to enjoy a clean, homelike environment, in a total sample of 54 residents.Findings include: On 1/26/26 at 10:29am, upon entering R52's and R64's room, a strong, pervasive odor of urine was detected. Upon entering R52's and R64's, which is also shared with R93, R119 and R136, a large puddle of urine which spread out from the area around the toilet was observed. On 1/26/26 at 10:30am, R52 said, I don't know who pissed on the floor. It (R52's and R64's) always smells like piss in here. R52's face sheet documents diagnoses that include but are not limited to psychosis, schizophrenia, hallucinations, and violent behavior. R52's BIMS (brief interview for mental status) score, dated 1/14/2026, is 12 which indicates R52's cognition is moderately impaired. On 1/26/26 at 10:33am, R64 said, There's been pee on our bathroom floor before. Sometimes, I have to use a different bathroom. I'd like for there not to be pee on the floor, but I guess some people can't make it in the toilet. R64's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease and schizoaffective disorder. R64's BIMS (brief interview for mental status) score, dated 12/16/2025, is 15 which indicates R64 is cognitively intact. On 1/26/26 at 10:35am, R119 said, It's alright here. Yeah, the resident in the other room is always pissing on the floor. Don't know what his (other resident) problem is. Nasty! R119's face sheet documents diagnoses that include but are not limited to diabetes, chronic obstructive pulmonary disease, and psychotic disorder. R119's BIMS (brief interview for mental status) score, dated 12/11/2025, is 15 which indicates R119 is cognitively intact. On 1/26/26 at 10:39am, during observation of R52, R64, R93, R119 and R136's bathroom, with V11 (Housekeeper), V11 said, Oh yeah, that's urine. That resident (pointing to R52) is always urinating on the floor. I haven't gotten to this room yet. I'll get this cleaned up. Record review of facility's job description titled, Housekeeper, dated 3/23/2017, documents, in part, The primary purpose of the Housekeeper is perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/ or the Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. Clean floors to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting etc. Record review of facility provided pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, . 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 provide equal access to quality care regardless of diagnosis. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on interview and record review, the facility failed to follow their comprehensive care plan policy by failing to develop a person centered care plan for a resident to include measurable objectives and timeframes to meet the resident's medical and nursing needs that were identified in the comprehensive assessment for Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia for one (R20) resident of 54 residents reviewed for care plans.Findings include:R20 is [AGE] years of age. Current diagnoses include but are not limited to Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anemia, Pyothorax without Fistula, Emphysema, Paranoid Personality Disorder, Pneumonia, and Paranoid Schizophrenia.R20's comprehensive assessment section C Cognitive Patterns dated 01/14/2025 documents a brief interview for mental status score of 15 which indicates R1 is cognitively intact.On 01/27/2026 at 2:25 PM, V21 MDS (Minimum Data Set) Coordinator was inquired of R20 not having a care plan for his medical diagnoses. V21 said, R20 has Anemia, Type 2 Diabetes, Hypertension, and Elevated Cholesterol. He's taking medication for them. He's on Metformin for his diabetes, Carvedilol for hypertension, and Atorvastatin for cholesterol. I don't see it on his care plan. He should have a care plan so the caregiver knows what's going on and how to give care for what his diagnosis are and what care he should be receiving.R20's admission comprehensive assessment section I active diagnoses dated 10/02/2025 documents his medical conditions in part as Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia.R20's admission [DATE] and current January 2026 care plans do not document his medical conditions of Anemia, Type 2 Diabetes Mellitus, hypertension, and Hyperlipidemia.R20's medication administration record documents the following physician ordered medications to be administered- Sodium Chloride tablet 1 gram by mouth three times a day related to anemia start date 9/26/2025. Carvedilol oral tablet 6.25mg (milligrams) give 1 tablet by mouth two times a day related to hypertension start date 9/26/2025. Hydralazine HCI (Hydrochloride) 10mg oral tablet give 1 tablet by mouth every 6 hours as needed for elevated blood pressure related to hypertension start date 9/26/2025. Metformin HCI (Hydrochloride) oral tablet 500mg give one tablet by mouth two times a day related to type 2 diabetes mellitus start date 9/26/2025. Atorvastatin Calcium oral tablet 10mg give 1 tablet by mouth at bedtime related to hyperlipidemia start date 9/26/2025. These medications were administered by nursing staff as prescribed by the physician from 9/26/25 through 01/29/2026.The revised 11/17/17 comprehensive care plan policy states in part:Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The comprehensive care plan must describe the following:o The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-beingo Any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment.A comprehensive care plan must be-o Developed within 7 days after completion of the comprehensive assessment.o Prepared by an interdisciplinary team, that includes but is not limited to- The attending physician. A registered nurse with responsibility for the resident. A nurse aide with responsibility for the resident. A member of food and nutrition services staff. To the extent practicable, the participation of the resident and the resident'srepresentative(s). An explanation should be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.o Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The CAAs provide a link between the MDS and care planning. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.

Based on observation, interview and record review, the facility failed to ensure that staff carry out physician orders and failed to ensure that resident received ordered medications for his skin condition. This failure affected one (R2) of one resident reviewed for skin condition in a total sample of 54.Findings include:R2 is [AGE] years old and have resided at the facility since 2024, face sheet lists the following medical history: major depressive disorder, bipolar disorder, cellulitis lower limb, type 2 diabetes, essential primary hypertension, hypothyroidism, etc.On 01/26/2026 at 10:10AM, R2 was noted with very dry scaly skin on both hands and legs, he stated that he can take his own shower, the dry skin is from eczema, he is supposed to get a cream three times a day, but the nurses do not give it to him, they tell him that he was supposed to remind them. On 01/27/2026 at 9:50 AM, R2 was observed again still with dry scaly skin on both hands and legs, stated that he did not get any cream yet.Per record review, R2 have the following order, MD Appointment: Please schedule urgent appointment with dermatology for eval of bilateral hands, order date 10/9/2025.On 1/27/2026 at 2:45PM, V2 (DON) was asked about the above order, and she said that R2 went to the dermatologist and have a follow up appointment scheduled. Surveyor requested for the after-visit summary from the appointment.On 1/28/2026 around 8:30AM, V2 presented the after-visit summary for R2 dated 1/12/2026 which showed the following orders:Triamcinolone Acetonide External Ointment 0.1 % (Triamcinolone Acetonide (Topical)) Apply to hands and feet topically two times a day related to CELLULITIS OF LEFT LOWER LIMB (L03.116) for 14 Days cover with Vaseline.Diphenhydramine HCl Capsule 25 MG Give 1 capsule by mouth two times a day for Allergies for 14 Days.Ivermectin Oral Tablet 3 MG (Ivermectin) Give 4 tablet by mouth one time only for Rash until 01/28/2026 23:59.Fluocinonide 0.05% ointment, twice daily to hands and feet x 2 weeks.Antihistamine twice daily, Allegra AM, Zyrtec PM.Review of resident's active physician orders showed the above medications with a start date of 1/27/2026 (the day surveyor inquired about resident's appointment)Review of resident's progress note showed the following documentation by V2 (DON) dated 1/27/2026 at 16:24: MD made aware of orders from resident dermatology appointment and order was given to put orders in now. All orders are noted and carried out. On 1/28/2026 at 10:34AM, V2 (DON) said that the resident went to the dermatologist on 1/12/2026 but the orders from the doctor were not carried out. She called the doctor yesterday (after surveyor requested to see the after-visit summary) and the doctor told V2 to put the orders in now. V2 said that she spoke to the assigned nurse yesterday and she told her that the orders were not carried out because she forgot. V2 said that the expectation is for the assigned nurse to contact the doctor and verify any new orders when residents return from appointments and then carry out the orders. V2 added that the resident has missed those medications for 2 weeks now.On 1/28/2026 at 11:19AM, V24 (RN) said that she was the assigned nurse for the resident the day he went to the dermatologist on 3PM to 11:00PM shift. V24 did not know that the resident went for an appointment, there was no documentation, and she did not receive any report from the outgoing nurse. V24 added that she did not see the after-visit summary or the new orders, she is not even sure that resident went out on her shift so it may have been in the morning. V24 said that the protocol they follow when a resident return from an appointment is to call the doctor, verify any new orders and carry them out. V24 did not tell V2 that she forgot to carry out the order, she told her that she was not aware of the order or resident going out on an appointment that day.Job description for Registered Nurse (RN) and Licensed Practical Nurse (LPN) dated 05/02/2017 states in part; the RN/LPN is responsible for providing direct nursing care to residents and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervisions must to ensure that the highest degree of quality care is always maintained.Essential duties and responsibilities for RN and LPN include, receive and transcribe telephone orders from physicians and record on the physician's order form.Physician orders electronic signing, confirming and monthly review policy revised 1/11/18 states in part, when the nurse receives a physician order (verbal, telephone, prescriber written), the nurse will enter the order into the electronic medical record. The nurse will ensure that the orders entered are complete and accurate.

Based on interview and record review the facility failed to provide care in accordance with professional standards for medication administration during an emergency crisis when one resident (R1) was found unresponsive and administered insulin. This failure affected one (R1) of four residents reviewed for medication administration and has the potential to affect 43 residents identified as having diagnosis of Diabetes Mellitus in the facility.Findings include:R1 's medical record showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Type 2 diabetes Mellitus without complications, epilepsy unspecified not intractable with status epilepticus, other seizures, unsteadiness on feet and schizoaffective disorder, depressive type. R1 expired on [DATE] at the hospital.R1's medical record showed that R1 was found unresponsive on [DATE] at 5:30am with blood sugar 290(MG/DL).R1's Medication Administration Record dated [DATE] at 6:00am documents V11, Registered Nurse, administered one unit of Humalog insulin (regular scheduled does) and three units of Humalog insulin (sliding scale order) at 6:00am due to R1's blood sugar of 290. This indicates that V11 administered insulin as ordered to an unresponsive resident before calling a code, 911 (emergency line), or physician.On [DATE] at approximately 8:40am, V2 DON (Director of Nurse's stated, V11 no longer works at the facility, and I can't know why she charted like that it does not make any sense. The note dated [DATE] at 5:30am she went to do the accu-check (Blood Glucose Monitoring) at 5:30am and found R1 unresponsive. CPR started code blue initiated (V2 was reading from the progress note).On [DATE] between 8:53am and 9:00am, V1 (Administrator) read both V11's note dated [DATE] timed 5:30am and 6:53am and said V11 charted backwards, I think she meant at 4:30am R1 was seen alive pacing back and forth during rounds that was done every two hours and at 5:30am she went to do accu- check and give insulin R1 was found unresponsive. V1 stated, V11 no longer work at the facility to be able to explain the notes by herself.On [DATE] between 12:47pm and 12:59pm, V16 (Physician) stated he is familiar with R1 who is overweight, with seizures, and non-compliant with diet. V16 stated that R1 was sent to endocrinologist for follow-ups and has gone to ER (Emergency Room) couple of times. When the surveyor asked V16 in your (V16) professional opinion is it appropriate to administer insulin to resident that was found unresponsive. V16 stated that hypothetically speaking many residents walk around with blood sugar 290 and above so the blood sugar level is not the problem, there must be an underlining problem they may have heart attack. Something else is going on. V16 stated that in case of Hypoglycemia between 20 to 30mg/dl then something with high sugar can be given like Glucagon. I (V16) would have called 911 first and that also comes with experience. The survey then told V16 that V11 documented that she gave 4units of insulin as ordered. V16 stated in part that he ordered it per recommendation from (local hospital recommendation). V16 stated that experience comes in, I would have called 911 first before giving the insulin. V16 stated in part that charting is the only document that we can go by. Nurse decision is off, and clinical judgement is off. V16 stated nursing documentation is very important.On [DATE] at approximately 1:02pm, surveyor asked V2's if V11 should have administered insulin to an unresponsive resident. V2 stated, I would not, but V11 is the only one that can answer that, and she no longer work here.On [DATE] at 1:35pm V1, Administrator, stated the facility does not have any insulin administration policy in general during an emergency crisis.On [DATE] at 11:34 and 11:37am V10 LPN (Licensed Practical Nurse) was on duty on [DATE] when R1 was found unresponsive but was unable to be reached during the course of the investigation.The facility policy on Medication administration General Guidelines documented that medications are administered as prescribed in accordance with good nursing principles and practices legally authorized to do so.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse by not investigating an allegation of physical abuse. This failure applies to two of three residents (R1 and R2) reviewed for abuse.Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Generalized Anxiety Disorder, Secondary Parkinsonism, and Dystonia (Involuntary Muscle Contractions) who was admitted to the facility 11/23/2022. On 07/21/2025 at 1:27 PM When asked by surveyor if he had an incident with R2 a week ago on 07/15/2025 R1 stated he ran over R2's foot and didn't know it, R2 hit him and he hit R2 back, then he pushed R2 down on the floor, a female staff broke it up, his head was hurt and he has a bump on his head, R1 stated he didn't want to fight, then showed the surveyor a small bump on the left side of his forehead and stated that's where R2 hit him on his head. R1's Annual Minimum Data Set documents his BIMS (Basic Interview for Mental Assessment) score was 15 indicated he is cognitively intact. R1's Current care plan documents he has a history of harming others, exhibits poor impulse control, has the potential to be physically aggressive related to Anger, and he is at risk for abuse. R1's Incident Report dated 07/15/2025 documents he hit a co peer's foot while using a rolling walker, and reported he was walking down the hallway hit his (co peer) foot and he hit me, and he was fully alert and oriented, the report writer was informed that R1 and co peer had a physical altercation. R1's Nursing progress note dated 7/15/2025 at 12:19 PM documents the writer was made aware that co peer was using rolling walker to ambulate and accidently hit the back of resident foot. Staff intervened immediately placing resident on 1:1 with staff. Physician, Director of Nursing, Administrator, and family were made aware. R1's Social Services Progress note dated 7/15/2025 at 5:48 PM documents the writer was informed that the resident displayed agitation towards peer. The resident was separated from the peer to de-escalate the situation. Resident was educated on effective coping skills, including deep breathing, counting, and walking away. Resident was also educated on establishing and maintaining healthy boundaries with peers, particularly in relation to the use of his rollator and practicing mindfulness. The writer encouraged the resident to seek staff when needed. R1's Behavior Management Team Review Meeting Note created by [NAME] (Psychosocial Rehabilitation Services Director) dated 07/15/2025 documents it was reported that he displayed agitated behavior towards a peer with precipitating and contributing factors including poor coping methods, poor conflict resolution, and poor impulse control. R1's Behavior/Mood Charting Report created by V3 (Director of Nursing) dated 07/15/2025 documents in the evening he was observed in the hallway displaying physical aggression triggered by other resident becoming physically aggressive toward him, and the behavior lasted 3 minutes. R1's Nursing Progress note dated 7/17/2025 at 08:02 AM documents he states his pain level is a 3 and he was given and as needed pain medication; at 5:01 PM it was noted R1 returned to facility from the hospital, he was sent to hospital from day program and was diagnoses with Syncope (sudden temporary loss of consciousness), he is alert and fully alert and oriented and able to verbalize needs. Resident denies falling or striking any part of body while having syncope episode. 2. R2 is a [AGE] year-old male with a diagnoses history of Unspecified Mood Disorder, Conduct Disorder, Schizoaffective Disorder, Paranoid Schizophrenia, Bipolar Disorder, Degenerative Brain Disease, Parkinson's Disease without Dyskinesia (Involuntary Muscle Movement), and Homicidal Ideations who was admitted to the facility 11/09/2023. On 07/21/2025 at 12:50 PM When asked by surveyor if he and R1 had an incident a week or so ago on 07/15/2025, R2 stated yes R1 just ran over his foot on purpose with his walker and doesn't care where he's going or what he rolls over, he and R1 started fighting and he kicked R1's (derogatory word), R1 stated the incident hurt my spirit, and his foot was hurt too, R2 stated V5 (Mental Health Technician/Behavior Aide) broke up the fight and V5 grabbed him from behind to break up the incident. On 07/21/2025 at 12:52 PM V5 (Mental Health Technician/Behavior Aide) stated on 07/15/2025 he witnessed V4 (Registered Nurse) responding to a commotion between R1 and R2 in the hallway, he then responded as well and observed R1 and R2 holding each other and stumbling, he broke R2's fall and V4 assisted R1, and they separated them both. V5 stated R2 reported R1 ran over his foot, and it was explained it was an accident. V5 stated he did not see R1 and R2 hitting each other during the incident. On 07/21/2025 at 2:06 PM R2 stated he did have a cut on his lip from the incident with R1 and raised his upper lip to show the surveyor the cut underneath his lip. R2's Current Care Plan documents he has the potential to be physically aggressive related to poor impulse control; he has a behavior problem related to displaying inappropriate behavior towards peer; and he has a mood problem. R2's social service progress note dated 5/30/2025 at 5:22 PM documents the writer was informed that the resident displayed agitated behaviors towards staff. R2's social service progress note dated 7/8/2025 at 6:05 PM documents the writer was informed that resident displayed agitation towards peer. R2's nursing progress note created by V3 (Director of Nursing) dated 7/15/2025 at 2:29 documents the writer was made aware that co peer was using rolling walker to ambulate and accidently hit the back of resident foot and the resident responded to internal stimuli towards peer. Staff intervened immediately placing resident on 1:1 with staff. Nurse completed body assessment resident was noted with a small superficial cut on the inner lip. Ice pack was placed on resident lip. Physician, Director of Nursing, Administrator, and family were made aware; at 3:38 PM it was noted that resident's room was moved due to altercation with peer. R2's Psychosocial Assessment created by V8 (Registered Nurse) dated 07/15/2025 documents the reason for the assessment was a resident-to-resident physical altercation, he has full recollection and awareness of the event, and observed changes in his mood or behavior included increased agitation. R2's Behavior Management Team Review Meeting Note dated 07/15/2025 documents it was reported that he displayed agitated behavior towards a peer, this was the second occurrence of similar behavior in the past 30 days with the most recent hospitalizations related to behavior occurrences being from 05/31-25 - 06/01/2025, with precipitating and contributing factors include poor impulse control, poor conflict resolution, poor coping methods, and poor emotional regulation. R2's Behavior/Mood Charting created by V3 (Director of Nursing) dated 07/15/2025 documents he was observed in the evening in the hallway displaying physical aggression triggered by other resident becoming physically aggressive toward him in the and the behavior lasted 2 minutes. R2's Skin Condition Report created by V3 (Director of Nursing) dated 07/15/2025 documents R2 had a new skin concern which included a laceration described as a small superficial cut to his inner lip. On 07/21/2025 at 1:09 PM V7 (Psychosocial Services Rehabilitation Coordinator/PRSC) stated she was informed by V6 (Psychosocial Services Rehabilitation Director/PRSD) that R2 and R1 Displayed agitation towards each other. On 07/21/2025 at 1:36 PM V3 (Director of Nursing) stated R2 had an altercation with R1 on 07/15/2025, she received a report that R1 was pushing his walker, and it ran into the back of R2's feet and R2 reacted to internal stimuli. V3 stated someone reported to her there was an altercation during this incident, and that one of them was hit but she can't recall who reported this to her. V3 stated if residents hit each other, we tell the V1 (Administrator) and V1 (Administrator) was informed about this incident. V3 stated R2 and R1's rooms were on the same hallway, so R2 was moved to another hallway to prevent any further altercations. V3 stated the nurses assessed R1 and R2 after the incident. On 07/21/2025 at 1:54 PM V1 (Administrator) stated on 07/15/2025 she responded to some commotion she could hear from a distance from her office, and found R1 at the central nurses station, she asked R1 what happened, and he told her he accidentally bumped R2's foot with his walker, R2 tapped him on the head, and he hit R2 back. V1 stated she then went to talk to R2, and he told her R1 hit him first, he doesn't like R1, but they never had any issues before, then began making delusional statements that she couldn't understand. V1 stated after explaining to R2 that R1 accidentally rolled over his foot, R2 stated R1 did it to him on purpose. V1 stated they did move R2's room because he and R1 were located on the same unit. On 07/21/2025 2:21 PM When asked by the surveyor if R1 and R2 hitting each other was deliberate V1 (Administrator) stated she doesn't think that R1 and R2 were maliciousness hitting each other, she wouldn't say that those hits were deliberate, a deliberate hit is if you're trying to cause the resident harm or if it causes harm where one of the residents went out to the hospital that would be considered deliberate. On 07/21/2025 at 3:40 PM V1 (Administrator) stated on 07/08/2025 it was reported to her that R2 was displaying aggression in the dining room. On 07/22/2025 at 11:18 AM V9 (Licensed Practical Nurse) stated she assessed R1 after the incident he had with R2 on 07/15/2025 and he had a little scratch on his finger, but she didn't see the incident and was told R1 and R2 hit each other during the incident. V9 stated R1 and R2 were already separated by the time she arrived down the hall where the incident took place. V9 stated she works with R1 regularly and the bump on his forehead is new. V9 stated the bump on R1's forehead doesn't look old, and he told her he did inform the Director of Nursing about it. V9 stated R1 is alert and oriented and is not cognitively impaired. On 07/22/2025 at 11:28 AM V9 (Licensed Practical Nurse) stated R1 did complain of pain in his hands after the incident on 07/15/2025. The facility did not provide any abuse investigation reports or documentation of any abuse investigation reports being submitted to the state agency for July 2025 in response to the surveyor's request upon survey entrance for any reportable investigations including interviews and witness statements. On 07/21/2025 at 10:55 AM V1 (Administrator) stated there had not been any reportable events in the facility in July 2025. The facility's Abuse Policy received 07/21/2025 states: The facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse.This will be done by: Implementing systems to promptly and aggressively investigate all reports of allegations of abuse.Filing accurate and timely investigative reports. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is willful infliction of injury. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term (willful) in the definition of (abuse) means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting. A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident to resident altercations that include any willful action that results in physical injury. Any incident or allegation involving abuse will result in an investigation.Investigation Procedures Include The appointed investigator will, at a minimum, attempt to interview anyone likely to have direct knowledge of the incident. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse by the accused individual. The administrator or person designated to act as administrator in the administrator's absences 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. When an allegation of abuse has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse has been reported and is being investigated.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse by not reporting an allegation of physical abuse to the state agency. This failure applies to two of three residents (R1 and R2) reviewed for abuse.Findings include: The facility did not provide any abuse investigation reports or documentation of any abuse investigation reports being submitted to the state agency for July 2025 in response to the surveyor's request upon survey entrance for any reportable investigations including interviews and witness statements. On 07/21/2025 at 10:55 AM V1 (Administrator) stated there had not been any reportable events in the facility in July 2025. 1. R1 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Generalized Anxiety Disorder, Secondary Parkinsonism, and Dystonia (Involuntary Muscle Contractions) who was admitted to the facility 11/23/2022. On 07/21/2025 at 1:27 PM When asked by surveyor if he had an incident with R2 a week ago on 07/15/2025 R1 stated he ran over R2's foot and didn't know it, R2 hit him and he hit R2 back, then he pushed R2 down on the floor, a female staff broke it up, his head was hurt and he has a bump on his head, R1 stated he didn't want to fight, then showed the surveyor a small bump on the left side of his forehead and stated that's where R2 hit him on his head. R1's Annual Minimum Data Set documents his BIMS (Basic Interview for Mental Assessment) score was 15 indicated he is cognitively intact. R1's Current care plan documents he has a history of harming others, exhibits poor impulse control, has the potential to be physically aggressive related to Anger, and he is at risk for abuse. R1's Incident Report dated 07/15/2025 documents he hit a co peer's foot while using a rolling walker, and reported he was walking down the hallway hit his (co peer) foot and he hit me, and he was fully alert and oriented, the report writer was informed that R1 and co peer had a physical altercation. R1's Nursing progress note dated 7/15/2025 at 12:19 PM documents the writer was made aware that co peer was using rolling walker to ambulate and accidently hit the back of resident foot. Staff intervened immediately placing resident on 1:1 with staff. Physician, Director of Nursing, Administrator, and family were made aware. R1's Social Services Progress note dated 7/15/2025 at 5:48 PM documents the writer was informed that the resident displayed agitation towards peer. The resident was separated from the peer to de-escalate the situation. Resident was educated on effective coping skills, including deep breathing, counting, and walking away. Resident was also educated on establishing and maintaining healthy boundaries with peers, particularly in relation to the use of his rollator and practicing mindfulness. The writer encouraged the resident to seek staff when needed. R1's Behavior Management Team Review Meeting Note created by [NAME] (Psychosocial Rehabilitation Services Director) dated 07/15/2025 documents it was reported that he displayed agitated behavior towards a peer with precipitating and contributing factors including poor coping methods, poor conflict resolution, and poor impulse control. R1's Behavior/Mood Charting Report created by V3 (Director of Nursing) dated 07/15/2025 documents in the evening he was observed in the hallway displaying physical aggression triggered by other resident becoming physically aggressive toward him, and the behavior lasted 3 minutes. R1's Nursing Progress note dated 7/17/2025 at 08:02 AM documents he states his pain level is a 3 and he was given and as needed pain medication; at 5:01 PM it was noted R1 returned to facility from the hospital, he was sent to hospital from day program and was diagnoses with Syncope (sudden temporary loss of consciousness), he is alert and fully alert and oriented and able to verbalize needs. Resident denies falling or striking any part of body while having syncope episode. 2. R2 is a [AGE] year-old male with a diagnoses history of Unspecified Mood Disorder, Conduct Disorder, Schizoaffective Disorder, Paranoid Schizophrenia, Bipolar Disorder, Degenerative Brain Disease, Parkinson's Disease without Dyskinesia (Involuntary Muscle Movement), and Homicidal Ideations who was admitted to the facility 11/09/2023. On 07/21/2025 at 12:50 PM When asked by surveyor if he and R1 had an incident a week or so ago on 07/15/2025, R2 stated yes R1 just ran over his foot on purpose with his walker and doesn't care where he's going or what he rolls over, he and R1 started fighting and he kicked R1's (derogatory word), R1 stated the incident hurt my spirit, and his foot was hurt too, R2 stated V5 (Mental Health Technician/Behavior Aide) broke up the fight and V5 grabbed him from behind to break up the incident. On 07/21/2025 at 12:52 PM V5 (Mental Health Technician/Behavior Aide) stated on 07/15/2025 he witnessed V4 (Registered Nurse) responding to a commotion between R1 and R2 in the hallway, he then responded as well and observed R1 and R2 holding each other and stumbling, he broke R2's fall and V4 assisted R1, and they separated them both. V5 stated R2 reported R1 ran over his foot, and it was explained it was an accident. V5 stated he did not see R1 and R2 hitting each other during the incident. On 07/21/2025 at 2:06 PM R2 stated he did have a cut on his lip from the incident with R1 and raised his upper lip to show the surveyor the cut underneath his lip. R2's Current Care Plan documents he has the potential to be physically aggressive related to poor impulse control; he has a behavior problem related to displaying inappropriate behavior towards peer; and he has a mood problem. R2's social service progress note dated 5/30/2025 at 5:22 PM documents the writer was informed that the resident displayed agitated behaviors towards staff. R2's social service progress note dated 7/8/2025 at 6:05 PM documents the writer was informed that resident displayed agitation towards peer. R2's nursing progress note created by V3 (Director of Nursing) dated 7/15/2025 at 2:29 documents the writer was made aware that co peer was using rolling walker to ambulate and accidently hit the back of resident foot and the resident responded to internal stimuli towards peer. Staff intervened immediately placing resident on 1:1 with staff. Nurse completed body assessment resident was noted with a small superficial cut on the inner lip. Ice pack was placed on resident lip. Physician, Director of Nursing, Administrator, and family were made aware; at 3:38 PM it was noted that resident's room was moved due to altercation with peer. R2's Psychosocial Assessment created by V8 (Registered Nurse) dated 07/15/2025 documents the reason for the assessment was a resident-to-resident physical altercation, he has full recollection and awareness of the event, and observed changes in his mood or behavior included increased agitation. R2's Behavior Management Team Review Meeting Note dated 07/15/2025 documents it was reported that he displayed agitated behavior towards a peer, this was the second occurrence of similar behavior in the past 30 days with the most recent hospitalizations related to behavior occurrences being from 05/31-25 - 06/01/2025, with precipitating and contributing factors include poor impulse control, poor conflict resolution, poor coping methods, and poor emotional regulation. R2's Behavior/Mood Charting created by V3 (Director of Nursing) dated 07/15/2025 documents he was observed in the evening in the hallway displaying physical aggression triggered by other resident becoming physically aggressive toward him in the and the behavior lasted 2 minutes. R2's Skin Condition Report created by V3 (Director of Nursing) dated 07/15/2025 documents R2 had a new skin concern which included a laceration described as a small superficial cut to his inner lip. On 07/21/2025 at 1:09 PM V7 (Psychosocial Services Rehabilitation Coordinator/PRSC) stated she was informed by V6 (Psychosocial Services Rehabilitation Director/PRSD) that R2 and R1 Displayed agitation towards each other. On 07/21/2025 at 1:36 PM V3 (Director of Nursing) stated R2 had an altercation with R1 on 07/15/2025, she received a report that R1 was pushing his walker, and it ran into the back of R2's feet and R2 reacted to internal stimuli. V3 stated someone reported to her there was an altercation during this incident, and that one of them was hit but she can't recall who reported this to her. V3 stated if residents hit each other, we tell the V1 (Administrator) and V1 (Administrator) was informed about this incident. V3 stated R2 and R1's rooms were on the same hallway, so R2 was moved to another hallway to prevent any further altercations. V3 stated the nurses assessed R1 and R2 after the incident. On 07/21/2025 at 1:54 PM V1 (Administrator) stated on 07/15/2025 she responded to some commotion she could hear from a distance from her office, and found R1 at the central nurses station, she asked R1 what happened, and he told her he accidentally bumped R2's foot with his walker, R2 tapped him on the head, and he hit R2 back. V1 stated she then went to talk to R2, and he told her R1 hit him first, he doesn't like R1, but they never had any issues before, then began making delusional statements that she couldn't understand. V1 stated after explaining to R2 that R1 accidentally rolled over his foot, R2 stated R1 did it to him on purpose. V1 stated they did move R2's room because he and R1 were located on the same unit. When asked by surveyor why the incident wasn't reported to the state agency, V1 stated it was a minor injury to R2's lip, it was a superficial cut, and R1 didn't have any injuries. On 07/21/2025 2:21 PM When asked by the surveyor if R1 and R2 hitting each other was deliberate V1 (Administrator) stated she doesn't think that R1 and R2 were maliciousness hitting each other, she wouldn't say that those hits were deliberate, a deliberate hit is if you're trying to cause the resident harm or if it causes harm where one of the residents went out to the hospital that would be considered deliberate. On 07/21/2025 at 3:40 PM V1 (Administrator) stated on 07/08/2025 it was reported to her that R2 was displaying aggression in the dining room. On 07/22/2025 at 11:18 AM V9 (Licensed Practical Nurse) stated she assessed R1 after the incident he had with R2 on 07/15/2025 and he had a little scratch on his finger, but she didn't see the incident and was told R1 and R2 hit each other during the incident. V9 stated R1 and R2 were already separated by the time she arrived down the hall where the incident took place. V9 stated she works with R1 regularly and the bump on his forehead is new. V9 stated the bump on R1's forehead doesn't look old, and he told her he did inform the Director of Nursing about it. V9 stated R1 is alert and oriented and is not cognitively impaired. On 07/22/2025 at 11:28 AM V9 (Licensed Practical Nurse) stated R1 did complain of pain in his hands after the incident on 07/15/2025. The facility's Abuse Policy received 07/21/2025 states: The facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse.This will be done by: Orienting and training employees on how to recognize and report occurrences of abuse. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is willful infliction of injury. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term (willful) in the definition of (abuse) means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting. A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident to resident altercations that include any willful action that results in physical injury, must be reported in accordance with regulations. Any allegation of abuse will be reported to the department of Public Health immediately, but not more than two hours after the allegation of abuse. When an allegation of abuse has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse has been reported and is being investigated.

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse by failing to protect residents from physical abuse. This failure applies to two of three residents (R1 and R2) reviewed for abuse.Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Generalized Anxiety Disorder, Secondary Parkinsonism, and Dystonia (Involuntary Muscle Contractions) who was admitted to the facility 11/23/2022. On 07/21/2025 at 1:27 PM When asked by surveyor if he had an incident with R2 a week ago on 07/15/2025 R1 stated he ran over R2's foot and didn't know it, R2 hit him and he hit R2 back, then he pushed R2 down on the floor, a female staff broke it up, his head was hurt and he has a bump on his head, R1 stated he didn't want to fight, then showed the surveyor a small bump on the left side of his forehead and stated that's where R2 hit him on his head. R1's Annual Minimum Data Set documents his BIMS (Basic Interview for Mental Assessment) score was 15 indicated he is cognitively intact. R1's Current care plan documents he has a history of harming others, exhibits poor impulse control, has the potential to be physically aggressive related to Anger, and he is at risk for abuse. R1's Incident Report dated 07/15/2025 documents he hit a co peer's foot while using a rolling walker, and reported he was walking down the hallway hit his (co peer) foot and he hit me, and he was fully alert and oriented, the report writer was informed that R1 and co peer had a physical altercation. R1's Nursing progress note dated 7/15/2025 at 12:19 PM documents the writer was made aware that co peer was using rolling walker to ambulate and accidently hit the back of resident foot. Staff intervened immediately placing resident on 1:1 with staff. Physician, Director of Nursing, Administrator, and family were made aware. R1's Social Services Progress note dated 7/15/2025 at 5:48 PM documents the writer was informed that the resident displayed agitation towards peer. The resident was separated from the peer to de-escalate the situation. Resident was educated on effective coping skills, including deep breathing, counting, and walking away. Resident was also educated on establishing and maintaining healthy boundaries with peers, particularly in relation to the use of his rollator and practicing mindfulness. The writer encouraged the resident to seek staff when needed. R1's Behavior Management Team Review Meeting Note created by V6 (Psychosocial Rehabilitation Services Director) dated 07/15/2025 documents it was reported that he displayed agitated behavior towards a peer with precipitating and contributing factors including poor coping methods, poor conflict resolution, and poor impulse control. R1's Behavior/Mood Charting Report created by V3 (Director of Nursing) dated 07/15/2025 documents in the evening he was observed in the hallway displaying physical aggression triggered by other resident becoming physically aggressive toward him, and the behavior lasted 3 minutes. R1's Nursing Progress note dated 7/17/2025 at 08:02 AM documents he states his pain level is a 3 and he was given and as needed pain medication; at 5:01 PM it was noted R1 returned to facility from the hospital, he was sent to hospital from day program with a diagnosis with Syncope (sudden temporary loss of consciousness), he is alert and fully alert and oriented and able to verbalize needs. Resident denies falling or striking any part of body while having syncope episode. 2. R2 is a [AGE] year-old male with a diagnoses history of Unspecified Mood Disorder, Conduct Disorder, Schizoaffective Disorder, Paranoid Schizophrenia, Bipolar Disorder, Degenerative Brain Disease, Parkinson's Disease without Dyskinesia (Involuntary Muscle Movement), and Homicidal Ideations who was admitted to the facility 11/09/2023. On 07/21/2025 at 12:50 PM When asked by surveyor if he and R1 had an incident a week or so ago on 07/15/2025, R2 stated yes R1 just ran over his foot on purpose with his walker and doesn't care where he's going or what he rolls over, he and R1 started fighting and he kicked R1's (derogatory word), R1 stated the incident hurt my spirit, and his foot was hurt too, R2 stated V5 (Mental Health Technician/Behavior Aide) broke up the fight and V5 grabbed him from behind to break up the incident. On 07/21/2025 at 12:52 PM V5 (Mental Health Technician/Behavior Aide) stated on 07/15/2025 he witnessed V4 (Registered Nurse) responding to a commotion between R1 and R2 in the hallway, he then responded as well and observed R1 and R2 holding each other and stumbling, he broke R2's fall and V4 assisted R1, and they separated them both. V5 stated R2 reported R1 ran over his foot, and it was explained it was an accident. V5 stated he did not see R1 and R2 hitting each other during the incident. On 07/21/2025 at 2:06 PM R2 stated he did have a cut on his lip from the incident with R1 and raised his upper lip to show the surveyor the cut underneath his lip. R2's Current Care Plan documents he has the potential to be physically aggressive related to poor impulse control; he has a behavior problem related to displaying inappropriate behavior towards peer; and he has a mood problem. R2's social service progress note dated 5/30/2025 at 5:22 PM documents the writer was informed that the resident displayed agitated behaviors towards staff. R2's social service progress note dated 7/8/2025 at 6:05 PM documents the writer was informed that resident displayed agitation towards peer. R2's nursing progress note created by V3 (Director of Nursing) dated 7/15/2025 at 2:29 PM documents the writer was made aware that co peer was using rolling walker to ambulate and accidently hit the back of resident foot and the resident responded to internal stimuli towards peer. Staff intervened immediately placing resident on 1:1 with staff. Nurse completed body assessment and the resident was noted with a small superficial cut on the inner lip. Ice pack was placed on resident lip. Physician, Director of Nursing, Administrator, and family were made aware; at 3:38 PM it was noted that resident's room was moved due to altercation with peer. R2's Psychosocial Assessment created by V8 (Registered Nurse) dated 07/15/2025 documents the reason for the assessment was a resident-to-resident physical altercation, he has full recollection and awareness of the event, and observed changes in his mood or behavior included increased agitation. R2's Behavior Management Team Review Meeting Note dated 07/15/2025 documents it was reported that he displayed agitated behavior towards a peer, this was the second occurrence of similar behavior in the past 30 days with the most recent hospitalizations related to behavior occurrences being from 05/31-25 - 06/01/2025, with precipitating and contributing factors including poor impulse control, poor conflict resolution, poor coping methods, and poor emotional regulation. R2's Behavior/Mood Charting created by V3 (Director of Nursing) dated 07/15/2025 documents he was observed in the evening in the hallway displaying physical aggression triggered by other resident becoming physically aggressive toward him in and the behavior lasted 2 minutes. R2's Skin Condition Report created by V3 (Director of Nursing) dated 07/15/2025 documents R2 had a new skin concern which included a laceration described as a small superficial cut to his inner lip. On 07/21/2025 at 1:09 PM V7 (Psychosocial Services Rehabilitation Coordinator/PRSC) stated she was informed by V6 (Psychosocial Services Rehabilitation Director/PRSD) that R2 and R1 Displayed agitation towards each other. On 07/21/2025 at 1:36 PM V3 (Director of Nursing) stated R2 had an altercation with R1 on 07/15/2025, she received a report that R1 was pushing his walker, and it ran into the back of R2's feet and R2 reacted to internal stimuli. V3 stated someone reported to her there was an altercation during this incident, and that one of them was hit but she can't recall who reported this to her. V3 stated if residents hit each other, we tell the V1 (Administrator) and V1 (Administrator) was informed about this incident. V3 stated R1 and R2's rooms were on the same hallway, so R2 was moved to another hallway to prevent any further altercations. V3 stated the nurses assessed R1 and R2 after the incident. On 07/21/2025 at 1:54 PM V1 (Administrator) stated on 07/15/2025 she responded to some commotion she could hear from a distance from her office, and found R1 at the central nurses station, she asked R1 what happened, and he told her he accidentally bumped R2's foot with his walker, R2 tapped him on the head, and he hit R2 back. V1 stated she then went to talk to R2, and he told her R1 hit him first, he doesn't like R1, but they never had any issues before, then began making delusional statements that she couldn't understand. V1 stated after explaining to R2 that R1 accidentally rolled over his foot, R2 stated R1 did it to him on purpose. V1 stated they did move R2's room because he and R1 were located on the same unit. On 07/21/2025 2:21 PM When asked by the surveyor if R1 and R2 hitting each other was deliberate V1 (Administrator) stated she doesn't think that R1 and R2 were maliciousness hitting each other, she wouldn't say that those hits were deliberate, a deliberate hit is if you're trying to cause the resident harm or if it causes harm where one of the residents went out to the hospital that would be considered deliberate. On 07/21/2025 at 3:40 PM V1 (Administrator) stated on 07/08/2025 it was reported to her that R2 was displaying aggression in the dining room. On 07/22/2025 at 11:18 AM V9 (Licensed Practical Nurse) stated she assessed R1 after the incident he had with R2 on 07/15/2025 and he had a little scratch on his finger, but she didn't see the incident and was told R1 and R2 hit each other during the incident. V9 stated R1 and R2 were already separated by the time she arrived down the hall where the incident took place. V9 stated she works with R1 regularly and the bump on his forehead is new. V9 stated the bump on R1's forehead doesn't look old, and he told her he did inform the Director of Nursing about it. V9 stated R1 is alert and oriented and is not cognitively impaired. On 07/22/2025 at 11:28 AM V9 (Licensed Practical Nurse) stated R1 did complain of pain in his hands after the incident on 07/15/2025. The facility's Abuse Policy received 07/21/2025 states: The facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is willful infliction of injury. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term (willful) in the definition of (abuse) means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting. A resident-to-resident altercation should be reviewed as a potential situation of abuse.

Based on interview and record review, the facility failed to follow their Physician's Order Policy by failing to discontinue medication as ordered by the physician. This deficient practice affects one resident of three residents reviewed for medication administration. This failure resulted in R3 receiving extra dosages of antiepileptic medication. Findings Include: R3 admitted in the facility on 2/28/25. R3 has a diagnosis of Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizure. R3 admitted in the facility with medications such as, but not limited to: Brivaracetam 100mg (milligrams) two times daily for seizure, Clobazam 10mg at bedtime for seizure, Divalproex Sodium 500mg two times daily for seizure, and Levetiracetam (Keppra) 750mg two times daily for seizure with order date of 2/28/25. R3's Neurology note dated 5/6/25, reads in part: R3 should NOT be prescribed Levetiracetam (Keppra) at the same time she is taking Briviact (Brivaracetam). Please discontinue Keppra. This was communicated to the ADON in the facility by phone on 4/23/25. After Visit Neurology Summary Note dated 5/8/25, reads in part: STOP Keppra. On 6/4/25 at 12PM, V19 (Nurse from Neurologist Office) stated that on 5/6/25, there was a reminder note faxed to the facility to discontinue Keppra medication, and that this was previously communicated with the V3 (ADON). V19 stated that on 4/23/25 the Neuro doctor office was prompted to call the facility due to the office received a medication record list from the facility from (V6), and upon review, Keppra was still on this list and R3 was not supposed to take Keppra along with Briviact (Anti-seizure medication). Neurologist note on 5/6/25 stated that R3 should NOT be prescribed Keppra at the same time as Briviact. Please discontinue Keppra. Resident telehealth appointment on 5/8/25, showed that R3 was still with order of Keppra, MD again gave an order to discontinue Keppra medication on 5/8/25. On 6/4/25 at 12:30PM, V6 (ADON) stated V6 recall Neuro physician office called asking for medication list to be reviewed before R3's upcoming appointment. V6 stated she did not received a call from the office of Neurologist after V6 faxed the medication list them. So if the doctor's office talked to any of the nurses on the floor that I do not know. In general, if we received orders form a specialist doctor outside the facility, the nurse still have to verify the order to the attending physician. And need to document if either attending physician agreed and disagreed with the new order. R3's progress notes reviewed from April to May 2025. And there is no noted documentation that Keppra was relayed to attending physician, either agreed or disagreed to discontinue the medication. Medication Administration Record reviewed for the month of April and May 2025. From April 23rd to 30th, R3 received Levetiracetam (Keppra) 750mg twice a day, except for the 1800 refusal on 4/23, 424, and 4/30. From May 1st to 8th, R3 received Levetiracetam 750mg twice a day, except for the 1800 refusal on 5/6 and 5/7. Physician Orders Policy with an effective date of 11/3/22, reads in part: To establish the procedure by transcribing new physician orders. To document and give clear indication that physician orders have been processed and action taken. Transcription of physician order: Carefully, review transfer record and discharge summary from the hospital or the transfer record from another health care facility. The licensed nurse should notify the physician of the resident's admission, clinical condition and findings, review and clarify transfer orders and previous orders as applicable.

Based on interviews and records review, the facility failed to administer medications to one (R1) of three residents reviewed for medication administration in a total sample of six. Findings include: Medical diagnosis in R1's current face sheet includes but not limited to: bipolar disorder, unspecified, schizophrenia, unspecified, hemiplegia, unspecified affecting right dominant side, personal history of traumatic brain injury. On 05/10/2025, at 9:30 AM, R1 was observed laying in bed talking to his roommate R4. R1 stated on 4/26/2025 going into 4/27/2025, he did not receive his pain medication during the night and he was in a lot of pain. R1 stated he asked V10 (Registered Nurse-Agency) for his medication but V10 told R1 that his medication was not available. R1 stated he asked for his medication the whole night but V10 kept saying medication was not available and there was nothing V10 could do about it. R1 stated he had to try and sleep with his pain until the following morning when the morning nurse gave him his pain medication. On 05/10/2025, at 4:00 PM, V1 (Administrator) stated V10 (Registered Nurse-Agency) was the nurse who was on duty on 4/26/2025 into 4/27/2025. V10 was responsible for giving R1 his medications. V1 stated on 4/27/2025, R1 complained to V1 that he did not receive his night pain medication on 4/26/2025 into 4/27/2025. V1 stated she called V10 to investigate what happened and why R1 did not receive his medication. V10 stated she checked on R1 at night and he was sleeping therefore, she (V10) did not give R1 his pain medication and did not chart R1 was sleeping. V1 stated after that phone call she (V1) tried to contact V10 on several occasions but V10 did not answer calls after that. V1 stated there was no way for her to know if V10 gave R1 his pain medication because V10 did not chart giving R1 his medication or the reason medication was not given. V1 stated if it's not documented, it is not done. On 05/05/2025, at 2:47 PM, V8 (Director of Nursing -DON) stated nurses are supposed to follow the physician orders and document reason for not administering a medication to a resident. V8 stated pain is what a resident says it is and a resident's pain needs to be taken seriously. Medications are given to prevent residents from walking around in pain. V8 stated on 4/26/2025, late night after midnight, R1 did not receive his pain medication. The following morning he did not receive acid reflux medication that should have been given. V8 stated V10 (Registered Nurse-Agency) was the nurse on duty and V10 stated she gave R1 his medication but did not sign the electronic medical administration record (eMAR). V8 stated if it is not documented, it is not done. V8 stated there is an emergency medication storage in the facility which is accessible to nurses in-case they run out of a medication. V8 stated the nurse calls the pharmacy to open the narcotics emergency box so the nurse can access the medication and administer to the resident. R1's Physician Order Sheet (POS) documents: HYDROcodone-Acetaminophen Tablet 10-325 MG (milligrams). Give 1 tablet by mouth every 6 hours for Pain - Severe. Active 10/29/2024. Omeprazole Tablet Delayed Release 20 MG. Give 1 tablet by mouth one time a day related to Gastro-Esophageal reflux disease without esophagitis at 6:00AM. Active 2/17/2021. Discontinued 5/14/2024 Review of R1's electronic Medication Administration Record (eMAR) dated 04/27/2025, documents R1 did not receive requested as needed HYDROcodone-Acetaminophen Tablet 10-325 MG and Omeprazole Tablet Delayed Release 20 MG as ordered on 04/27/2025 at 6:00AM. Policy titled Medication Administration General Guidelines dated 1-11-18 documents: -Medication are administered as prescribed in accordance with good nursing principles and practices and only by persons regally authorized to do so. -Medications are administered in accordance with written orders of the prescriber.

Based on interview and record review the facility failed to follow the discharge policy and give a copy of notice to discharge to the resident representative for one of three residents (R1) reviewed for discharge notice. Findings include: R1 face sheet shows diagnosis of schizophrenia, anxiety disorder, schizoaffective disorder, non-compliance with medication regimen for other reasons. R1 MDS dated ,d+[DATE] section Q denotes yes, that R1 plan to return to the community, section C for cognition, R1 BIMS score is 15 (cognitively intact), section GG for functional abilities shows R1 helper provides verbal cues for activities of daily living. On 2/22/25 at 10:18am V2 said R1 was involuntary discharged because R1 physically assaulted the staff, the safety of individuals in the facility is endangered due to R1 behavior/physical assault. V2 said R1 guardian received verbal notice of the transfer and discharge however she did not give R1's guardian a copy of the notice of involuntary transfer or discharge and opportunity for hearing for nursing home residents. Review of the notice with V2, V2 stated that she did check the box that the bed hold notice was given to the resident representative along with a copy of the notice. V2 confirmed that she did not give the resident representative a copy of the notice. R1 notice of involuntary transfer or discharge and opportunity for hearing for nursing home residents dated on 12/18/2024. Facility policy titled notice of transfer and discharge date d 3/22/2017 denotes in-part prior to discharge or transfer the facility will notify the resident and the resident representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. The facility will send a copy of the notice to a representative of the office of the long-term care ombudsman. This may be done by submitting a monthly list of discharges to the ombudsman. For a resident-initiated transfer or discharges sending a copy of the notice to the ombudsman is not required. Record the reason for the transfer or discharge in the resident medical record. Timing of written notice except as otherwise specified below the notice of transfer or discharge will be made at least 30 days before the resident is transferred or discharged .

Based on interview and record review, the facility failed to report an allegation of resident to resident abuse to the State Survey Agency for two of two residents (R292 & R105) reviewed for abuse in the sample of 39 residents. Findings including: On 1/6/25 at 10:30 AM, survey team requested V1 (administrator and abuse prohibition coordinator) all reportable incidents within the last 90 days. V1 presented the survey team with 3 incidents reported to public health regional office (RO) however did not have the incident of 12/18/24 involving R292 and R105. On 1/7/25 at 11:15 AM, V1 (administrator) stated to survey team that the incident on 12/18/24 involving R292 did not warrant reporting as it did not involve another peer (resident).Surveyors asked who was involved in the incident altercation, V1 indicated that R292 struck the CNA V19. Surveyors clarified if R292 had any physical or verbal altercation with any resident during this incident, V1 stated, No, only with staff members. On 12/18/2024 at 19:20 PM, V8 (Social Services) wrote, Note Text: It was reported that this resident (R292) displayed increased agitation including making verbal threats towards peers (residents) and staff, making false allegations as exhibited by delusional thinking patterns. She was not easily redirected, despite attempts to intervene and decrease any further interventions by staff. Nurse offered PRN (as needed- medication) and this resident refused. She targeted female staff (striking and kicking female staff). Resident was escorted to the conference room removing her from other external stimuli. Police was called for assistance. Upon arriving to the facility, Officer and his partner entered the facility, attempted to calm and redirect this resident. She became assertive with the two officers. Nurse notified Physician and Mother/Guardian. There were orders to send her out to the hospital for a psych evaluation. Resident was transported with a petition to Hospital and escorted by EMT (Emergency Medical Technician) and police. On 1/7/25 at 11:40 AM V13 (CNA Scheduler) stated, I was the late night manager on duty and as I was coming in to the facility and (R292) was in the dining room/foyer area. She was aggressively trying to get to resident (R105) and she wanted to fight him. She said I am going to beat his ass and my CNA (V19) went around to get to the door and R292 hit her in the face. I grabbed R292 and walked her to the conference room to calm her down. We were sitting in conference room for a good hour. When she came in here to ensure to make sure she was okay we called police and she did the same thing to them (got aggressive) and they told her they would restrain her if she didn't calm down. Surveyor asked what R292 said to R105, V13 stated, She said that she was gonna beat his (expletive language) I don't know what triggered R292 and I don't think they had a relationship On 1/7/25 at 12:10 PM, R105 was in his room in bed. Surveyor asked about the incident that occurred on 12/18/24 with R292. R105 indicated that R292 disrespected him by threatening him with physical violence and demeaned him by calling him a (expletive language). Facility policy 11/28/2016 titled Abuse Prevention and Reporting reads in part, Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. When an allegations of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has informed, the resident's representative and the Department of public health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigation.

Based on interview and record review, the facility failed to protect residents from resident-to-resident abuse (R11, R97) and staff-to-resident abuse (R18) for three of seven residents reviewed for abuse in the sample of 28. R11 sustained an injury to the head after being hit with a light fixture by R2. R97 sustained a cut on the nose after being hit by R109. Findings include: 1.) On 07/25/23 at 10:15 AM, R11 was observed in his room and said he was watching a movie. R11 stated that he and his roommate got at it a while ago because his former roommate (R2) always had his TV (Television) very loud, and this went on for like a year. R11 said that he had told R2 on several occasions to reduce his TV volume which R2 left on high volume day and night, but R2 would not listen to R11's request. R11 said he had told staff about it (No name provided), but nothing was done. R11 said that a few days ago, late at night, R2's TV was very loud, and R11 asked R2 to reduce the volume, then R11 went to the bathroom after asking R2 to reduce his TV. R11 said as he was in the bathroom, R2 followed R11 to the bathroom and was trying to hit R11. R2 hit the bathroom light, which was on the ceiling and pulled it. The light broke off and hit R11 on top of his head. R11 said he started bleeding. When R2 saw R11 was bleeding, he(R2) started running towards the nurses' station. R11 said he got out of the bathroom and ran after R2 towards the nurses' station. No staff were on the hallways. R11 said it was not until he and R2 were close to the nurses' station that a staff member (no staff name provided), come towards R11 and R2, and that is when the staff saw R11 was bleeding from the top of his head. R11 pointed to a small scar on top of this head and said, this is the scar from R2 hitting me with the bathroom light fixture. On 07/25/23 12:11 PM, R2 was observed in the hallway, outside on the dining room talking to peers. R2 said he and R11 used to share a room, but one day, R2 went to the bathroom when R11 was there and wanted to see what was in the crystal light hanging in the bathroom ceiling. R2 said he pulled the light from the ceiling, and the light come down and hit R11 on the head, and R11 had blood coming out of R11's head. R2 said R11 then come towards R2 and tried to hit him. R2 ran out of the room and fell on the floor, as R11 was coming towards R2, swinging at R2, and saying, I will kill you N . R2 said the hallway was clear and there was no staff to be seen. R2 said he got up before R11 could get to him, and he reached the nurses' station. Staff (no name provided) came to R2 and R11 and separated them. R2 said it was very early in the morning when this happened, before breakfast. On 7/26/2023 at 11:41, V7(Psychiatric Rehabilitation Service Director/PRSD) said residents have a right to be free of abuse. V7 said when residents have an altercation and call each other names or hit each other, that's resident-to-resident abuse. On 7/26/2023 at 3:21pm, V21(Mental Health Technician) said on the day R2 and R11 had a confrontation it was about 3am or 4am in the morning. She heard R2 and R11 screaming at each other and came out of their room, trying to fight each other. V21 said she broke up the fight then saw R11 was bleeding from his head. V21 asked R2 and R11 what happened. R11 said he was trying to use the bathroom, and R2 did not want the light on, therefore R2 kept cutting the light off. R2 told V21 that he got angry and pulled the light fixture off the bathroom ceiling and hit light fixture hit R11 on the head. V21 further said that R11 told her that R2 hit him on the head with the light fixture. V21 said after seeing some blood on R11's head, she took R11 to V36 (Licensed Practical Nurse/LPN), for assessment and treatment. V21 said hitting and calling names is a form of abuse and residents should be monitored to prevent resident to resident abuse. On 07/27/2023 at 10:55am, V36 (LPN) said on 7/2/2023 early in the morning, she was made aware by V21 and V28 (Mental Health Technician) that R2 and R11 were involved in an altercation and R11 was bleeding from the head. V36 said she assessed R2 and R11, and observed R11 was bleeding from a small cut on the head. V21 said she assessed R11 and cleaned the small cut, offered R11 pain medication, but R11 declined. V36 stated that residents should not be hitting each other. They are supposed to be redirected. Facility Reported Incident Report (FRI) dated 7/2/2023 documents: On 7/2/2023 at 4:30am, V28(Mental Health Technician) heard and saw R2 and R11 yelling in the hallway. V28 saw R11 was bleeding from the head. FRI further documents 7/2/2023 V21 heard R2 and R11 yelling and coming out of their room and R2 hit R11. R11 was bleeding some from the head. 45001 2.) R97 has diagnoses that include but are not limited to schizoaffective disorder, bipolar type. Minimum Data Set (MDS) dated [DATE], indicates R97 is cognitively intact. R97's care plan indicates R97 is a potential risk for abuse/neglect related to factors that increase vulnerability. R97's Abuse/Neglect Screening dated 4/20/2023, indicates R97 is a potential high risk for abuse. R97's Nurses Note dated 6/29/2023, documents in part: Received resident with bleeding nose with the report that resident got into physical altercation with roommate. R109 has diagnoses that include but are not limited to schizoaffective disorder, major depressive disorder, bipolar disorder, auditory hallucinations. MDS dated [DATE], indicates R109 is cognitively intact and experiences hallucinations. R109's care plan indicates R109 has the potential to be verbally/physically aggressive and is at potential moderate risk for abuse/neglect. R109's Abuse/Neglect Screening dated 4/24/2023, indicates R109 is a potential moderate risk for abuse. R109's Behavior Note dated 6/29/2023, documents in part: Resident reported that resident was talking to self when peer told resident to shut up. Resident stated that peer was angry, and resident felt threatened and that's when the physical altercation began. Resident sustained a laceration to the back of right hand. On 7/25/23 at 10:50 AM, R109 stated R109 had an altercation with R97 in their room. R109 said R97 asked R109 why did R109 push the door open like that. R109 had just come in the room from a smoke break. R109 said R109 was singing to self and R97 told R109 to shut up. R109 said R97 was looking at R109 with a mean look. R109 said R97 was mean mugging R109 and started walking towards R109. R109 said R109 started swinging. R109 said R109 hit R97 in the face. R109 said R109's hand started bleeding and R97 left out of the room. R109 said R109 feels safe. On 7/25/23 at 11:05 AM, R97 stated R97 did not want to talk about the incident. R97 said R97 was hit and got a cut on the nose. R97 said R97 does not feel safe because R97 got hit. On 7/26/23 at 1:10 PM, V13 (Mental Health Tech) stated V13 was at the central behavior desk at approximately 3 PM. R97 came from the east wing drenched in blood on face. R97 said R109 beat me. V13 notified the nurse, V7 (Psychiatric Rehab Service Director), and V3 (Director of Nursing). V13 said R97 had an injury on the nose and R109 had a scrape on the knuckles on the right hand. V13 said V13 took R109 for 1 to 1 in the sensory room. R109's room was changed. R109 told V13 that R109 was listening to music. R97 said to cut the s*** down and cussing at R109. R109 told R97 to watch R97's mouth. R109 said R109 got up and hit R97. V13 said R97 and R109 were friends beforehand. V13 said R97 gets smart at the mouth sometimes, gets verbally aggressive to residents and staff. 7/26/23 at 2:50 PM, V1 (Administrator) stated I was administrator at that time. Around 11 AM, I heard a Mental Health Tech page, which means there is a situation. I went to the central desk. I observed R97 had blood on the nose and shirt. R97 said R109 was doing a lot of talking and R97 told R109 to shut up. R109 hit R97. R97 said it happened in the room. First aid was given to R97. R109 said R109 got a cut on the hand. R109 was assessed by the nurse. We did a room change, initiated an investigation, reported to the State Agency. Doctors were notified. Neither residents were sent out to the hospital. 7/26/23 at 3:13 PM, V7 (Psychiatric Rehab Service Director) stated V7 heard an uproar. R109 was at one end of the hallway with staff. R97 was at central desk with staff. I saw blood on R97's face. R97 said R97 was hit by that guy. Staff told me R97 was hit by R109. R109 said R109 hit R97 because R97 was in R109's space. Facility Resident Abuse Investigation Form, date incident occurred: 6/29/2023, documents in part: R109 has history of poor boundaries and was responding to external stimuli. R97 and R109 were in their room. R109 started talking to R97 and R97 told R109 to be quiet. R109 then displayed poor boundaries and struck R97. Facility policy Abuse Prevention and Reporting-Illinois, revised 10/24/22, documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 15301 3.) R18's medical record (Face Sheet and MDS) document R18 is a severely cognitively impaired, admitted to the facility on [DATE] with diagnoses including but not limited to: Polyosteoarthritis, Schizophrenia, Schizoaffective Disorder Bipolar Type, Restlessness and Agitation, and Major Depressive Disorder. On 7/25/2023 at 11:50 AM, R18 was observed sitting on the side of the bed in his room. R18 was asked about the incident involving him and V37 (Former Housekeeper). R18 said, I don't want her (V37) in here. She hit me with a garbage can. 0n 7/26/2023 at 9:34 AM, V13 (MHT) said, I heard yelling. The housekeeper (V37) was yelling for a MHT (Mental Health Tech). She was standing in front of his (R18's) room, sweating, holding a garbage can in her hands. He (R18) was sitting up on his bed. She (V37) said to me, come get this n*****. I separated them. I told (V37) to go down the hall so that I could remove (R18) from his room and take him to the sensory room. He told me she hit him with the garbage can. I told the manager on duty (V39 (Admissions/Marketing Director). I think she (V39) heard the yelling. Attempts were made to contact V37. V37 was not available for interview. Facility's final incident report of 7/7/2023 documents in part: Type of Alleged Abuse: Verbal. Summary of interview of person reporting the incident: V13 (MHT): I saw the resident (R18) sitting on his bed and (V37) the housekeeper was standing outside of his (R18) room holding a garbage can and cussing. I told her (V37) to calm down and took her away from his room and I let the manager on duty know. Summary of interview with person involved: V37 (Former Housekeeper): I went into the room and as soon as I walked in the room (R18) started cussing at me. I tried to go into the bathroom to clean the trash, and when I walked out, he called me B****. I was mad and I cussed back at him. Summary of investigator's findings: MOD (Manager on Duty V39 Admissions/Marketing Director) reported that (V37) and (R18) were in a verbal altercation. (V37) went in to clean (R18's) room and (R18) did not want his room clean(ed) at the time. (V37) kept going in there and (R18) was getting agitated, which lead to (R18) becoming verbally inappropriate and spitting on (V37). This then led to (V37) responding verbally inappropriately. MHT (V13) intervened and separated. V37's statement, obtained by V39 on 7/2/2023 at 1:07 PM, documents in part, V37 went to R18's room. R18 started cussing at V37, telling her to leave his room. V37 ignored R18 and tried to go into bathroom to clean out trash. R18 called V37 f***** b**** and pushed V37 out of his (R18) room. V37 tried to get back into the room. V37 went to adjoining room, entering R18's room through the shared bathroom. R18 spit on V37, V37 left room. V37 said (in statement), I didn't react. Yes, that's what I said. I wouldn't put my hands on anyone. I was mad, then you got cameras. On 7/25/2023 at 3:38 PM, V1 (Administrator) said, V37 was terminated for inappropriate staff behavior and V39 was not available for interview. Facility's Abuse Prevention and Reporting-Illinois policy (Reviewed/Approved by: IDT 12/17/2021) documents in part, The facility affirms the rights of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse may include but are not limited to: Harassing a resident; Yelling or hovering over a resident, with the intent to intimidate.

There are multiple deficiencies identified. 1.) Based on interview and record review, the facility failed to properly supervise a resident with a known history of elopement who was assessed as requiring staff supervision for ambulation on and off unit; failed to supervise the resident while smoking; failed to have a physician order for unsupervised outside pass privileges; failed to follow their policy for missing resident/elopement; and failed to follow their behavior management level program agreement. These failures affected one of one (R1) resident reviewed for supervision and resulted in R1 leaving the facility on 3/28/23 while on an unsupervised smoke break. While out in the community, R1 was without access to food, shelter, or therapeutic medication and was subsequently admitted to the hospital on 4/10/23 for aggression and presented with exacerbation of mood and psychotic symptoms. The Immediate Jeopardy that began on 3/28/23 when the facility failed to monitor R1 with a known history of elopement, which resulted in the resident leaving the building unsupervised. V1 (Administrator) was notified of the Immediate Jeopardy on 5/8/23 at 11:54AM. The survey team verified by observations, interviews, and record review, that the Immediate Jeopardy was removed on 5/9/23 but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the interventions implemented. Findings include: R1 is a 37- year-old male who was admitted to the facility on [DATE], with past medical history including, but not limited to bipolar disorder unspecified, moderate intellectual disability, essential primary hypertension, hyperlipidemia, type 2 diabetes, nicotine dependence, other symptoms and signs involving appearance and behavior. Review of facility Minimum Data Set (MDS) dated [DATE], section G (functional) coded R1 as requiring supervision for all ADLs including ambulation on and off unit. Facility sign-out/in record presented by the facility shows that R1 signed out to the front on 3/28/23 at 10:15AM. Progress note dated 3/28/23 reads that R1 was granted an independent community pass. During an unsupervised smoke break, R1 left the facility and did not return. During an interview with R1's relative on 5/3/23 at 2:49PM V20 (Family Member) said, R1 never finished high school and has exhibited psychiatric problems since he was a young adult. V20 said, R1 can feed himself and dress himself, but he needs help with his other needs such as cueing for maintaining hygiene and taking medications. V20 indicated that R1 cannot make sound decisions and because of this, she became his representative payee after his grandmother, who was the previous payee, passed away. V20 said, R1 ended up in another nursing facility in (name of city), after being hospitalized at some point when he left this facility. Review of resident's medical record show the following progress note documented by V10 (Psychiatric Rehabilitation Services Coordinator/PRSC) on 1/31/2023 at 9:32AM: Resident approached writer (for the seventh time) about getting an independent pass. Writer denied resident request and explained that because he was just readmitted from the hospital that he was ineligible for a pass at this time. Resident stated that he understood. Writer will revisit topic later. Another progress note dated 1/31/2023 at 14:30 states in part: It was brought to writers' attention that resident has an unauthorized exit from the facility. Resident Mother notified facility that resident visited sisters' home and was provided funding to return to [the facility]. Facility aware of resident exit. At this time, a missing person's report has been filed and awaiting Resident return. MD (Medical Doctor), Administration and Nursing aware of all the above. Review of resident's care plan did not show an active care plan for risk of elopement. On 5/3/23 at 2:50pm V10 (PRSC) said that I created the elopement care plan as part of the plan of correction for the elopement that occurred on 1/31/23. I discontinued the care plan 2/24/23 because we decided that R1 could work on getting a community pass. On 5/3/24 at 3:40pm V10 said, as far as the elopement assessments, from my understanding because R1 was trying to get a community pass, we couldn't mark him as being at risk for elopement. I scored it as no risk so that he would be eligible to petition for a pass even though he eloped in the past. On 5/1/23 at 10:38AM V21 (Family Member) said, R1 left the facility before in January, improperly dressed without coat and socks in the cold. He was originally transferred to this facility because he needed treatment for his mental health and assistance with activities of daily living. V21 said she begged staff not to give R1 a pass to the community because he was likely to leave and not return and he was unable to take care of himself without assistance. When V21 was notified that R1 left on pass and did not return on 3/28/23, she called the facility and asked why staff would give him a pass when R1 already showed that he can't take care of himself. On 5/5/23 at 11:23am R1 was interviewed over the phone. R1 was alert and oriented but responded slowly, speaking with disorganized thoughts. R1 said, I was on a red pass (independent) and went outside to smoke and kept going. I went to see if I could find another nursing home to go to. I was hoping to transition to an independent facility with a single room and I didn't know that I would be sharing a room with three other people before I got here. When I left, I was gone for about a week. I was hopping trains most of the time. I didn't take any medication from the facility and didn't have any food. Facility Policy titled Community Pass Guidelines revised 11/25/19 states in part: The resident has the right to community access with the consent of the facility, physicians' orders, and the resident' cooperation with the standards described within. Review of most recent physician orders for R1 did not show any order for independent community pass. Further review of facility, Release of Responsibility for Leave of Absence (sign in/out) form (dated 3/28/23) documented that R1 signed out of the facility at 10:15AM to go outside at the front of the facility. On 5/3/23 at 12:16PM, V1 (Administrator) said, when the residents write front on the sign-out sheet, it usually means they are going out to smoke. When R1 went outside, he was expected to smoke and come back in but since he had a community pass it wasn't unusual that he did not come back right away. On 5/4/23 at 1:45PM V15 (Mental Health Tech/MHT) said, I was working a double on the day that R1 went outside and did not return. He went outside to smoke and didn't come back in the with other residents, but I didn't think too much of it because he had an independent pass. We don't supervise residents who go out to smoke on the front because they have a peer or independent community pass. R1 had had the independent pass for a long time but they never told him about it, so he didn't know. Since I was there later that night, I noticed that it was around 7 or 8pm that he had not returned. I informed V10 (PRSC) and the nurse. I'm not sure what they did after that. Community Survival Skills assessment dated [DATE] was signed by V4 (Director of Behavioral Health) on 3/29/23. R1 left the facility unsupervised on 3/28/23. Most recent care plans reviewed for R1 documented that Level II (peer) and Level III (independent) pass were both implemented on 2/24/23. On 5/2/23 at 12:32PM, surveyor requested documentation that would support R1 going out with a peer pass. V1 said, unfortunately, those documents are not a part of the resident's record and are not kept. They are currently in the shred box. We have some people looking through them to see if we can find them. During the course of this survey, the facility did not provide documentation that R1 went out and was supervised on Level II pass at any time. Review of Smoking Safety Risk assessment dated [DATE] by V10 (PRSC) noted that R1 required supervision while smoking and was not able to store smoking materials. Progress Note dated 3/28/23 at 9:10PM written by V6 (Group Facilitator) reads: staff determined R1 had not returned from community pass. On 5/4/23 at 3:30PM, V18 (Licensed Practical Nurse/LPN) said, I worked 3-11PM shift the day that R1 left. The CNAs were doing head count and noticed that R1 was not in the building. I don't remember seeing him during my shift. I was informed that R1 was on community pass from the previous shift and had not returned around 8pm. I called V1 (Administrator), and he informed me to call the police and then he called and asked the MHTs (Mental Health Tech) that were in the building to go and look for him in the surrounding area. I called the police and gave them a description and they asked me if I wanted to file a missing person's report and I said no because I didn't think he was missing but still out on pass. I called the family to let them know that he had not returned. I heard that he came back to the facility some days later, but they wouldn't let him come back and sent him to the hospital. Facility policy titled, Code Pink- Missing Resident/Elopement revised 11/15/18 states in part: All personnel are responsible for reporting a cognitively [impaired] resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. The following steps should occur: 3. Notify the sheriff and/or police department and file a missing person report. The facility was unable to provide any documentation that a missing person's police report was filed on 3/28/23 for R1. Facility progress note dated 3/29/23 at 8:02PM written by V26 (Assistant Director of Nurses/ADON) said that R1's mother was called and left a voicemail. Progress note dated 3/30/23 at 2:50PM said that R1's mother called the facility saying she needed to speak with a manager and wanted to know why we gave her son community access so he could run away. Progress note dated for 3/29/23 at 8:47 AM was written on 3/30/23 at 2:50pm and said that a missing person's report was filed for R1 with the local police department. Surveyor called the police department and a representative indicated that there was no report filed for R1 missing on that day. Further review of progress notes written on 3/29/23, 3/30/23 and 3/31/23 indicated that facility staff were calling various shelters, hospitals, and the morgue but they were unable to locate R1. Progress note written on 4/5/2023 at 6:53pm by V10 (PRSC) stated, Writer spoke with resident's mother. She confirmed that resident was located and prefers to be homeless over returning to the facility. Administration notified. Writer asked for resident's phone number, but mother declined. Writer encouraged mother to reach out to resident and see if he was interested in returning. Writer also explained the 10 Day policy. On 5/3/23 at 2:00PM, V12 (Facility 2 Representative) said, R1 was admitted to them from a local hospital on 4/18/23, where he had an inpatient psychiatric evaluation from 4/10/23 to 4/18/23. Hospital admission record dated 4/8/23 noted that R1 presented to the emergency room with no complaints reporting that he left the facility and wanted to go back, however was told that he needed to come to the Emergency Department prior to returning. He was evaluated and nurse to nurse communication was documented from the hospital to the facility at 9:32PM. The hospital discharged R1 back to the facility via private ambulance at 10:33PM. At 11:56PM, a nurse from the facility called back to the hospital stating that 'the patient was discharged a week ago'. This nurse was unable to be identified. Further notation states that a facility nurse said, 'I just came on shift and was just told about this and [the ambulance] won't take him back to you'. Facility nurse said, 'I am just fulfilling orders, I will speak to my management.' Fire Department run sheet dated 4/08/23 at 6:18PM stated, in summary, patient presented to EMS as a walk-in patient stating he needed to be mentally evaluated prior to returning to his housing. Patient was assisted to the ambulance and secured and assessed. Patient was transported to [local hospital]. ED (Emergency Department) contacted with report and received no orders. Patient arrived at the ED where care and report were transferred to the [ED RN]. Incident address on the report indicated this fire department station is located across the street within view of the facility. On 5/5/23 at 10:57AM V27 and V28 (Fire Department Paramedics) said, R1 walked up to the station and knocked on the door. He said he came from the nursing home across the street, and they told him to go to the hospital because he needed a psychiatric evaluation. We didn't talk to the facility at all because we didn't see that there was any point to that once we had assessed him and got him situated on the stretcher. We were pressed for time. I have personally gotten a call where I responded to him before in January, so I was familiar with him and knew that he lived at this facility. When R1 arrived at the Emergency Department, he was admitted , and staff filled out a Petition for Involuntary/Judicial Admission form. The form dated 4/9/2023 states in part: this petition is being initiated by reason of 1. Emergency inpatient admission by certificate; 2. Emergency admission of the developmentally disabled. [R1] is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed; in need of immediate hospitalization for the prevention of such harm. The petition goes on to state that this assessment was based on the following: [R1 was] received from EMS (Emergency Medical Service) with reports of aggressive behavior. [R1 was] received alert, oriented, calm, and cooperative, endorses that he was out on pass for 6 days and that he attempted to go back to facility, and they informed him that he needs a psych eval and he came to this ED yesterday for the evaluation. [Thereafter, R1 was] sent back to the facility and was told that he needs an inpatient stay and that his meds need to be adjusted. R1 was transferred to another hospital in (name of city) where he was admitted on [DATE] for a chief complaint of aggression. This hospital record dated 4/10/23 documented that R1 was diagnosed with schizoaffective disorder/ Schizophrenia and Mild interpersonal conflict and was started on quetiapine (an antipsychotic medication). During assessment, in the History and Physical section, it was noted that R1 exhibited psychotic disorganized thought process, appeared to be responding to internal stimuli and exhibited guarded demeanor and paranoid ideation. Behavior appeared impulsive and unpredictable. During this assessment, R1 admitted to having a previous history of poly substance abuse. On 5/5/23 at 1:11PM V4 (Director of Behavioral Health) said, I was not made aware of R1 returning to the facility. If he were to have showed up, we would ask him what he needed and give him verbal directions to the hospital because it was considered that he left against medical advice. If he was coming to pick up his belongings, the staff could've given them to him or called 911 if he was in serious need of care. According to google maps, the distance from the facility to the nearest hospital is 4 miles. On 5/5/23 at 3:40PM V34 (Assistant Administrator) said, it was administration who decided that R1 would be discharged . He did have some belongings that were left behind that his sister came to pick up about a week ago. On 5/9/23 at 2PM V29 (Medical Director) said, I was not made aware of R1 leaving the facility during a smoking break unsupervised. The staff should be supervising smoking breaks all the time. If the resident left even for 10 minutes, they should have enacted the protocol by going to look for him, to find him. In this case the resident absconded and would not be considered leaving against medical advice. Leaving against medical advice requires an understanding, provided to the resident that they are leaving the facility who is providing care for their needs. They must sign out to ensure their understanding that, even though they may not have access to food, medication, and safe shelter, they are choosing to leave the facility. If they refuse to sign, then that should be witnessed by more than one person and communicated to the administrator. My understanding of the peer pass system is that when a resident first comes into the facility, they have a three-week observation in order to determine if they can follow the rules and be safe in the community. The team says this resident is okay and gradually gives them a pass to go outside- usually for a limited time. Residents cannot be supervisory agents of one another. Someone who needs supervision can go outside and into the community, but they should be escorted by a staff member because staff has some legal standing and a level of responsibility for keeping the residents safe. At the very least, they will be able to observe the resident if they decided to go off and leave because then the staff member would be able to communicate that and the protocols for finding the resident will take place. Common sense tells me that residents cannot supervise each other. If smoking breaks were supervised, it would 100% prevent people from taking off. I haven't been made aware of anything like this happening before but occasionally if someone wants to leave and they let me know. I say to follow the protocol. The circumstances of allowing this resident who has absconded back into the facility, depends, such as how is the resident presenting? Does he appear to be safe to come back into the facility? Sending the patient away at the door would not be advised, particularly if the resident had a relationship with the facility and has recently been living there. They should not have told him to find his way to the hospital alone, but they could have sent him to the emergency room using an ambulance or emergency services to ensure safe transport. The Immediate Jeopardy that began on 3/28/23 was removed on 5/9/23 when the facility took the following actions to remove the immediacy. 1. R1 is no longer at the facility. 2. All residents who successfully petitioned for a community pass and have been deemed able to navigate in the community were reassessed to ensure that their community and elopement assessments are accurate. Initiated 5/5/23 3. All residents were reassessed to determine their ability to smoke unsupervised. Their smoking assessment indicates they are independent smokers. The assessments were updated as appropriate. The Psychiatric Rehabilitation Services Director and the Director of Behavioral Services were responsible for updating the assessments. Initiated 5/5/23 4. The level 2 pass program will be eliminated. Residents wanting independent passes will go on supervised outings with staff. These supervised outings will help facility assess residents trying to obtain an independent pass. Initiated 5/8/23 and ongoing 5.Assessments were reviewed to ensure accuracy, implement interventions as needed and update care plan accordingly. Assessments will be reviewed by Inter Disciplinary Team composed of Administrator, Director of Nurses, and Psychiatric Rehabilitation Services Director. Initiated 5/5/23 and ongoing 6. Ongoing education of all staff regarding supervision policy to address that staff are not to leave any area with residents present who require supervision and maintain supervision of any supervised exits, verifying residents' community access pass prior to allowing them to exit facility, and smoke break procedures. Facility will ensure staff understanding of the policy via a QA tool. If it is determined staff do not have a sufficient knowledge base, re-education will occur. All staff will be trained by 5/5/2023 and any staff on leave or unavailable were called and are being in serviced via phone, via zoom call and again before next scheduled shift. The Administrator, Assistant administrator, Human Resources Director, Assistant Director of Nurses were responsible for the staff training. Initiated 5/5/23 and ongoing 7. Elopement and community pass binder are at the front desk and each nurse's station. PRSD is responsible for maintaining and updating the elopement binder. Facility added residents with passes to the elopement binders. Completed 5/5/23 8. The Medical Director was notified by the Administrator and reviewed the facility's immediate action plan. He is in agreement with immediate action plan. Completed 5/5/23 9. QAPI review with Medical Director to review plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Department heads will be responsible for QA monitoring. Action plan will be reviewed monthly at QAPI meeting. Initiated 5/5/23 2.) Based on interview and record review, the facility failed to monitor residents who were identified as needing staff supervision during smoking breaks and failed to supervise residents without an independent community pass while out in the community with other residents. These failures affected 19 of 25 residents who were reviewed for supervision while smoking with community access. Findings include: According to a list provided by the facility, nine residents (R6, R8, R9, R10, R11, R12, R13, R14 and R15) have been assessed to have a Level II Peer Pass. Of those nine residents, seven of them (R6, R8, R9, R10, R11, R12 and R14) smoke and were assessed to require supervision while smoking (Safe Smoking Assessment). 10 residents (R7, R16, R17, R18, R19, R20, R21, R22, R23 and R24) out of 15 residents who have an independent (Level III) community pass smoke and have been assessed to require supervision while smoking. Smoking assessments for R6, R7, R8, R9, R10, R11, R12, R14, R17, R18, R19, R20, R21, R22, R23 and R24 were reviewed and noted to be updated on 5/5/23. Elopement assessments for theses residents were also reviewed. On 5/8/23 at 12:54PM V4 (Director of Behavioral Health) said, we went and reassessed all the residents who have a community pass to make sure their assessments reflect that they are appropriate to be out in the community. We combined the community survival assessment with the elopement risk assessment. The smoking assessment has a point system that automatically generates the points, but I don't recall what the point scale is evaluating or what the numbers mean on the assessments. It is appropriate for residents to smoke in front of the facility unsupervised because they have a community peer or independent pass. Residents can't light their own cigarettes because they need supervision while smoking. The cigarettes are lit by the receptionist or the MHT (Mental Health Tech) that lets the residents out of the building during smoke breaks. On 5/08/23 at 2:00PM V1 (Administrator) said, we are working on the policy now, and have decided to get rid of the Peer Pass system. We will implement the policies tomorrow once they have been approved. V1 presented revised policy which was approved with the abatement plan on 5/9/23 at 10:30AM. In the Facility's Behavior Management Level Program Level II expectations were revised to indicate that this pass will be with staff only, whereas the previous system in place allowed residents to go out into the community with and be supervised by their peers. On 5/9/23 at 3:35 PM V3 (PRSD) said, per the new policy we have incorporated two additional smoke breaks at 10:45AM and 5:30 PM that will be supervised by either the activity staff or the MHT. We have taken all the blue passes (Peer) and the residents who don't have passes will continue to smoke supervised on the back patio. Residents are now able to go out into the community if they are with staff. All the residents who have been assessed to have a Level II (peer pass) have been reassessed and their care plans have been updated. I, (V4), the psychotropic nurse, V26 (ADON), and the medical team have been updated on the new policy. The goal is for every staff member to be updated on the new policy by the end of business day. Residents still have the opportunity to have a red independent pass where they can go out alone. On 5/9/23 at 3:35 PM V31 (MHT) and V32 (MHT) were interviewed regarding the new policy. V32 said we were just updated coming into the facility that there will be no more blue passes. Residents who leave the building need to be supervised and it will take 30 days to move up a level to get an independent pass. V31 said things that would be looked at in order for a resident to get a level three pass are hygiene, making sure they attend their groups regularly and supervision during group outings to see how they behave. V32 said the residents can go outside as long as activities or the MHT take them out. V31 said this new policy started today. I've been working here for about six months. V32 said I started two months ago. V31 said if a resident is missing or leaves the group while we're outside, we're supposed to report it to the Administrator right away.

Based on interview and record review, the facility failed to allow a resident to return to the facility after being out on a facility provided pass. The facility did not properly discharge the resident and did not have documentation of efforts to provide the resident with proper notice of discharge. This failure resulted in R1 being in the community unsupervised and without therapeutic medication. R1 was subsequently admitted to the hospital for aggression and presented with exacerbation of mood and psychotic symptoms. The Immediate Jeopardy began on [DATE] when the facility failed to allow a resident to return after being out on a facility provided pass. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:54AM. The survey team verified by observations, interviews, and record review, that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the interventions implemented. Findings include: R1 is a 37- year-old male who was admitted to the facility on [DATE], with past medical history including, but not limited to bipolar disorder unspecified, moderate intellectual disability, essential primary hypertension, hyperlipidemia, type 2 diabetes mellitus without complications, nicotine dependence, other symptoms and signs involving appearance and behavior. The facility's Release of Responsibility for Leave of Absence form is used as the facility's sign out sheet for all residents. This form showed that R1 signed out at 10:15AM on [DATE] to go out to the front of the building but never signed back in. On [DATE] at 10:40am, V2 (Chief Nurse Officer Regional) said that the plan was for R1 to discharge back to a similar (supportive living) facility as he was previously in, before June. R1 is alert and oriented with a BIMS 15. R1 was taking his medication and was not part of the [NAME] Program because he was short term. He was last seen by the psychologist on [DATE]. R1 left on ,d+[DATE]. He signed out on pass and had no guardian or POA. We found out that he wasn't coming back when we spoke with his mother on ,d+[DATE]; that's when his mother confirmed that he wasn't coming back. On ,d+[DATE] R1's mother said that he's probably at a relative's house or a shelter. Then we reached out to shelters to see if he was anywhere. We did not have his cell phone number and the mother would not give it to us. He never came back for his medication and his belongings. R1's sister came to pick up his personal belongings on ,d+[DATE]. [DATE] at 11:23AM, R1 was interviewed over the phone with V21 (Family Member) on a three-way call by the survey team and he said, I was on a red pass and went outside and kept going. I went to see if I could find another nursing home to go to. I was hoping to transition to an independent facility with a single room and I didn't know that I would be sharing a room with three other people before I got here. I was gone for about a week. I am staying at (homeless shelter) now. When I left, I went to my sister's house and she gave me $15, that's all the money that I had. I came back to the facility but a white woman in the therapy office said I couldn't come back unless I went to the hospital first. I went to the hospital, and they said I still couldn't come back. They didn't help me get there. I walked to the fire department across the street and told them that they wouldn't let me come back and they took me to the hospital, then they sent me to another hospital, and I stayed there for about a week. I still had belongings like a bag of clothes and stuff, but they didn't tell me I could get it. My previous facility sent me to the current one because I told them that I didn't want to be there anymore. V21 added that R1 can't manage his own money. If it were left up to him, he would never pay his rent or eat nutritious food. His grandmother was his payee before she died and now my daughter (R1's sister) is the payee. Hospital record dated [DATE] at 6:23PM documents the following: [AGE] year-old male presents to ED for psych eval, patient reportedly left a nursing home and is wanting to go back, however patient was told he needs to come to ED for evaluation prior to returning. Patient denies HI, delusions, hallucination. There are no other complaints at this time. At 10:33PM, the same hospital record documents: Patient discharged , instructions given, follow ups discussed. Patient verbalized understanding, shows no signs of distress, patient is alert and oriented. Patient going back to previous facility, blood pressure elevated, Ed MD aware, patient has no other questions or concerns at this time. At 11:44PM, same medical record documented the following: Facility RN called after receiving over the phone report stating that patient was discharged a week ago, this RN explained to the nurse that was not communicated. What was explained is that the worker and the previous RN was told that patient needed to have psychiatrist evaluation prior to being discharged back to the nursing home. The nursing home RN stated, I just came on shift and was told about this and (ambulance company) won't take him back to you. This is the same nurse who took report prior to patient's departure, she also stated, I am just fulfilling orders and will speak to my management. [DATE] at 10:57AM V27 and V28 (Emergency Medical Technician from the local Fire Department) said that R1 walked up to the station and knocked on the door. He said he came from the nursing home across the street, and they told him to go to the hospital. We didn't talk to the facility at all because we didn't see that there was any point in that once we had assessed him and got him situated on the stretcher. We were pressed for time. I have personally gotten a call from (R1) before, so I was familiar with him and knew that he lived at (facility). R1 called 911 back in January because they were trying to send him to the hospital, and he said that the private ambulance was taking too long. He said he wanted to go somewhere else but ultimately, we ended up not taking him because he needed a psychiatric evaluation, and the nearest hospital wouldn't have been able to treat him for that. I haven't had any additional calls or any instances where a resident has come over to say they are being denied entry. Emergency department physician progress note dated [DATE] at 3:35AM documented: [AGE] year-old developmentally delayed presents for psychiatric evaluation after voluntarily leaving nursing home, returning after 8 days. He states he would like to go back; they are requesting that he be evaluated. Denies any SI, HI hallucinations, bizarre, however this appears to be his baseline. No physical complaints of shortness of breath, vomiting, abdominal pain, calm cooperative .he was subsequently transported via EMS (Emergency Medical System). I was informed subsequently that the supervisor at the nursing home had discharged the resident from their facility, RN (Registered Nurse) did explain to them that this is inappropriate, we were not informed of this, and patient has already been discharged and accepted back to the facility, they will speak to their superior. Hospital record also included hospital nurse's note dated [DATE] at 10:13AM, which documented: patient received from EMS with reports of aggressive behavior .came to this ED yesterday for evaluation, then sent back to the facility but was told he needs inpatient stay and that his medications need to be adjusted. Emergency department nurse's note dated [DATE] at 11:11AM includes received a call from facility administrator stating that patient was out on pass and never returned and was discharged from the system. He reported that patient has displayed this behavior before, administrator was given a fax number to send discharge instructions so that alternative placement can be secured, patient made aware that he cannot return to the facility. On [DATE] at 2:20PM, V12 (Facility 2 representative) stated that the resident was admitted to their facility from ,d+[DATE] to [DATE] with a diagnosis of schizophrenia. R1 was admitted from a psychiatric hospital from [DATE] to [DATE] before coming to their facility. Hospital record dated [DATE] states the following: Patient presents as 37yr year old male previously diagnosed with schizophrenia/schizoaffective disorder presents to the emergency room after exacerbation of mood and psychotic symptoms. Per petition, patient received from EMS with reports of aggressive behavior, patient received alert and cooperative, endorses that he was out on pass for 6 days, attempted to go back to facility and they informed him that he needs a psychiatrist evaluation, and he came to this emergency room yesterday for evaluation, patient then went back to the facility and was told that he needs an inpatient stay and that his medications needs to be adjusted. [DATE] at 3:30PM, V18 (Licensed Practical Nurse/LPN) said that she recalls the resident, he was assigned to the set with R1 on [DATE] but R1 was already gone by the time she came to work on second shift. It was reported to her that R1 was out on community pass and did not return. When they had a head count around 8PM they noticed that the resident was still not back, they searched all the rooms and did not find him. V18 notified the administrator who instructed her to inform all the MHTs (Mental Health Technician) to go out and search for R1 within the area. The administrator also told her to call the police. V18 said that she called the police and gave them a description of the resident. The police asked her if she wanted to file a missing person report and she said no because she was thinking that the resident would come back. V18 stated that she also called the family. V18 was asked if R1 ever expressed the need to leave the facility and she said no, but one time he brought a paper for her to sign stating that he has been of good behavior and taking his medications. V18 said she told him that she could not sign the paper because she does not know him well enough to sign that. V18 also said that she heard that the resident came back to the facility a couple of days later but was sent to the hospital. [DATE] at 1:11PM V4 (Director of Behavioral Health) said that she does not know of anytime R1 returned to the facility after he left. V4 does not normally work the weekend. If resident showed up, the facility could have given him verbal direction on how to get to the hospital. Surveyor asked V4 why the facility would give the resident verbal direction and she said, he is independent and out in the community, he was considered as gone AMA (against medical advice) after he signed out on a pass and did not return. V4 was asked if R1 still had belongings at the facility after he went out on a pass and she said that she is not sure if the resident had any belongings; if he did, staff could have assisted him. V4 added that R1 never told her that he wanted to be discharged . [DATE] at 1:39PM, V1 (Administrator) said that R1 came back to the facility after he left, inquiring about food and they explained to him that he has gone AMA and would have to go to the hospital for evaluation. V1 said that the facility called the hospital ahead of time and they were requesting a referral. They went back and forth with the hospital about it. V1 added that he was not present at the facility when R1 returned, a staff member called him, and he cannot recall who the staff was because he does not work on weekends. V1 was asked if they asked R1 to sign the AMA paper at that point and he said, no, I am not sure why not. V1 said that he asked someone at the facility to give R1 a sandwich since R1 said that he was hungry. [DATE] at 2:02PM, V29 (Medical Director) said that that when a resident leaves the facility and does not return, the first thing is to file a missing person report, even if the resident was gone for 10 minutes. If for any reason the facility cannot find a copy of the report, it should be re-filed. V29 added that AMA is not when a resident signs out and absconded from the facility. If a resident wants to leave AMA, they should sign the AMA form; even if they refuse to sign, the facility should explain to the resident the risks of leaving AMA. V29 said that when R1 came back to the facility after being away for several days, telling him to go to the hospital on his own is the worst thing to do, especially for someone with a history, they should have put him in a safe place and made sure that he is stable and called an ambulance to take him to the hospital and take it from there. Review of facility AMA (Against Medical Advice) policy revised [DATE] stated in part that it is the policy of the facility to acknowledge the right of a resident to sign him/herself out of the facility without the consent of or an order from the attending physician providing that the resident has the decisional capacity to do so. Under procedure, the policy states that prior to leaving the facility, discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs as well as preferences. The resident's physician will be notified of the resident's request to leave the facility against medical advice. The nurse on duty will provide the resident and/or legal guardian of information regarding the resident's current treatment and medication regimen. Medications will be provided to the resident or the legal representative with physician conversation that harm would ensue without such medications. Any resident or legal representative choosing to discharge or be discharged without the consent of, or an order from the attending physician is expected to sign the AMA form. In the event that resident is signing himself/herself out AMA, his/her legal representative and /or family member will be notified by facility personnel. Resident leaving the facility against medical advice is responsible for their own transportation with the safety of the resident maintained. If resident is unable to physically transfer/discharge self from the facility safely, the facility will notify the resident's representative/POA, and ombudsman. APS (Adult Protective Services) will be notified if the facility feels the AMA discharge setting does not meet the resident's post discharge and appears unsafe. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. R1 no longer resides at the facility. 2. Education will be provided to the IDT team, admissions, Social Service staff and Nurses on proper discharge and transfer using revised policy for Bed hold/discharge transfer policy. Director of Nurses, Assistant Director of Nurses and Psychiatric Rehabilitation Services Director will be responsible for in-service. Initiated [DATE] 3. Elopement risk, unauthorized leave, community survival assessment will be revised by corporate and will be used to provide education to the nursing and social service staff. Initiated [DATE] 4.The following policies were reviewed and revised: -Therapeutic pass -Bed/hold discharge/transfer notice -AMA policy -ALL WILL INCLUDE circumstances under which we would not accept the patient back and any conditions required prior to re-admission. Initiated [DATE] to be completed by [DATE] 5. These policies and revised assessment will be used to provide training to all nursing staff, social service staff and IDT. The training will be provided by corporate staff. All prn, part time and on leave staff will be re-educated prior to next scheduled shift. Staff will acknowledge information via signature. Initiated [DATE] to be completed by [DATE] 6. The Medical Director was notified by the Administrator and reviewed the facility's immediate action plan. He agrees with immediate action plan. Initiated [DATE] 7. QA team met to review policy and procedures changes including the Medical Director. Administrator, Assistant Administrator will conduct audit of discharged residents weekly. To be completed on [DATE] 8. Policy on bed/hold/discharge transfer and therapeutic pass will be sent to each responsible party and each resident who is their own responsible party and acknowledged by signature. Mail will be sent certified. Any returned not signed will have a call placed and will be witnessed by two staff and documented as such. To be completed on [DATE]

Based on interview and record review, the facility failed to accurately assess a resident for an independent outside pass. This failure affected one (R1) of three residents reviewed for resident assessments and resulted in R1 being approved for an independent community pass despite having a documented history of elopement and self-care deficits. R1 did not return to the facility after leaving on pass and was subsequently admitted to the hospital with a diagnosis of schizophrenia, exacerbation of moods and psychotic symptoms. Findings include: R1 is a [AGE] year-old male who was admitted to the facility on [DATE], with past medical history including, but not limited to: bipolar disorder unspecified, moderate intellectual disability, essential primary hypertension, hyperlipidemia, type 2 diabetes mellitus without complications, nicotine dependence, other symptoms and signs involving appearance and behavior, etc. Per record review, facility Minimum Data Set (MDS) assessment dated [DATE], section G (functional) coded R1 as requiring supervision for all ADLs including ambulation on and off unit. Section C (cognition) of the same assessment coded R1 with a BIMs score of 15. On 5/1/23 at 10:38AM V21 (Family Member) said, R1 left the facility before in January improperly dressed without coat and socks on, in the cold. He was originally transferred to this facility because he needed treatment for his mental health and assistance with activities of daily living. V21 said she begged staff not to give R1 a pass to the community because he was likely to leave and not return and he was unable to take care of himself without assistance. When V21 was notified that R1 left on pass and did not return on 3/28/23, she called the facility and asked why staff would give him a pass when R1 already showed that he can't take care of himself. On 5/3/23 at 2:49PM V20 (Family Member) said, R1 never finished high school and has exhibited psychiatric problems since he was a young adult. V20 said, R1 can feed himself and dress himself but he needs help with his other needs such as cueing for maintaining hygiene and taking medications. V20 said that R1 cannot make sound decisions and because of this, she became his representative payee after his grandmother, who was the previous payee, passed away. V20 said that R1 ended up in another nursing facility in (name of city) after being hospitalized at some point when he left this facility. Further review of resident's medical record shows the following progress note documented by V10 (Psychiatric Rehabilitation Services Coordinator/PRSC) on 1/31/2023 at 9:32AM - Resident approached writer (for the seventh time) about getting an independent pass. Writer denied resident request and explained that because he was just readmitted from the hospital that he was ineligible for a pass at this time. Resident stated that he understood. Writer will revisit topic later. Progress note dated 1/31/2023 at 14:30 (2:30PM) states in part: It was brought to writers' attention that resident has an unauthorized exit from the facility. Resident Mother notified facility that resident visited sisters' home and was provided funding to return to facility. Facility aware of resident exit. At this time, a missing person's report has been filed and awaiting Resident return. MD, Administration and Nursing aware of all the above. [sic] Elopement risk assessments dated 1/30/2023 and 2/24/2023 documented that R1 has history of wandering and elopement, has a diagnosis of dementia and/ or mental illness, has reported and documented episodes of elopement and has signs of compromised decisional capacity and substantially impaired judgement and /or physical limitations that would place the resident at risk in the community. assessment dated [DATE] concluded that the resident is at risk to elopement and should be placed on an elopement protocol; the assessment of 2/24/2023 however concluded that R1 is not at risk of elopement at this time. Another elopement assessment initiated by V10 (PRSC) dated 3/23/2023 documented that R1 does not have a history of wandering or elopement, does not have a diagnosis of dementia and/or mental illness, does not have documented episodes of elopement and /or attempts to elope and does not have signs of decisional capacity and substantially impaired judgement that would place him at risk in the community. The same assessment was signed by V4 (Director of Behavioral Health) on 3/29/2023. R1 left the faciity on an independent pass on 3/28/23. On 5/3/2023 at 2:50PM, V10 (PRSC) was asked why the elopement assessment for 3/23/2023 stated that R1 does not have a history of elopement and no documented episodes of elopement as well as not having compromised decisional making capacity, and why the document was signed by another staff the day after the resident left the facility. V10 said, I guess the answer to those questions should have been a yes because R1 has eloped before. Looking at the elopement risk assessment dated [DATE], I initiated the assessment. I don't know why it was signed and locked by V4. I usually create my own documents and sign them so that they are locked. This document may have been looked over by V4 which is why she signed it. When an assessment is open, the information can be changed before it is locked. V10 added, I created the elopement care plan on 2/16/23 for the Plan of Correction for the elopement that happened on 1/31/23. I discontinued the care plan on 2/24/23 because we decided that he could work on getting a community pass. R1 does not any active care plan in place for elopement or exit seeking behavior. 5/1/23 at 2:36PM, V4 (Director of Behavioral Health) said that she signed the elopement assessment initiated on 3/23/2023 by V10 on 3/29/2023 because she noticed that the PRSC who initiated the assessment did not lock it; so, she locked it and signed it. V4 stated that she did not change anything in the assessment and did not look at the resident's history. When asked if it is possible for someone to make an adjustment to as assessment if it is not locked by the person that initiated it, she said, yes. 5/5/23 at 11:23AM, R1 was interviewed over the phone. R1 was alert and oriented but responded slowly, speaking with disorganized thoughts. R1 said, I was on a red pass (independent) and went outside to smoke and kept going. I went to see if I could find another nursing home to go to. I was hoping to transition to an independent facility with a single room and I didn't know that I would be sharing a room with three other people before I got here. When I left, I was gone for about a week. I was hopping trains most of the time. I didn't take any medication from the facility and didn't have any food. Facility progress note dated 3/29/23 at 8:02PM written by V26 (Assistant Director of Nurses/ADON) said that V21 (R1's mother) was called and left a voicemail. Progress note dated 3/30/23 at 2:50PM said that R1's mother called the facility saying she needed to speak with a manager and wanted to know why we gave her son community access so he could run away. On 5/3/23 at 2:00PM, V12 (Facility 2 Representative) said, R1 was admitted to them from a local hospital on 4/18/23, where he had an inpatient psychiatric evaluation from 4/10/23 to 4/18/23. Hospital record dated 4/10/2023 states the following: Patient presents as 37yr year old male previously diagnosed with schizophrenia/schizoaffective disorder presents to the emergency room after exacerbation of mood and psychotic symptoms. A job summary for social services presented by V1 (Administration) states that the primary purpose is to implement the programs of the social services department, to assure that the medically related emotional and social needs of the resident are met/maintained on as individual basis, to safeguard health, safety and welfare of all manner in accordance with facility's established policies and procedures applicable laws and regulations and the directions of your supervisor who include the PRSD, administrator and/or other members of the facility's management to whom such persons report. The responsibilities listed include, but not limited to completing proper documentation upon admission, quarterly, and annually. Documenting the resident's progress on a regular basis, including incidental, monthly, and quarterly notes. Contacting community agencies for the purpose of resident referral.

Based on interview and record review, the facility failed to follow their change of condition policy by not effectively communicating to a resident's physician the extent of the injury related to a fall, including the resident experiencing extreme pain because of a visible leg deformity after a fall. This failure applied to one (R4) of six residents reviewed for quality of care and resulted in R4 not being sent out to the hospital emergently for assessment after a fall and not being provided with any pain medication while experiencing 10/10 pain as a result of the injury. Findings include: R4's face sheet shows R4's past medical history not limited to epilepsy, anxiety, pain in thoracic spine, and personal history of (healed) traumatic fracture. MDS (Minimum Data Set assessment) summary dated 11/28/2022 showed R4 is cognitively intact, requires supervision with activities of daily living and requires setup help only with locomotion and mobility. R4's care plan last revised on 01/18/2023 showed he is at risk for falls. Last documented fall was on 01/05/2023 with injury, left wrist fracture. Reviewed final incident report completed by V1 (Administrator) dated 02/23/2023 that showed R4 had a fall on 02/16/2023. Time of occurrence is documented as n/a and that R4 was transferred to the emergency room for evaluation due to complaint of pain to left leg. X-ray revealed left tibia and fibula fracture. Reviewed R4's nursing progress notes and noted the following: Note dated 2/15/2023 23:27 showed R4 was horse playing with peer, fell and sustained injury to the lower limb above the ankle. Cold compress applied and the Dr. (doctor) notified. Orders received for R4 be sent to the hospital. Note dated 2/16/2023 00:45 showed R4 was picked up by emergency medical services. Note dated 2/16/2023 01:03 showed R4 was taken to a different hospital than previously ordered because he was in so much pain. Note dated 2/16/2023 10:15 showed R4 was being evaluated for diagnosis of left fibula and tibia fractures. On 03/27/2023 at 2:33 PM, R4 said on the night of 02/15/2023 while in R7's room, he was walking towards the nightstand and said his pant leg got caught on the bed frame of R7's bed which caused him to fall to the floor. He then said while trying to free his leg, he heard a cracking sound. R4 said another resident helped him get up off the floor and into a wheelchair then went to the central nurse's station and told an unknown nurse. R4 said the nurse told him his leg is probably broken then called an ambulance service, not 911 like he asked. R4 proceeded to say that he was in excoriating pain and begged multiple times for staff to call 911. R4 said it took about 3.5 hours from the time of fall for the ambulance to pick him up. R4 added that all he received for his pain was a cold pack. Reviewed R4's ambulance transport treatment summary dated 02/16/2023 showed facility notified ambulance service on 02/15/2023 at 11:33 PM and on 02/16/2023 at 12:39 AM, R4 was received by emergency medical staff while sitting in a wheelchair in the hall near room. R4 was observed with extreme left ankle swelling, redness, and general swelling from knees to ankle. R4 reported pain at 10/10. R4 was secured onto a stretcher then left facility enroute to specific hospital ordered by his primary physician. R4 left facility at 12:47 AM. Summary also showed that during transport, R4 started experiencing more pain and could no longer tolerate such a long transport, so R4 was taken to the nearest hospital where upon arrival, R4 could no longer bend leg. Reviewed R4's hospital records dated 02/16/2023 that stated he arrived in the emergency department at 01:16 AM via emergency medical services from the facility post fall. Per his record, R4 stated the incident happened around 10:15 pm and he rated his pain upon arrival at 10/10. R4 was admitted to the hospital with closed fracture of distal tibia, closed fracture of distal fibula, closed fracture of proximal fibula which required surgical intervention. On 03/27/2023 at 2:25 PM, R7 said she and R4 were in her room the night he fell and broke his leg. She said R4 went to run from [her] then tripped and fell to the floor. R7 added that at first, she thought R4 was playing with her until he started complaining of pain to his leg and ankle. R6 then said after about five minutes or so, she looked at R4's leg and saw that it was swollen so she went to get the nurse. R7 said they (doesn't remember names) got him up, told him to lay down, then put ice on his leg. She added that an hour later, R4's leg was swollen even more, and that he was asking to go to the hospital. On 03/29/2023 at 10:15 AM, V17 (Certified Nursing Assistant) said she walked in around 11:00 PM for her shift on the night R4's incident occurred. She said other aides told her that R4 fell on second shift. She said that she could hear R4 yelling out profanities and saying he hit his foot. On 03/29/2023 at 2:44 PM, V18 (Licensed Practical Nurse/LPN) said on 02/15/2023 that she was working second shift on the central unit and saw staff pushing R4 in a wheelchair sometime before 11:00 PM. She said that they were coming from the west wing heading to the east wing, where R4 resided. She then said V15 (Registered Nurse) came to her station and said she (V15) was just told by R4 that he fell in his room. V18 (LPN) told V15 about what she saw previously then headed up front near the double doors with V15. V18 then said she saw R4 sitting in a wheelchair and his leg was swollen. V18 added, I think I called the doctor and told him R4 fell and said he needs to get sent out. She added that V15 gave R4 an ice pack, then she (V18) left the facility and went home. On 03/29/2023 at 3:02 PM, V21 (Licensed Practical Nurse) said around 11:00 PM during change of shift report to V15 (RN), an aide brought R4 to the east side and said he fell . V21 said we asked what happened, R4 said he fell and wanted a pain pill. She then said that she finished giving report to V15 then left to go home. V21 added that she did not assess R4 nor give him any pain medication. On 03/27/2023 at 3:27 PM, V15 (Registered Nurse) said that she was just coming in, that it was after 11PM. She then said some aides brought R4 in a wheelchair to her while she was at the east nurse's station. V15 added that staff and R4 told her to call 911. She continued to state that R4 said he fell in his room. When V15 asked how R4 fell , he refused to tell. V15 then said she saw his right leg was deformed looking and swollen, then took resident in the wheelchair to the central nurse station where she and another nurse assessed R4 and placed a cold compress on his leg. V15 said she next contacted V9 (Director of Nursing/DON) then called the doctor who said transfer resident to his hospital. V15 then said she called the ambulance service and was told it would take approximately two hours. When asked why 911 wasn't called given the condition of R4's leg, V15 said, I don't know what to say, I was new and didn't call 911 because I had already called the ambulance service. V15 added that she did not administer any pain medication to R4 because she was told he already received some. On 03/27/2023 at 3:43PM, V2 (Assistant Director of Nursing/ADON) said after a fall occurs, her expectations are for the nurse to do an immediate risk management assessment immediately after. She then said when there's visible and obvious injury, nursing staff should call 911 immediately, and not the ambulance service. On 03/28/2023 from 4:14 PM - 4:29 PM, V16 (Medical Doctor) said regarding R4's incident on 02/15/2023 that the facility contacted him about the fall and said, it doesn't look good. V16 told the facility to send R4 to the hospital then added that the level of emergency determines whether a resident is sent out 911. V16 added that what a nurse tells him is subjective so if the extent of R4's injury had been described in more detail and if his complaints of extreme pain were communicated to him, he would have ordered 911 be called and for pain medication to be administered immediately. V16 then said at this time, knowing R4's reported pain level at the time of incident, the nurse misjudged the timeframe R4 had to wait for the ambulance and the nurse should have understood the significance of the resident having to wait two plus hours for the ambulance to arrive. Reviewed R4's physician's orders that showed transfer resident to hospital emergency room for medical evaluation and treatment (ordered 02/15/2023) and acetaminophen tablet give 2 - 325 milligram tablets every 6 hours as needed for pain (ordered 09/02/2022). Reviewed R4's medication administration record for February 2023 that showed acetaminophen was not administered to him on 02/15 or 02/16/2023. Reviewed condition change policy last revised 11/13/2018 that showed the purpose is to ensure that medical problems are communicated to the attending physician and responsible parties in a timely, efficient, and effective manner. The policy also showed that the facility will consult with the resident's physician or authorized designee when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly. A need to alter treatment significantly includes to commence a new form of treatment to deal with a problem.

Based on interview and record review, the facility failed to follow their policy and procedure for pain management by not informing the resident's physician that the resident was experiencing 10/10 pain after a fall and failed to administer any pain medication after the resident verbalized being in pain. This failure applied to one (R4) of six residents reviewed for pain management and resulted in R4 experiencing severe pain (10/10) without any interventions to address R4's pain for over two hours, while waiting for hospital transport. Findings include: R4's face sheet shows R4's past medical history not limited to epilepsy, anxiety, pain in thoracic spine, and personal history of (healed) traumatic fracture. Minimum Data Set (MDS) summary dated 11/28/2022 showed R4 is cognitively intact, requires supervision with activities of daily living and requires setup help only with locomotion and mobility. Facility submitted final incident report completed by V1 (Administrator) dated 02/23/2023 that showed R4 had a fall on 02/16/2023. Time of occurrence is documented as n/a and that R4 was transferred to the emergency room for evaluation due to complaint of pain to left leg. X-ray revealed left tibia and fibula fracture. Documented actions taken by facility included pain management offered. On 03/27/2023 at 2:33 PM, R4 said on the night of 02/15/2023 while in R7's room, he was walking towards the nightstand and said his pant leg got caught on the bed frame of R7's bed which caused him to fall to the floor. He then said while trying to free his leg, he heard a cracking sound. R4 said another resident helped him get up off the floor and into a wheelchair then went to the central nurse's station and told an unknown nurse. R4 said the nurse told him his leg is probably broken then called an ambulance service, not 911 like he asked. R4 proceeded to say that he was in excoriating pain and begged multiple times for staff to call 911. R4 said it took about 3.5 hours from the time of fall for the ambulance to pick him up. R4 added that all he received for his pain was a cold pack. R4's care plan showed he is at risk for pain related to chronic bilateral thoracic back pain, last revised on 12/05/2022. Interventions showed to monitor/record/report to nurse resident complaints of pain or requests for pain treatment and notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Date Initiated: 09/02/2022. Reviewed R4's physician's orders that showed transfer resident to hospital emergency room for medical evaluation and treatment (ordered 02/15/2023) and acetaminophen tablet give 2 - 325 milligram tablets every 6 hours as needed for pain (ordered 09/02/2022). Reviewed R4's medication administration record for February 2023 that showed acetaminophen was not administered to him on 02/15 or 02/16/2023. On 03/27/2023 at 3:27 PM, V15 (Registered Nurse) said that R4 informed her that he fell in his room. She added that R4's leg was deformed looking and swollen so she placed a cold compress on his leg. V15 added that she did not administer any pain medication to R4 because she was told he already received some. On 03/29/2023 at 10:15 AM, V17 (Certified Nursing Assistant) said she walked in around 11:00 PM for her shift on the night R4's incident occurred. V17 then said other aides told her that R4 fell on second shift, then she could hear R4 yelling out profanities and saying he hit his foot. On 03/29/2023 at 3:02 PM, V21 (Licensed Practical Nurse) said around 11:00 PM during change of shift report to V15 (RN), R4 said he fell and wanted a pain pill. She then said that she finished giving report to V15 then left to go home. V21 added that she did not assess R4 nor give him any pain medication. Reviewed R4's ambulance transport treatment summary dated 02/16/2023 at 12:39 AM that showed R4 was received by emergency medical staff while sitting in a wheelchair in the hall near room. R4 was observed with extreme left ankle swelling, redness, and general swelling from knees to ankle. R4 reported pain at 10/10. Summary also showed that during transport, R4 started experiencing more pain and could no longer tolerate such a long transport so R4 was taken to the nearest hospital. Reviewed R4's hospital records dated 02/16/2023 that stated he arrived in the emergency department at 01:16 AM via emergency medical services from the facility post fall. Per his record, R4 stated the incident happened around 10:15 pm and he rated his pain upon arrival at 10/10. R4 was admitted to the hospital with closed fracture of distal tibia, closed fracture of distal fibula, closed fracture of proximal fibula which required surgical intervention. On 03/28/2023 from 4:14 PM - 4:29 PM, V16 (Medical Doctor) said regarding R4's incident on 02/15/2023 that the facility contacted him about the fall and said, it doesn't look good. V16 added that if the extent of R4's injury had been described in more detail and his complaints of extreme pain had also been communicated to him, he would have ordered 911 be called and for pain medication to be administered immediately. V16 then said, at this time, knowing R4's reported pain level at the time of incident, the nurse misjudged the timeframe R4 had to wait for the ambulance and the nurse should have understood the significance of the resident having to wait two plus hours for the ambulance to arrive. Reviewed pain management program policy last revised 07/06/2018 that showed the purpose is to establish a program which can effectively manage pain to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The policy also showed the goal is to promote resident comfort, to preserve and enhance resident dignity and facilitate life involvement through an effective pain management program. The pain medication used shall be appropriate for the population served with standards to initiate a pain assessment protocol when a change of condition occurs that requires pain control. The policy added that a resident's physician will be notified of the resident's complaints of pain not relieved by comfort measures, including pain medications.

There are multiple deficient practice statements. I of II. Based on interview and record review, the facility failed follow their abuse policy and prevent a vulnerable resident from being taking advantage of sexually by other residents. This affected 3 of 3 residents R15, R16 and R17 reviewed for manipulation and sexual abuse. This failure resulted in R16 and R17 manipulating R15 into performing sexual acts for a trade of money and food. The Immediate Jeopardy began on 2/1/23 when V35 (Emergency Medical Technician/EMT) witnessed R15 having a sexual encounter with R17 at the facility. V6 (Administrator) was informed of the Immediate Jeopardy on 2/21/23 at 12:18 pm. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 2/23/23. Although the immediacy was removed, the noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. Findings Include: 1.R15 has the diagnosis of Schizophrenia. Brief interview for mental status dated 11/21/22 documents a score of ten which indicates moderately cognitively impaired. Care plan dated initiated (3/31/22) documents: I am at potential risk for abuse/neglect. On 2/2/23 at 1:02pm, R15 was assessed to be alert to self with a delusion thought process. R15 was unable to report the month, date, year, president's name, name of the facility, or type facility R15 resided. R15 reported she was the boss of the building. R15 said, I can fire/terminated you (state employee). Don't come in my room. Don't touch me. This is my room, and I don't have any room mates. R15 was not being touched by anyone. R17 observed standing outside of R15's doorway. R17 said, R15 is my lady friend. R15 was asked, who R17 was and what their relationship to each other was. R15 said, I don't know R17. On 2/2/23 at 1:10pm, R17 who was assessed to be alert to person, place, and time, said, R15 is my lady friend, and we have sex. R15 doesn't know any better. R15 is not right in the head. I can have sex with R15 for food or a few dollars ($2.00 or $3.00). R15 is always hungry. R15 doesn't have any money. I (R17) had sex with R15 for juice and a cracker. I (R17) did not have sex with R15 yesterday. On 2/23/23 at 11:40am R17 said the young ladies at the facility like older guys with money. R17 said he's one of the older guys that have money at the facility and the ladies know that. R17 said a lot of the women at the facility be hungry and they will have sex for chips, cigarettes, pop, money. R17 said it's one young lady, she's fine, she's pretty and if she approaches him for money, he's going to give it to her so that he can have sex with her. R17 said he will not turn her down, she's pretty. R17 did not give surveyor the name of the female that he was talking about. On 2/2/23 at 1:46pm, V34 (Mental Health Tech/MHT) said, I saw R15 giving R17 oral sex. I wasn't aware R15 was sexually active. R15's orientation comes and goes. R15 can keep a conversation at times and other times R15 is not able to engage in a tangential speech/thought process. On 2/2/23 at 3:05pm, V22 (Psychosocial Rehab Service Coordinator/PRSC) said, R15 does not have a capacity to consent for sex. The assessment was not done because R15 is not sexually active. We only complete that assessment if residents are participating is sexually activities. On 2/2/23 at 3:58pm, R16 said R15 asked me for five dollars. I gave R15 the money. It is expected that R15 performs a sexual act for the money. I have never had sex with R15 for free. R15 performed oral sex on me. On 2/23/23 at 2:15pm R16 said R15 approached him and said, You got money? R16 said when R15 ask for money, it's expected that the money is payment for sex. R16 said R15 does not say that the money is for sex. R15 has never said she will have sex with him for exchange of money. R16 said sex is expected. R16 said a lot of the women at the facility ask for money and it's understood that the money is an exchange for sex. R16 said it's like a prostitution ring at the facility. R16 said the chicks at the facility are hungry and they are needing money. On 2/7/23 at 8:56am V35 (Emergency Medical Technician/EMT) said, I entered R15's room after knocking. R15 and R17 were both naked from the waist down. R15 attempted to cover her vaginal area. R15 was unable to answered orientation questions related to date, month, year and unable to report R17's name. R15 started yelling, stop touching me, (R15 was not being touched) I'm a cop and I need help. R15 was alert and orient to self, had a psychiatric episode, and refused/failed to yield to verbal redirection. I could not de-escalate R15. I am normal good at de-escalation. On 2/7/23 at 10:05am, V36 (Psychotropic Nurse) said, I check orientation by asking basic questions that the average person with intact cognition will be able to answer. I checked R15 orientation on 2/6/23. I asked R15 questions about, the current date, year and who is the president was. R15 can recite the date if a calendar is around. R15 was unable to recite the date and who the president was. R15 knew where she was, able to tell me she was going to lunch, and walked away. Care plan dated initiated 6/29/2018 documents: I (R15) have a diagnosis and history of severe mental illness (SMI) as manifested by delusions-poor ability to reason. Care plan dated initiated (10/11/21) documents: I (R15) am able to exercise the right to engage in sexual/intimate relationship. I have received counseling, as appropriate regarding sexual practice and behavior, boundaries, respect for roommates, healthy relationship and only engaging in this type of relationship with consenting party. I will exercise safety and appropriateness when choosing to partake in sexual activity. R15's capacity for sexual consent dated 2/2/23 documents (Resident's awareness of relationship) Is the resident aware of who is initiating sexual contact - yes. (Resident's awareness of potential risk) documents: C2- can the resident described how (he/she) will react when the relationship ends- no. Conclusion: Resident (R15) is aware of what sexual activities she engages in. Sexuality- Capacity to Consent Determination Policy dated 1-7-19, documents: Purpose: To establish criteria for determining the capacity to consent when resident to resident sexual activities occur. Capacity and Consent: Residents without the capacity to consent to sexual activity may not engage in sexual activity. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. Abuse policy dated 11/28/16 documents: The facility affirms the right of our residents to be free from abuse, neglect, or exploitation. Sexual abuse includes but is not limited to sexual harassment, sexual coercion or sexual assault including non-consensual or non-competent to consent sexual activity. Generally. Sexual contact is nonconsensual if the resident either appears to want the contact to occur but lacks the cognitive ability to consent. A resident's apparent consent to engage in sexual activity is not valid if it obtained through intimidation, coercion, or fear, whether it is expressed by the resident or suspected by staff. The surveyor confirmed via observation, interview and record review the following removal plan was implemented by the facility: Aperion Care Chicago Heights Abatement Plan, action taken: 1. R15, R16, and R17 has an updated capacity to consent for sex assessment. This was completed as of 2/2/23. R15 has not displayed any emotional distress and remains at baseline for mood and behavior. R15, R16, and R17's capacity to consent were reassessed and are determined that they have the capacity to consent to sexual relationships. 2/21/23 completed. 2. Residents that have been identified being at risk from sexual exploitation have had their care plans updated to reflect interventions to prevent abuse. List updated on 02/22/23. List of identified residents was provided to survey team. 2/22/23 completed. 3. Residents that have been identified for being at risk from sexual exploitation were interviewed if they have been taken advantaged of or manipulated to perform sexual acts. None of them responded yes. 2/21/23 completed. 4. Residents that have been identified for being at risk from sexual exploitation will be placed on 1:1 education with the assigned PRSC to meet weekly and discuss how to protect themselves from being sexually exploited, coerced, or manipulated. 2/21/23 completed. 5. Residents that have been identified for being at risk from sexual exploitation will be assigned to rooms that are in immediate view of nursing station for more frequent monitoring. 6. R15 is placed on 1 on 1 counseling with PRSC. R15 is placed on money management program. R16 and R17 is placed on 1 on 1 counseling with PRSC. R16 and R17 will sign behavior contract for sexual solicitation and bartering. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. 2/22/23 and ongoing. 7. Staff will be in-serviced/trained on how to recognize sexual abuse and sexual exploitation and the facility's abuse protocol to prevent it from happening to other residents. The education will include Abuse prevention reporting policy specifically the definition of abuse, sexual abuse, sexual exploitation, sexual assault, rape and internal reporting requirements and identification of allegation and protection of residents. This training will include reporting of any observations or reports of exchange of money by residents and reporting any observations/reports of sex acts. Staff competency will be determined through a scenario based post- test and signature. All staff will be re-educated prior to next scheduled shift including staff that are on leave and are on vacation. Administrator and Assistant administrator are conducting the training. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. No revision of the current abuse policy has occurred. The noncompliance was a failure to follow current policy. 2/23/23 completed. 40066 II of II. Based on interviews and records reviewed the facility failed to follow their abuse prevention policy to prevent resident to resident physical assault. The facility also failed to ensure facility staff utilized safe crisis prevention intervention techniques during physical interactions with residents. This affected 6 of 8 residents (R5, R6, R8, R9, R10, and R14) reviewed for physical abuse prevention. Findings include: 1. R8's diagnosis includes but not limited to Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Schizophrenia, Type 2 Diabetes, Atherosclerotic Heart Disease, Major Depressive Disorder, and Dementia. R8 was admitted to the facility on [DATE]. R8 is moderately cognitively impaired. On 2/16/23 at 1:24PM V29 (Certified Nursing Assistant/CNA), said on 1/25/23 she was in the dining room when she heard another CNA say R8 has a black eye. V29 said she then went and reported the incident. V29 said V31 (Restorative CNA) spotted it first. V29 said I reported to V6 (Administrator). V29 said then V3 (Registered Nurse) and I went to speak to R8. V29 said V3 entered R8's room, but because R8 does not like V29 she waited in the hallway. V29 said she heard R8 say one of the staff came in the room and jumped her. V29 said R8 said a young lady hit her in the mouth and in the face. V29 said she heard R12 (R8's roommate) say she saw the person. On 2/16/23 at 3:24PM V21 (Assistant Administrator) said she was in the office when V29 reported R8's black eye to V6. V21 said V29 said she saw R8 with a black eye. V21 said I sent the initial report to IDPH and then went to speak with R8. V21 said I tried to speak with R8 a few times all R8 said was some b----- had hit her. V21 said R8 said someone with braids. V21 said she spoke with R8 about 15 minutes after V29 had initially reported. V21 said I thought possibly the roommate R14 had hit R8. V21 said V29 said R14 had done it. V21 said I did not speak with V31 about this incident. V21 said on the first day of the investigation I got interviews from all staff in the facility. The surveyor asked V21 if staff had reported to her that R8 said a lady hit her. V21 said not that I am aware of. V21 said R12 had initially said someone with braids came in and struck R8. V21 said R8 was the victim in this incident. V21 said residents should not be putting hands on each other. On 2/17/23 at 10:38AM V31 (Restorative CNA) said when R8 walked into the dining room on 1/25/23, I saw R8 had a black eye. V31 said she heard R8 say She got her a** whooped. The surveyor attempted to interview R8 twice during the survey. R8 did not cooperate and cursed at the surveyor, both times. The surveyor attempted to interview R12 about the incident on 1/25/23, R12 stated I don't have a statement. R8's Abuse/Neglect Screening dated 12/8/22 notes resident triggers a potential high risk for abuse. R8's Abuse/Neglect Screening dated 1/25/23 notes R8's roommates reported I was struck in the face by an unknown person. R8's Risk Management documents R8 said a peer got aggressive with her. Progress notes dated 1/25/23 written by V5 (Director of Nurse/DON) documents it was reported that R8 was noted with discoloration to her right eye. Preliminary 24-hour Abuse Investigation Report dated 1/25/23 states R12 (R8's roommate) reported to V21 (Assistant Administrator) that R8 was struck in the eye by someone with braids. Review of R8's care plan revised on 6/18/22 does not include that R8 has been struck by another resident. Additionally, the care plan denotes I am at not current risk for abuse. The last intervention update is dated 7/12/22. 2. R14's diagnosis includes but not limited to Schizophrenia, Asthma, Diabetes, Anemia, and Delusional Disorder. R14's census list notes she was a roommate with R8 from 5/9/22 until 2/1/23. R14 had a room change on 2/1/23. R14's last Abuse/Neglect screening dated 12/2/22 notes she had an altercation with another resident. R14's Aggressive Behavior assessment dated [DATE] documents R14 has a history of recent episode of aggressive/agitated behavior and/or noncompliance with medications, treatment, regiment, and resisting care. R14 has a history of abuse/neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior. R14's care plan related to abuse was last updated on 12/2/22. No intervention noted following the 1/25/23 incident with R8. 3. R6's diagnosis includes but not limited to Schizoaffective Disorder, Psychotic Disorder, Physiological Condition, Schizophrenia, Adult Failure to Thrive, Delusional Disorder, Bipolar Disorder, Major Depressive Disorder, and Paranoid Personality Disorder. On 2/16/23 at 11:43AM V5 (Director of Nursing/DON) said I think R6 had an altercation with R8 on 1/29/23. On 2/16/23 at 12:42PM V28 (Licensed Practical Nurse/LPN) said R6 slapped R8. R6's progress notes denote It was reported to the writer that resident was aggressive towards peer in the hallway. R6's Aggressive Behavior assessment dated [DATE] documents R6 noted to be in a physical altercation where she was the aggressor. No other assessments after this date were noted. R6's Behavior/Mood Charting dated 1/29/23 denotes R6 was Physically aggressive and wandered. R6's Petition for Involuntary/Judicial admitted d 1/30/23 denotes Resident physical aggressive towards a peer without provocation. R6's care plan denotes she has potential to be verbally aggressive towards staff with 2 incidents in September 2022. R6's care plan denotes an incident of responding to internal stimuli and became physically aggressive towards a peer. Care plan initiated date listed as 1/6/23. R8's risk management record date of incident 1/29/23 notes R8 said peer got aggressive with her in the hallway. Per the surveyors record review this is the second incident for R8 with an injury observed on 1/25/23 and this incident dated 1/29/23. 38796 4. Facility final report to the department dated 2/1/2023 denotes in part date of incident 1/27/23, physical abuse, yes for injuries, no medical attention, minor scratches to face, R5 is person accused. Summary of person reporting incident R10, she just came in my room and hit me in my face. V3 (Nurse) reports R10 came up to her with scratches on his face and told V3 that R5 scratched him. R5 then told me that he R10 stole my tablet, and I (V3) explained to her that he (R10) did not steal her tablet because that is his (R10). R10 has history of having poor boundaries and physically aggression with peers. R5 has history of being verbally and physically aggressive with peers. While R10 was in his room after dinner, R5 went into his room and struck him in his face, reacting to internal stimuli, thinking he had stolen her tablet. This resulted in small scratches to face. First aide was administered. R10 received full body assessment. Resident remains at his baseline, with no emotional stress verbalized or observed. R10 scores a 15 on the BIMS assessment. R5 scores a 15 on the BIMS assessments. On 2/16/23 at 9:57am R5 said R10 had her tablet, the facility was aware of it. R5 said she told V6 (Administrator) about her missing tablet and that R10 had it. R5 said the first time the altercation is when she tripped R10 and attacked R10 while he was on the floor. R5 said she then went into R10's room and busted up R10's television. R5 said R10 had her tablet and that's why she did that. R5 said the second time she went into R10's room and had a physical altercation with R10 resulting in R10's face being scratched. R5 said she did this because R10 had her tablet. R5 said V22 (Psychiatric Rehabilitation Services Coordinator/PRSC) told her (R5) that she has a new tablet, but they must keep it in the office because the tablet was locked due to putting the password in wrong. R5 said she did not make a password for the tablet. R5 said she did not see the tablet. On 2/14/23 at 1:35p.m V21 (Assistant Administrator) said R5 was having delusions that R10 stole her tablet and went into R10's room and struck R10 in the face. V21 said R5 was recently in the hospital and her belongs were in a closet and the facility could not access her belongings at that time. V21 said she does not know if anyone spoke to R5 about her belongings and ensured her that her things were not stolen, that the facility could not get to them at that time, and that R10 did not steal her tablet. V21 said R5 was having delusion prior to striking R10. V21 said the facility did not substantiate abuse but did substantiate the incident occurred. V21 said R5 struck R10 first. R5's progress notes dated 1/12/23 denotes in-part resident noted increasingly delusional today. Reported to writer that she had a baby yesterday. She then broke a peer's television due to believing he had her tablet. MD (Medical Doctor) called, and the order was received to transfer resident to hospital. Ambulance service called with eta (expected time of arrival) of 45 minutes. R5's progress notes dated 1/12/23 Resident had a delusion that another resident stole her tablet, which resulted in a physical altercation. R5's progress notes dated 1/27/23 denotes in-part resident went to another resident room and hit him in the face, asked why she stated that peer stole her tablet MD (Medical Doctor), DON (Director of Nursing) aware. No injury at this time. Denies pain and discomfort. Will continue to monitor. Review of R5's inventory sheet dated 7/16/2021, it is denoted that R5, in fact does own a tablet while a resident of the facility. R10's progress notes dated 1/12/23 denotes in-part writer met with resident after an altercation occurred with peer due to her delusional. Writer counseled resident on coming to staff about concerns instead of engaging in altercation with peers. Resident stated that he still felt safe and wants to remain in facility until resident moves into his apartment. Staff will continue to monitor. R10's progress notes dated 1/27/23 denotes in-part resident had physical altercation with female peer in his room. When asked what happened, resident stated, peer came to my room and hit me in the face Female peer accused him of stealing tablet from her room, both were separated and redirected to their room. Nursing assessment revealed bruises in his face and neck, first aid rendered. MD (Medical Doctor), DON, brother notified, will continue monitor. During this survey it was concluded that R10 was the target of R5 physical aggression related to R5 believing that R10 had her tablet. The facility failed to present an initial concern form with resolution for R5 tablet from 1/12/23. R5 returned to the facility on [DATE] (after hospital stay for physical aggression). R5 continue to have concerns for her missing tablet on 1/27/23 prior to R5 physically assaulting R10, thinking R10 had her missing tablet. Facility policy titled abuse prevention and reporting with last revision date of 10/24/2022 denotes in-part this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefor prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatments of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatments of residents. This will be done by establishing an environment that promotes residents' sensitivity, residents' security and prevent mistreatment, identifying occurrences and patterns of potential mistreatments. Abuse means any physical or mental injury, or sexual assault inflicted upon a resident other than by accidental means. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful, in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. 5. R9's MDS dated [DATE], denotes R9 BIMS is 15. On 2/16/23 at 10:06am V26 (Mental Health Tech/MHT) said he worked on 12/23/22 on the 11:00pm to 7:00am shift. V26 said he did not refuse R9 to call the police. V26 said R9 was heard yelling at R13, about a cigarette, and R9 flipped over R13's table in his room. V26 said R9 did not hit R13. V26 said R9 was then redirected from R13's room to her room. R9 began throwing things in her room. R9 was standing in her doorway. V26 said R9 was saying You can't keep me in here. I didn't do anything. You can't trap me in here. I'm going to call the police. V26 said R9 start hitting him and scratched his face. V26 said he used CPI technique to restrain R9 from hitting him. V26 demonstrated that he held R9 by the wrist to stop her from hitting him, then he held R9 down on the bed and then brought R9 to the floor and continued to hold her down by holding her wrist. V26 said this was to prevent R9 from hitting him. V26 explained CPI is nonviolent techniques used to subdue a combative, aggressive resident. V26 said when a female staff arrived, he asked her to stay with R9 until she calmed down. V26 said once R9 calmed down he told the aide to let R9 up. (V26 does not know who the female CNA was) V26 said he called a 800 number and he reported the situation, and he was sent home for 2 days pending investigation. V26 said the police did come to the facility, but he does not have any information and he did not talk to the police. V26 said he doesn't know if a police report was filed, he left the facility pending investigation. V26 said the nurse did come to check R9 out, but he does not know who the nurse was. V26 said on 2/9/23 around 7:20-7:25am (after smoke break), R9 was having behaviors on the east wing. V26 said R9 asked the nurse for her meds or something and she became verbally aggressive and R9 was saying get the f away from me. V26 said the nurse told R9 to get water from the central nurse station (V26 said that's where R9 nurse is). V26 said when he responded to the code yellow (behavior) he observed R9 flaring her hands back and forth and yelling. V26 said he asked R9 to go to her room, R9 didn't. V26 said that when he and V37 (MHT) staff held R9 by the arms to escort her from that area, and R9 swung at V37. V26 said R9 stumbled and fell , R9's pants fell . R9 threw her pants. (V26 said this happen in the room next to the nurse station on east unit). V26 said they stood R9 up and R9 scratched his face. The nurse gave R9 a PRN (as needed medication). R9 was escorted to her room after that. V26 said there were no behaviors after that and R9 went to the hospital. V26 said he was not sent to home after that. On 2/16/23 at 12:41pm R9 is observed to be alert, and orient to person, place, time, and situation. R9 said around Christmas Eve her and R13 got into an altercation when she asked him for a cigarette. R9 said R13 threw a chair at her, but it did not hit her. R9 said she did not hit R13 either, it was a verbal altercation. R9 said she was escorted to her room by V26 (Mental Health Tech/MHT), and that's when V26 would not let her out her room. R9 demonstrated that V26 stood in doorway of her room, with his arms and legs spread out (blocking doorway). V9 said V26 also was trying to restrain her by holding her arms and hold her down to prevent her from leaving her room. R9 demonstrated that V26 was holding her by the wrist. R9 said V26 also hit her in the face after restraining her to the floor. R9 said she was trying to get out the room when V26 was blocking the doorway. R9 said at some point V26 got off her and the aide came in the room with her (R9). R9 said the police did arrive and spoke to her, and the police said she could stay at the facility. R9 said V26 should not be holding her by the wrist like that and V26 should not hit her in the face on 12/23/22. R9 said the facility don't listen to her or other residents when they report abuse to them and they're not going to do anything to V26. R9 said a man should not be handling a female like that. Facility final report to the department dated 2/11/23 denotes in-part R9's name, date of incident 2/9/23, date incident reported 2/10/23. R9 stated On December 25,2022, V26 did not allow me to contact the police after I was physically assaulted by another resident. V26 then began tussling with me while preventing to leave my room. Then on 2/9/23, V26 was verbally aggressive with me and hit me in my face. R9's document from the hospital social worker dated 2/10/23 denotes in-part R9 endorsed that a staff member named V26 has been physically abusive towards her during her stay at Aperion Care, with the first instance of abuse taking place on 12/25/22 in which R9 stated that V26 did not let allow her to contact the police after she was physically assaulted by another resident at Aperion Care and V26 began tussling with her while simultaneously preventing her from leaving her room. R9 endorsed that the second instance of abuse took place right before her admission at (hospital name listed), and she stated V26 was verbally aggressive towards her and physically assaulted her by hitting her in the face. On 2/14/23 at 1:27p.m V6 (Administrator) said the facility does not substantiate abuse and the facility waits for the department to investigate and substantiate the facilities abuse allegations. On 2/16/23 at 2:12pm V6 (Administrator) said he is not aware of any incidents with R9 and V26 on 12/23/22. V6 said he is not aware that V26 was sent home pending investigation for incident on 12/23/22. V6 said he is not aware of V26 sustaining and scratches to the face after attempting to redirect R9. Review of facility initial report to the department denotes V6 was CC in the email notification confirmation to the department on 2/10/23 at 4:34pm. Initial report to the department denotes R9 reported to the hospital that V26 (MHT), refused to let her call the police when another resident physically assaulted her. She also alleged that on 2/9/23, V26 struck her in the face and was verbally aggressive towards her. R9 did not report these allegations until she was at the hospital. MD (Medical Doctor), Ombudsman and (police department) notified. Full report to follow. On 2/16/23 at 2:37pm V21 (Assistant Administrator) said the hospital contact her and informed her that R9 reported being physically assaulted by V26 once on Christmas and on 2/9/23. V21 said she conducted the investigation of R9 allegation. V21 said the hospital sent her the email statement of R9. V21 said she did not ask V26 about the allegation of tussling with R9 because she did not know what that word meant. V21 said she did not look up the definition of tussling either. V21 said R9 has delusions. V21 said she watched the video recording of the incident with R9 and V26 on 2/9/23 and she observed R9 swing her arms out and kicking at V26. V21 was asked is it reasonable to believe that R9 did not want V26 to touch her since there was an altercation on 12/23/22. V21 said no, R9 has delusions. V21 was made aware that V26 alleged he used CPI on R9 and R9 scratched him in the face. V21 was made aware that R9 said V26 was physically aggressive with her and was holding her by the wrist. V21 said R9 has delusions, and she's not aware of anything happening on 12/23/22. V21 was made aware that V26 said he had to use CPI on R9 by hold her by the wrist. Webster dictionary defines, tussling/ tussled means engage in vigorous struggle. On 2/17/223 at 10:25am V5 (Director of Nursing) was asked if she was aware of the incident with R9 and V26 that occurred on 12/23/22. V5 said she was not aware of anything happening between V26 and R9. V5 was made aware that V26 alleged he used CPI on R9 and R9 scratched him in the face on 12/23/22. V5 was made aware that R9 said V26 was physically aggressive with her and was holding her by the wrist. V5 said R9 has delusions, and she's not aware of anything happening on 12/23/22. V5 was made aware that V26 said he had to use CPI on R9 by hold her by the wrist. V5 was asked is it reasonable to believe that R9 did not want V26 to touch her since there was an altercation on 12/23/22. V5 said yes, it's reasonable but R9 has delusions. V5 said she was aware of the incident when V26 used CPI on R9 on 2/9/23 and that entire situation arises due to R9 requesting water from the nurse and the nurse did not give R9 water. V5 was made aware that V26 alleged he used CPI on R9 and R9 scratched him in the face. V5 was made aware that R9 said V26 was physically aggressive with her and was holding her by the wrist. V5 said R9 has delusions, and she's not aware of anything happening on 12/23/22. During this survey, the facility failed to provide an incident report for R9 and V26 on 12/23/2022, and incident report for 2/9/23 when V26 used CPI on R9. The review of V26's timecard reveals V26 was on duty on 12/23/22 from 11:12pm until 12:32am. V26 employees report of injury dated 12/23/22 denotes in-part V26 was trying to stop a resident (R9) from attacking another resident when she punched him in the face and scratched him in the neck, under the left eye and above the nose. On 2/16/23 at 10:06 a.m.V26 denied that R9 had physical co [TRUNCATED]

Based on interviews and records reviewed the facility failed to supervise and monitor R3 during outdoor activity. This failure resulted in R3 leaving the facility while facility staff were playing basketball. The facility also failed to determine the pass privilege policy for R4. This failure resulted in the facility staff opening the door and allowing R4 that was assessed to be an elopement risk to leave the facility without checking the elopement book or verifying R4's pass privilege. The Immediate Jeopardy began on 1/31/23 when staff used the door code to allow R4 to leave the facility without checking that R4 was on elopement protocol and did not have pass privileges. V6 (Administrator) was notified of the Immediate Jeopardy on 2/16/23 at 12:15 pm. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 2/22/23 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: 1.R3 has cognitive impairment. R3's diagnosis include, but are not limited to Schizoaffective Disorder, Bipolar, Suicidal Ideations, Patient's other non-compliance with Medication Regimen, Asthma, Cocaine Abuse, Depressive Disorder with Psychotic Symptoms, Auditory Hallucinations, and Dorsalgia. R3 admitted to the facility on [DATE] following a psychiatric hospitalization . R3's Notice of PASRR (Pre-Admission Screening and Resident Review) Level II dated 12/21/22 states you came to hospital psychiatric unit on 12/13/22 as you were having increased mental health symptoms with thoughts to end your life by jumping in front of a car. When you are not at the hospital, you do not have a place to live. Important for a provider to know (in part) you need help from others to make safe decisions. You believe things to be true that others don't find to be true. You have a history of Cocaine abuse; you tested positive for Cocaine when you got to the hospital. R3's PASRR Grouping You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. That diagnosis is A serious mental health condition. R3's smoking safety risk assessment dated [DATE] states R3 requires supervision only (no assistance) with smoking. This is the only smoking assessment in R3's record. Elopement risk assessment dated [DATE] denotes R3 does not have dementia and/or severe mental illness. (R3 has Schizoaffective disorder, Bipolar Type, Suicidal Ideations, and Major Depressive Disorder.) This assessment denotes R3 is not at risk for elopement. Community survival skills dated 12/29/23 denotes R3 does not appear to be capable of unsupervised outside pass privileges at this time. R3's Cognitive assessment dated [DATE] notes R3 has a score of 5, severely impaired. R3's Functional Status assessment dated [DATE] notes R3 requires supervision for bed mobility transfers and walking in the room. R3's care plan initiated on 1/4/23 denotes a history of severe mental illness (Schizoaffective) as manifested by: Delusions persecutory, delusions - paranoia, delusions - poor ability to reason, hallucinations -auditory, need for ongoing psychoactive medications. R3's care plan denotes he wishes to discharge to another facility and has a history of substance abuse, and R3 is a smoker. R3's orders do not state a pass privilege. R3's progress notes for 2/5/23-2/8/23 read eloped. On 2/11/23 at 11:38AM V3 (Registered Nurse) said R3 came in homeless. He had fingers and toes amputated in the past, but not recently. V3 said R3 would occasionally ask if I could give him a ride. V3 said she would ask him to where, but he was unable to give an address, somewhere on the northside. V3 said R3 was always sleeping. He was cooperative. He eats and then go back to bed. V3 said R3 walked stable. V3 said I was told that R3 eloped and I saw in the computer. V3 said the CNAs (Certified Nurse Assistants) stated, He ran out and He eloped. V3 said the CNAs stated they don't know how he got out. On 2/11/23 at 11:53AM V9 (Certified Nursing Assistant/CNA), said R3 would ask Can you call someone?. V9 said I don't know who he wanted to call so I would tell him to tell the nurse. V9 said R3 can walk and has a normal pace. V9 said R3 is not here today. I don't know where he is. I have not seen him. V9 said I asked my nurse (V3) where R3 was and V9 stated She said he eloped. V9 said she is expected to do a head count 3 times a day at 7:00AM, 10:00AM, and at 2:00PM. On 2/11/23 at 12:24PM V13 (CNA) said after 5:00PM we started looking for R3. V13 said we found out R3 was not there. V13 said we called a code pink and started looking. V13 said I was not assigned to R3 that day (2/5/23). On 2/11/23 at 12:32PM V11 (Licensed Practical Nurse) said on 2/5/23 V14 (CNA) reported he could not find R3. V11 said I went to go look for R3 and could not find him. V11 said we checked the whole building we called the Administrator and the Director of Nursing (DON). V11 said the police were called and they came out. V11 said it was around 5:00PM. V11 said I had not seen (R3) that day. V11 said I am not sure when they last saw him. V11 said I don't know what happened to him. No one has told me anything. V11 said R3 did not tell me he was leaving on 2/5/23. V11 said we called a code pink. V11 said we were still looking for R3 when the police came. V11 said we stopped looking after about an hour of searching. On 2/11/23 at 12:43PM V12 (CNA) said I worked on 2/5/23 but I did not see R3 at all that day. On 2/11/23 at 12:53PM V14 (CNA) said a Code Pink is elopement. V14 said a code pink was called for R3 on 2/5/23. V14 said we did not find him. The code started around 5:00PM or 5:30PM. V14 said when I didn't see him after taking him his dinner, I realized he was not there. V14 said I started my shift on 2/5/23 at 3:00PM. V14 said I did not see R3 on 2/5/23 at all. V14 said we don't have a head count until 6:00PM on my shift. V14 said We wait for after dinner to look for them. V14 said we could not find R3, and we stopped looking. V14 said I am not sure if someone looked outside for R3. V14 said I was the first person to report R3 missing. On 2/11/23 at 1:22PM V16 (Mental Health Tech) said R3 walked slow, he does not move fast, his thinking process is not there. V16 said R3 would not stay outside for long, he would not even finish his cigarette, he was always cold. When V16 was talking about R3 he said you would have to ignore him for him to get out. On 2/11/23 at 1:43PM V15 (CNA) said I started my shift on 2/5/23 at 3:00PM. V15 said we had cigarette breaks and then dinner. V15 said I was outside for smoke break from 3:15PM and 3:30PM. V15 said I did not see R3 at that break. V15 said R3 usually walks around the facility, he walks normal at a normal pace. V15 said a code pink was called for R3 on 2/5/23. V15 said I don't know when the last time anyone saw him was. V15 said we stopped looking for him after dinner time. V15 said I did not go outside to look for him. V15 said I believe staff is supposed to look outside for a code pink. V15 said I don't think anyone knows where he is. On 2/11/23 at 3:11PM V1 (CNA) said during the 6:00PM head count it was noticed that R3 was missing. V1 said R3's baseline was to walk normal without assistive devices. V1 said R3 had a normal pace. V1 said during a code pink, no one is assigned to look outside. V1 said I did not look outside on 2/5/23. V1 said I don't know if anyone looked outside. V1 said the code pink was called clear code for (R3), but that is not clear. V1 said R3 was not found during the code pink on 2/5/23. On 2/11/23 at 3:35PM V2 (Human Resources) said V18 (Former Mental Health Tech) was terminated due to not supervising the residents during the smoke break between 1:15PM and 3:15PM on 2/5/23. On 2/12/23 at 9:12AM V6 (Administrator) said V18 was terminated for not being in his assigned spot, in the building working on 2/5/23. V6 said V18 was playing basketball. V6 said he was told the activity room patio door was open. V6 said V19 and V20 (Activity Aide) were terminated because the activity door was open and V19 and V20 were not doing a good enough job to supervise the residents. V6 said I did the investigation because during the 6:00PM head count on 2/5/23, it was reported that R3 was missing. V6 said he watched the surveillance video and saw R3 playing basketball on the activity patio around 2:40PM. V6 said then I saw him leave thru the gate. V6 said he was able to see R3 went east on the street saw him go past 1 house on the video. V6 said I did not see staff go after him. V6 said from the video the 2 activity aides (V19 and V20) were inside the facility while the doors were open. V6 said there was no staff on the patio while the residents were outside. V6 said V19 and V20 were telling me they were watching the patio from the doorway. V6 said I could not see them watching from the doorway on the video. V6 said We are unsure where R3 is at this time. At 9:42AM V6 provided V11's phone number as the person who spoke with the police. V6 provided the police report number. V6 said when he came to work on Monday, 2/6/23, the gate latch to the sidewalk/street at the end of the driveway that leads to the patio, was not latched. On 2/12/23 at 9:31AM V8 (Activity Aide) accompanied the surveyor on a tour of the activity patio. V8 said the residents play basketball out here. V8 said if we open the patio, we have a Mental Health Tech or Activity Aide sitting by the chairs by the gates. The surveyor observed 3 gates with latches. 1 gate off the activity patio leading into the smoking patio. Second gate leads from smoking patio to the facility driveway, where the facility vehicles are parked. This gate is shorter, about 4 feet. A third gate was noted at the end of the driveway from the driveway leading to the sidewalk and street. On 2/12/23 at 11:20AM the surveyor was accompanied by V17 (Maintenance Staff) who measured the distance from the activity patio to the street. Total distance was 144 feet. R3 walked about 144 feet around the outside of the facility to leave. On 2/12/23 at 11:28AM V3 said we always have done head count forever. V3 said we started doing this specific head count (green sheet) on 12/2/22. V3 said the CNAs take a census sheet and sign off when the resident is here. V3 said I take the papers and leave them on the table. On 2/12/23 at 12:49PM V5 (Director of Nursing/DON), said CNAs are expected to do rounds on residents every 2 hours. V5 said CNAs should do a bed check at the start of the shift. V5 said CNAs should lay eyes on everyone at the start of the shift. On 2/14/23 at 12:13PM V6 said I was told surveyors can't watch the video. At 12:20PM V6 said I did not report to IDPH that R3 was missing because I was told we would report if there were an injury. At 12:27PM V6 said I do not know what staff searched the surrounding areas. At 1:37PM V6 said the staff did not document the date or time the hospitals were contacted in search of R3. 2. R4's diagnosis includes but not limited to Bipolar, Moderate Intellectual Disabilities, Hypertension, Hyperlipidemia Type 2 Diabetes, Constipation, Morbid Obesity, and Nicotine Dependence, Cigarettes. R4 was admitted on [DATE] from another facility. On 2/12/23 at 12:49PM V5 (DON) said she was informed on 1/31/23 that R4 was not located. V5 said she as notified around 2:00PM from the head count. V5 said a code pink was called. V5 stated while doing the search, R4's family called and spoke with V4 (Psychiatric Rehabilitation Services Coordinator/PRSC) and said R4 was at his sister's house. V5 said R4's sister did not pick R4 up from the facility. V5 said I have no idea how he got out. V5 said R4 left unauthorized. V5 said the sister brought R4 back to the facility a couple of days later. On 2/14/23 at 10:21AM V6 (Administrator) said R4 was trying to obtain a community pass and wanted to visit his sister. V6 said R4 had told his caseworker (V4). V6 said on 1/31/23 V23 (Minimum Data Set/MDS Coordinator) did not verify R4's pass status and entered the code and let R4 out of the facility. V6 said he was made aware that R4 was missing after a head count. V6 said R4 went to his sister's house, and she brought him back. At 2:33PM the surveyor asked V6 if a resident comes missing and the whereabouts of the resident are found, does the facility have the ability to pick up the resident. V6 said We have the capability with 3 vans to pick up residents. We would coordinate the transport back to the facility. The surveyor asked if the family asked the facility to come pick up the resident from an unauthorized leave, would the facility pick the resident up? V6 said yes. On 2/14/23 at 10:47AM V4 (PRSC) said V4 completes the elopement assessments when a resident comes into the facility. V4 said R4 had expressed he wanted to go to another facility, specifically he wanted to go to a condominium, a 1 bedroom. V4 said he was working with R4's family towards that. V4 said R4 had said he did not want to share a room. V4 said R4's judgment was off. V4 gave the examples of R4 saying he wanted to leave and go to a shelter with four dollars, leaving his personal items out, he constantly left his shoes and phone out. V4 said R4 makes poor decisions. V4 said he did a second elopement risk assessment on 1/30/23 because he was at my office door a lot and expressed he wanted to leave. V4 said R4 gave him the thought that R4 might elope. V4 said there had been a couple times when R4 expressed he wanted to get a pass. V4 said he reported those times to V5 or V6. V4 said I sent out an email about it. (V4 did not provide a requested copy of the email.) At 10:58AM V4 said he was in the facility on 1/31/23 when they noticed R4 was gone. V4 said R4's mother called me and asked how he got a pass because R4 was at his sister's house. V4 said I put R4's mother on hold and called the Mental Health Techs and they did a room search and that is when we were aware that R4 was missing. R4 said we did a code pink. V4 said I was the first to be aware that R4 was gone. V4 said R4 was not eligible for a community pass because he was still within his 30- or 60-day review period. V4 said at 21 days R4 would have been able to go out with family. V4 said R4 had just reached the limit to be considered for a pass. V4 said I think we were going to be deny his community pass. V4 said when speaking with R4's family they told him that R4 could not be out on his own. V4 said R4's sister said R4 got on the bus to get to her house. V4 said a Community Skills Assessment is to be done on admission, or within 72 hours from admission. On 2/14/23 at 11:57AM V22 (PRSC) said Community Skills Assessment are done initially after admission, update quarterly, change of condition, or if the resident requests a pass. V22 said the purpose of the Community Skills Assessment is to find out if residents are capable of functioning in the community. V22 said these are done within a week from admission. V22 said the nurses should communicate expressions of residents requesting to leave or if residents are making statements of wanting to leave. V22 said from there we would do an elopement assessment or update the care plan. V22 said if a resident is found at risk for elopement it should be on the care plan. On 2/14/23 at 12:30PM V25 (R4's family) said on 1/31/23 R4 came by here. I called the facility and they said they did not know he got out. V25 said R4 grabbed his coat but had no shirt on when he arrived at her house. R4 said I live in XXXX and R4 got on the bus to get here. V25 said R4 walked from the bus stop to her house. V25 said she was told by V4, that the facility could not come out and get him and that she needed to bring him. V25 said she gave R4 twenty dollars and told him to go back to the facility. V25 said later she called the facility and they said he was not back. V25 said 2 days later R4 returned to her home and asked for more money. V25 said she took R4 back to the facility. On 2/14/23 at 12:56PM R4 was asked how he got out of the facility on 1/31/23 and R4 told the surveyor I left out, I walked out the front door. R4 said he walked to Lincolnwood Highway. R4 said he left after lunch. R4 said he took the bus, and it dropped him off at the mall and he we walked a couple blocks to his sister's home. R4 said it took him about 30 minutes to get to his sister's home. The surveyor asked R4 where he stayed the 2 nights he was not in the facility. R4 said I stayed on the bus. R4's progress notes dated 1/20/23 at 3:00PM document R4 was increasingly aggressive toward staff, exit seeking behavior and difficulty in redirection. A social service progress note documents R4 approached the writer (V4) about signing out against medical advice (AMA). R4 reported he did not want to be in the facility anymore. R4 said he would prefer to be at the shelter. Per progress notes R4 was taken to the hospital. R4 returned to the facility on [DATE]. R4's progress notes dated 1/31/23 at 9:32 written by V4 documents R4 approached V4 (for the seventh time) about getting an independent pass. V4 denied R4's request and said R4 was just readmitted from the hospital and was ineligible for a pass. V4 documented R4 understood. R4's progress notes dated 1/31/23 at 2:30 document it was brought to the writer's attention V5 that R4 has an unauthorized exit from the facility. R4's mother notified the facility that R4 visited his sister and was provided funding to return to the facility. Facility aware of resident exit. At this time, a missing person's report has been filed and awaiting resident return. R4's progress notes dated 2/2/23 documenting R4 was brought back to the facility by his sister. R4's elopement/unauthorized leave risk review dated 12/22/23 notes 1b.is there a diagnosis of dementia and/or severe mental illness - No. (R4's diagnosis includes Bipolar.) 2b. Signs of compromised decisional capacity and substantially impaired judgement and/or physical status limitations that would place the resident at risk in the community -yes. 4e. Has the physical ability to leave the building? No 5a. Elopement risk decision 3. Not at risk. R4's elopement/unauthorized leave risk review dated 1/30/23 at 6:59PM notes 1b.is there a diagnosis of dementia and/or severe mental illness -yes. 4c. Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan. 4e. Has the physical ability to leave the building? No 5a. Elopement risk decision 1. At risk to elope and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. R4's smoking risk assessment dated [DATE] denotes he can smoke independently with supervision only. Review of R4's January - February 2023 physician orders do not include an order for a community pass or outing. Review of R4's hospital records dated 1/21/23 note R4's petition states R4 was displaying exit seeking behaviors. R4's care plan printed by the facility on 2/14/23 does not include his risk for elopement. Review of a facility provided letter dated 1/24/23 at 8:36AM denotes R4 reported to staff that he became aggressive and wanted to leave the facility. Census report for R4 denotes he was on therapeutic leave of the facility on 1/31/23. Facility Human Resources Notice of Correction Action for V23 (MDS Coordinator) dated 2/1/23 documents on 1/31/23 employee opened door from secured section of facility for resident without verifying resident community access. The facility undated Smoking policy notes assigned staff will monitor the residents in the smoking program. Staff will remain in the designated area, during the entire scheduled smoking times with the residents. The facility undated Security, Supervision, and Safety Policy states the facility has incorporated the practice of making regular rounds at regular identified intervals throughout each day. Maintains a stringent smoking program which prohibits indoor smoking, limits smoking times, access to materials and allows for ongoing supervision of resident smoking. Code Pink Missing Resident/Elopement revised 11/15/18 states an incident report and notification to the state agency should be made. The policy states the facility should contact the morgue if the residents has not been located for 24 hours. Upon return the nurse should complete a new elopement risk assessment and update the plan of care. The facility's Community Pass Guidelines revised on 11/17/17 states a community skills assessment will be completed upon admission. The surveyor through observation, interview and record review confirmed the following removal plan was implemented by the facility: Aperion Care Chicago Heights Removal Plan, action taken: 1. Complete and submit an elopement investigation for resident. Date: 2/22/23 2. Review all resident's community survival assessment, update interventions as appropriate. Audit will be completed by PRSC's. Date: 2/16/23 3.Review of all community access passes for residents. Audit will be completed by PRSC and reviewed by PRSD. Date: 2/16/23 4. Educate all staff on supervision policy to address staff are not to leave any area with residents present and to keep supervision of any exits, verifying residents' community access pass prior to unlocking exit door, and smoke break procedures. All staff will be trained by 2/16/2023 via skills presentation and any staff on leave or unavailable staff will be educated via phone and again before next scheduled shift. Facility will ensure understanding of policy through drills. Date: 02/16/2023 and ongoing 5.Complete an elopement risk, restricted leave binder at the front desk and each nurse's station. This binder shall have an identifiable picture of all at risk residents. PRSD is responsible for maintaining and updating the elopement, restricted leave binder. Binder was available during R4 elopement. Elopement binder protocol was changed to include residents with community access within elopement binder. Date 2/22/23 6. Elopement risk policy reviewed and updated. All staff will be trained by 2/16/2023 via skills presentation and any staff on leave or unavailable staff will be educated via phone and again before next scheduled shift. Facility will ensure understanding of policy via QA tool. Date: 2/22/23 7. Review all elopement risk assessments to ensure accurate assessment, implement interventions as needed and update care plan accordingly. Elopement risks assessments will be reviewed by IDT team composed of Administrator, DON, and PRSD. Date 2/22/23 8. Ensure all exit doors are checked every shift for alarm function, alarmed at all times, and in working order. All doors secured with an alarm and will be tested daily by Maintenance Director and manager on duty during the weekend. This will be tested every shift for 30 days then daily. Facility will work with alarm vendor is repair or replace mag lock for dining room door. QA tool in place and will be completed by maintenance and manager on duty. Date: 2/22/23 9. Code Pink Policy was not updated due to incident, but supervision policy was updated to address issue from incidents. Code Pink (Elopement-missing person) drill was performed on 02/16/2023 by administrator and will be performed weekly for one month and monthly thereafter. Staff will be re-in-service on code pink (elopement-missing person) if/when revisions are made and upon annual review of annual policy by social services, nurse management, and administration. New hires will be in-serviced on code pink (elopement/missing person) during their general orientation. Facility had been completing elopement drills monthly. Facility will evaluate effectiveness by staff recognition of missing patient and timely response of all staff. Code Pink drills will be performed by IDT team (Administrator, DON, and PRSD) three times a week for a month, then weekly thereafter for 6 months. Date: 2/16/23 and ongoing 10. Medical director notified of incident on 02/16/2023 by the facility by the Administrator and reviewed the facility's immediate action plan. He agreed with immediate action plan. Date: 2/16/23 11. QAPI review with Medical Director to review elopement incident and plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Action plan will be reviewed monthly at QAPI meeting. Date: 2/22/23

There are multiple deficient practice statements. I. Based on observation, interview, and record review the facility failed to address and implement interventions to stop and/or prevent residents from sexually assaulting and exposing genitalia inappropriately to residents and visitors in the facility and failed to ensure female residents were protected from these behaviors. This failure resulted in R33 inappropriately touching female visitors (V43, V44 and V45) and exposing himself to other residents (R2, R113) in common areas with the potential to touch or harm other female residents within the facility. This affected 6 residents (R2, R113, R51, R98, R171 and R173). The Immediate Jeopardy began on 1/8/23 V1 (Administrator) was notified on 1/11/23 at 2:11 pm of the Immediate Jeopardy. The facility presented an initial removal plan on 1/11/23 at 4:08 pm. The plan was accepted, and 1/18/23 the surveyor conducted an onsite record reviews and interviews and could not confirm the removal plan was implemented. The facility presented a modified removal plan on 1/20/23 at 8:18 am. The surveyor conducted an onsite record reviews and interview on 1/20/23 to confirm the removal plan was implemented. V3 (Assistant Administrator) was informed the Immediate Jeopardy was removed on 1/20/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: A. R33's medical record notes R33 with diagnoses including paranoid schizophrenia, bipolar disorder, and major depressive disorder. R33 progress notes dated 7/28/22 documents: Writer witnessed resident displaying inappropriate behaviors, including exposing himself while in the central area in front of peers. Staff immediately redirected his behavior. R33 involuntary petition dated 8/23/22 documents: Resident is increasing agitated and socially inappropriate. He is slamming items in the facility to the floor, he is exposing himself to staff. R33's aggressive behavior assessment dated [DATE] documents resident has history of abuse/neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior: moderate problem. R33 progress notes dated 12/17/2022 at 13:02: Resident noted to be increasingly socially inappropriate. Res noted to be walking down the hall attempting to touch female staff and female residents on their breasts and behinds. Writer counseled resident on keeping hands to himself. Male MHT staff also redirecting resident. Staff will continue to monitor and redirect to ensure staff and resident safety. Review of R33's MDS (Minimum Data Set), dated 12/14/22, notes section E for behavior other behavior symptoms not directed towards others (physical symptoms such as hitting or scratches self, pacing rummaging, public sexual act, disrobing in public, throwing, or smearing food or bodily waste or verbal/ vocal symptoms like screaming, disruptive sounds) behavior of this occurred 1 to 3 days. Review of R33's behaviors care plan, initiated 2/7/22, notes R33 exhibits sexually inappropriate behavior towards staff and co-peers. This care plan was last updated on 5/20/22. It has a target date 3/20/2023 denotes I (R33) exhibit sexually inappropriate behavior toward staff & co-peers. These behavioral symptoms are manifested by making crude, sexually orientated, profane, or suggestive remarks, and co-peers displaying sexually inappropriate behaviors. On 6/26/19- I was verbally displaying sexually inappropriate behavior towards female peer. On 8/13/19- I was displaying sexually inappropriate toward staff (nurse practitioner). On 2/6/2020: I allegedly displayed sexually inappropriate behavior toward female co-peer. On 9/30/21: I touched a female staff on the behind. On 10/30/21: I touched two female staff inappropriately on the behind and breast. On 12/1/21 and 2/16/22: I touched a female staff on the behind. On 12/7/2021: I attempted to grab a female staff's chest inappropriately. On 5/20/22: I touched a female staff on her behind. I will accept redirection, behave in a safe and respectful manner, and refrain from displaying sexually inappropriate behave. I will refrain from making sexually inappropriate remarks and displaying sexually inappropriate behavior through next review. Administer PRN medication as ordered. Implement limit setting with me. Specify appropriate versus inappropriate behavior. If I attempt to touch inappropriately place your hand over mine and gently (but firmly) push it down and away, clarifying it is not appropriate. R33 redirected to maintain appropriate boundaries w/ staff and peers - 5/13/22. R33 will be placed on 1:1 monitoring. Staff will intervene and redirect me when sexually inappropriate behavior is observed - 2/16/22. I (R33) have a behavior problem touching others inappropriately, as evidenced by it has been reported by staff that resident has tried and/or touched their butt or chest area. 8/17/2021: I inappropriately grabbed activity staff on her buttocks. I will display minimal episodes of touching others inappropriate behaviors related to grabbing at staff's chest or behind through next review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with others. Encourage the resident to express feelings appropriately. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss R33's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Maintain an appropriate distance from resident when interacting. On 1/8/23 around 9:45 am, V43 (surveyor) was in the common hallway near central nursing office talking to another resident when R33 came from behind and touched her chest. On 1/8/23 around 10:00 am, V44 (surveyor) was talking with another resident when R33 touched her breast. Another female V45 (surveyor), was in the hallway facing R150's room when R33 walked behind her and touched right buttocks as he passed by. About 15 minutes later, V44 (surveyor) was speaking with other residents (R113, R2) in the hall when R33 came up and pulled his penis out. R33 then began making inappropriate comments and abruptly walked away. On 1/8/23 10:30 am, V45(surveyor) said R169 stopped V45 in the hallway. V45 her back against wall. R33 approached V45, leaned forward, and touched V45's left breast and then walked away. R33 returned a few minutes later and attempted to touch V45 again. On 1/8/23 at lunchtime, R33 pulled penis out at the central monitoring station area, in front of mental health techs, residents, and V43. On 1/9/23 around 10:15AM, V44 (surveyor) was in the dining room speaking with a resident when R33 came from behind V44, R33 touched her bottom and made inappropriate comments. On 1/9/23 12:34 pm, V7(Mental Health Tech) said she heard the residents say R33 just touched a surveyor. R33 walked and sat down and V7 asked him if he touched the surveyor he just said [NAME], [NAME]. V7 said she told R33 about personal space and he sat in central area for about 5 minutes and left. V7 said she reported the incident to V13(Supervisor) on 1/8/23 at 12:13PM. On 1/10/23 at 9:55am, V9 (PRSC/psychiatric rehabilitation services coordinator) stated that R33 exhibits sexually inappropriate behaviors, R33 touches the buttocks and breasts of female staff. V9 stated that R33 was on V28's (former PRSD) caseload until she resigned in early December 2022. At 3:00pm, V9's documentation on 12/17/2022 of R33's behavior was reviewed with V9. V9 stated that V9 does not recall which staff or residents R33 touched. V9 stated that if she documented it, then it happened. V9 stated that V9 does not recall reporting this incident to any staff other than the MHT staff. V9 stated that R33 does not exhibit sexually inappropriate behaviors daily, possibly weekly. V9 stated that right before V9 came to speak with this surveyor, R33 attempted to touch her inappropriately. V9 stated that staff are expected to report all behaviors to the PRSCs . On 1/10/23 at 2:40pm, V13 (Mental Health Supervisor) stated that V7 (MHT) notified V13 of an incident of inappropriate behaviors with a female, possibly CNA (Certified Nurse Assistant). When questioned if V13 reported this incident to V1 (Administrator), V13 responded No. V13 stated I guess I should have reported it to V1. When questioned if V13 reported it to V1 on 1/9/23, V13 responded 'V13 did not work yesterday. When questioned if he notified V1 today, V13 stated that he thought it resolved on own. On 1/10/23 at 2:58pm R113 was interviewed about the incident with R33 that occurred on 01/08/23. R113 stated. He took out his private parts while we were standing here talking. He will show it to people for no reason. When I see him in the halls, he is always bothering people. I would say he pulls out his penis about once or twice a week that I see. He shows it to all different people. Sometimes staff is there and see him do it. They will just tell him to put it away. Sometimes he listens and other times they must give him a shot because he won't calm down. They don't do much more than that. I do see him touching people. I don't really see how many times he does that, but he grabs at girls' breasts and their butts. He does it to staff and other residents. On 1/13/23 at 11:14AM, R113 who was alert and oriented at time of interview said it made her feel bad and not safe at that time because she knew it was wrong. On 1/12/23 at 3:19PM, V28 (former PRSD) said R33 has history of sexual inappropriate actions towards staff. V28 said she never received report about inappropriate behaviors towards resident. We educated staff on what to do if R33 became inappropriate with them. Interdisciplinary team was aware of his behaviors. Unable to recall any further staff names that were affected. On 1/13/23 at 10:15am, V7 (MHT) stated that R33 exhibits sexually inappropriate behaviors daily. V7 stated that all staff are aware of R33's inappropriate behaviors. V7 stated that R33 frequently pulls his pants down in front of staff/residents or pulls penis out. V7 stated on 1/8/23, R33 was calm and walking at a normal pace. V7 stated that the behaviors R33 was exhibiting were level one behaviors. V7 stated that R33 does not get sent out to the psychiatric hospital until he is exhibiting behaviors at a level 5, such as running through hallway, cursing staff and other residents, and destroying property. Facility census dated 1/12/23 documents: 59 female residents. Facility census dated 1/8/23 documents 171 residents. Facility abuse prevention and reporting policy revised 4/2022 documents: The resident has the right to be free form abuse, neglect, misappropriation of resident property and exploitation. Sexual abuse is nonconsensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially breast and perineal area: all types of sexual assault battery such as rape, sodomy and coerced nudity; forced observation of masturbation and/or pornography. On 01/20/23 the surveyor verified by observations, record review and interview that the facility implemented the following to remove the immediacy: 1.R33 is no longer at the facility. Psychiatrist ordered a discharge to the hospital for a psychiatric evaluation on 1/10/23. Resident was placed on supervision prior to transfer to hospital. Facility will re-evaluate R33 after completion of treatment. Upon return, resident will be placed on increased staff supervision, provided a room change closer to the nurses' station, evaluated by the psychiatrist, and assessed for appropriate therapeutic programming. 1/10/23 started and ongoing. 2.Staff were in-serviced/trained on how to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to other residents. All staff will be re-educated prior to next scheduled shift including staff that are on leave and are on vacation. Administrator and Assistant administrator are conducting the training. The training includes the Abuse prevention reporting policy, specifically the definition of abuse, Sexual abuse, sexual assault, rape and internal reporting requirements and identification of allegation and protection of residents. Staff acknowledged information via signature. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. The abuse prevention training program posttest questionnaire is the material utilized. No revision of the current abuse policy has occurred. The noncompliance was a failure to follow current policy IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. 1/10/23 started at 2:45pm. 3.Residents that have been identified for being at risk for sexual abuse have had their care plans updated to reflect interventions to prevent abuse. List of identified residents was provided to survey team. Intervention implemented 1/10/23 . 4.Resident identified with sexually inappropriate behavior was counseled and placed on close staff supervision, was educated on symptom management, maintaining boundaries and importance of utilizing coping skills to manage symptoms, and will be followed up with by staff and/or psychiatrist regularly. QA tool titled Abuse reporting, interventions and investigation will be completed weekly by the Administer or Assistant Administrator. Observations noted during regular rounds will be discussed at the QA Committee. Concerns will be discussed among the members, a plan of action is devised, and past plans of actions evaluated. Intervention implemented 1/10/23 B. R51 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder, schizoaffective disorder, panic disorder and borderline personality disorder. R51's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 15/15 which indicates cognately intact. On 1/13/23 at 1205PM, R51 who was alert and oriented at time of said she does not feel safe in the facility due to R25 behaviors. R51 said about 3 weeks ago R25 licked her chest and she hit him. R51 said she told an activity aide. On 1/13/23 1:31pm, V1 (Administrator) denied any knowledge of incidents for R51. On 1/13/23 at 4:12PM, V24 (Mental Health Tech/MHT) said he saw R51 and R25 in the hallway. R51 reported that R25 licked her chest. V24 said he told V19( MHT Supervisor). Facility abuse reportable dated 1/13/23 documents under staff interviews: V24 (Mental health tech, MHT) I saw it happened. R51 was fully clothed during the incident. I corrected R25 action and redirected him. C. R128 was admitted to the facility on [DATE] with a diagnosis major depressive disorder and psychotic disorder. R128's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 15/15 which indicates cognately intact. On 1/13/23 at 12:05 pm, R128 who was alert and oriented at time of interview said one month ago, R25 grabbed her butt and it happened 3 months prior as well while waiting in line for smoking. R128 said she was unclear if she reported second inappropriate touch but the first time, she thinks she reported the incident to V1 (Administrator). R128 said she does not feel safe in the facility due to R25 behaviors. On 1/13/23 1:31pm, V1 (Administrator) denied any knowledge of incidents for R128. D. R98 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, alcohol abuse, major depressive disorder, homicidal ideations, and psychosis. R98's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 15/15 which indicates cognately intact. On 1/19/23 at 1:50 pm, R98 who was alert and oriented at time of interview said R25 grabbed her butt 2 times while waiting in line for smoking. R98 said she threatened R25 and was sent to the hospital. R98's hospital record dated 1/11/23 documents under chief complaint: Patient stated, I threatened to cut a man's d*** off because he smacked me on my a**. E. R171 admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder and conduct disorders. R171's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score 14/15 which indicates cognitively intact. On 1/18/2023 at 2:57 pm, R171 who was alert and oriented at time of interview stated that 3 days ago, R74 entered R171's room without permission. R171 stated that R171 was lying in bed after breakfast. R171 stated that R74 approached R171 and started pulling down R171's pants to perform oral sex. R171 stated that R171 grabbed R171's pants to prevent R74 from R74 removing pants any further and yelled. R171 stated that R171 informed R74 to stop and pushed R74's head away. R171 stated that R74 then pulled R74's pants down and attempted to get in bed with R171. R171 stated that again R171 pushed R74 away. R74 pulled pants up and exited R171's room. R171 stated that R171 felt like he was being molested. R171 stated that during smoke break in the evening, R171 reported incident to V59 (activity aide). On 1/18/23 at 3:40pm, R171 identified R74 at smoke break as the resident who pulled R171's pants down. On 1/19/23 at 2:16pm, R171 reported the same story. On 1/18/2023 at 3:19pm, R173 who was alert and oriented at time of interview, stated that 3 days ago R173 was talking with R171 in their room when R74 came into R173's room without permission and asked R173 if R173 wanted to have sex. R173 stated that R173 declined and told R74 to leave. R173 stated that R173 witnessed R74 go to R171 and began pulling R171's pants down to try to have sex with R171. R173 said he heard R171 say no and then R74 left the room. R173 stated that R173 did not report the incident. On 1/18/23 at 3:54 pm, V59 (Activity aide) said R171 reported to her during smoke break that R74 was going into R171's room and trying to pull his pants down. V59 does not recall which Mental Health Tech she spoke with. On 1/19/23 at 11:25 am V29 (PRSC/Psychiatric Rehabilitation Services Coordinator) said that R74 said R74 had sex with R171 but could not provide date of incident. V29 stated that a capacity for sexual consent was completed yesterday. V29 stated that it has not been determined if R74 understands no means no because of R74's intellectual disability. V29 stated that R171 informed V29 that this incident was not consensual and R171 would not like this behavior to happen again to him. V29 stated that R74 went into R171's room and pulled R171's pants down and then pulled his own pants down. II. Based on interview and record review, the facility failed to implement appropriate crisis prevention intervention techniques during a behavioral episode for one resident (R57). This failure resulted in R57 sustaining a left wrist fracture. Findings include: R57 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia, anxiety and major depressive disorder. R57's progress notes dated 11/11/22 at 6:31 pm documents: Writer notified by Mental Health Tech that resident was responding to internal stimuli and not able to be redirected. Resident unable to give description. Resident given prescribed medication. After medication was administered, resident charged at Mental Health Tech and staff-initiated Crisis prevention intervention (CPI). R57's progress notes dated 11/11/22 at 8:55 pm documents: Mental Health Tech informed writer resident left lower arm wrist area was swollen. Writer assessed area noted left lower arm /wrist area swollen, displaced and discolored. R57's hospital record dated 11/12/22 documents: left wrist distal radius fracture. severely displaced, comminuted distal radial fracture wit radial and palmar displacement. On 1/10/23 at 10:30 am, V1 (Administrator) said V48(Mental Health Tech) was terminated due to improper Crisis Prevention intervention by placing his hands on the resident which resulted in a fall and fracture. V48's employee file notice of corrective action dated 11/14/22 documents: Violation of company policy. After extensive investigation, it has been determined that associate used improper CPI on a resident. Associate was seen via camera footage lunging at resident and grabbing the resident's wrist, pushing her backwards, causing resident to fall. Residents left wrist was broken. Facility abuse prevention and reporting policy revised 12/17/21 documents: Abuse means any physical assault inflicted upon another resident other than by accidental means. 40066 III. Based on interview and record review the facility failed to prevent incidents of resident-to-resident physical assault. These failures affected 6 (R119, R29, R56, R60, R96, and R167) residents reviewed for physical abuse in the sample of 35. This failure resulted int R56 being assaulted and sustaining an abrasion to the chin area and a laceration to the left side of her head requiring 21 staples to the occipital area and treated for occipital condyle fracture. Findings include: A. R56's diagnosis including, but not limited to Parkinson's Disease, Bipolar Disorder, Anxiety, Alzheimer's Disease, Dementia, Schizoaffective Disorder, and Dementia. R56's Abuse/Neglect Screening dated 9/6/22 notes a score of 4= Moderate. Presents with a moderate level for abuse and neglect. Progress Notes dated 1/6/23 notes R56 verbalized to writer that she was hit in the head from the back by peer, noted with slight blood at the side of her head. Noted with laceration in the scalp. First aid rendered and 911 called. Progress Notes dated 1/8/23 notes R56 back from hospital with 21 staples in the head and neck brace because of fracture of the neck. R119's diagnosis including, but not limited to Psychotic Disorder and Schizophrenia. R119's Aggressive Behavior assessment dated [DATE] documents she was involved in a physical altercation with a male peer and admitted to being the initial aggressor. R119's care plan initiated on 11/14/18 documents she has the potential to be physically aggressive related to a diagnosis of psychosis. Documented behaviors directed towards other residents include scratching, pushing, physical altercations and aggression. Progress Notes for R119 dated 12/28/22 documents R119 is reported to be aggressively throwing punches when no one is there and talking to self. On 1/8/23 the surveyor observed R56 during initial observation made between 10:30-11:00 am. R56 was lying in bed, flat on her back, and wearing a neck brace. R56 was in an isolation room. Staff sitting, V23 (Certified Nurse Assistant/CNA) outside her room said she has COVID. The surveyor asked V23 what happened to R56. V23 replied I don't know what happened to her, it was last night . Surveyor did not enter the room to finish screening all other residents and then returned to kitchen for observations. Upon return to the unit 2:00 pm R56 was no longer in the facility. On 1/9/23 at 12:00 V6 (Registered Nurse) said she was on break in the Central Nurses' stations and R56 walked in and said R119 hit me from the back and she mad, she hit me. V6 said R56 said I don't know with what. V6 said R56 was alert. V6 said R119 won't speak to say why she hit R56. V6 said R119 was hallucinating, and I sent her out immediately. V6 said I saw the laceration on R56, and I called 911. V6 said I saw the laceration on the top of R56's head. V6 said R119 and R56 was walking in the hallway. V6 said R119 is no one's friend. V6 said this happened in the evening. V6 said I asked the CNAs about the incident, and they said they didn't see anything. V6 said R56's behavior does not include fighting; she has occasional anxiety. V6 said R119 always talks to herself, hallucinates, and when the psych doctor comes in, I tell them to evaluate R119. She talks like she is in conversations with 10 people. She was compliant with her medication. V6 said whatever they have done, it was not effective. V6 said R119 had been yelling and hollering all the time and verbally aggressive. V6 said when she spoke to Psych doctors about the behavior, they said that was her baseline. V6 said I told them she was not a baseline. V6 said I don't know what R119 used to hit R56 with. V6 said the incident happened in the back hallway. On 1/9/23 at 12:24 pm V20 (Licensed Practical Nurse) said R119 and R56 are not physically aggressive, I never seen her hit anyone. On 1/9/23 at 2:01 pm V9 (Social Services) said I am not aware of the situation with R56 and R119. V9 said she was not notified to perform an assessment or implement new intervention for R56 or R119. On 1/10/23 at 9:57 pm V22 (CNA), said R119 is pleasant, calm, does not cause any problems, quiet, and she does not bother anyone. On 1/10/23 at 2:06 pm V23 (CNA) said on 1/8/23 she sat outside of R56's room to monitor her. V23 said before the incident R56 used to walk around. On 1/11/23 V35 (Doctor) was asked by the surveyor if he expects his patients to be safe in the facility? V35 responded Yeah, absolutely. V35 said I would want my residents to be safe in the facility. B. R60's diagnosis including, but not limited to Paranoid Schizophrenia, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Abuse investigation form documents on 10/13/22 R60 has history of poor boundaries and impaired thought process. R29 has history of poor boundaries and physical aggression. It is documented that R60 and R29 were served at lunch and sat at the same table. R60 attempted to grab food off R29's tray. [This is different than V22's interview with surveyor.] R29 displayed poor boundaries and impulse control by striking R60. Nursing staff attempted to apply first aid to R60's superficial cut on lip, but R60 refused treatment. R60's care plan initiated on 4/21/20 documents R60 displays poor boundaries. Care plan initiated on 9/20/16 notes R60 has a behavior problem, poor insight regarding mental illness, noncompliance with medications related to diagnosis of Schizophrenia. Care plan initiated on 11/10/16 documents R60 has impaired cognitive function/dementia or impaired thought process as evidenced by disorientation, recall deficit, disorganized thoughts. R29's diagnosis including, but not limited to unspecified Psychosis, Schizoaffective Disorder, Bipolar Type, and Restlessness and Agitation. R29's PAS/MH Level II Notice of Determination dated 10/5/18 identified R29's findings to benefit from aggression/anger management R29's care plan dated 10/13/22 documents I have the potential to be physically aggressive towards others related to Anger and poor impulse control. R29's Aggressive Behavior assessment dated [DATE] notes R29 was involved in a physical altercation with a female peer and admitted to being the aggressor after she snatched food items off his breakfast tray. On 1/9/23 at 12:00 pm V6 (Registered Nurse) said I didn't see the incident with R29 and R60. V6 said R29 does not get along with others. He does not have friends. He just talks to himself. V6 said R29 still eats in the dining room. On 1/10/23 at 9:57 am V22 (Certified Nursing Assistant) said on 10/13/22 R60 grabbed R29's food tray. V22 said R60 and R29 were sitting at separate tables. V22 said R60 grabbed R29's food in front of him. V22 said R60 took the food off the tray, R29 got up and hit R60 and then R60 sat back down. V22 said R29 quickly fisted R60 and made direct contact with her lip. V22 said I was sitting at back table in the dining room. V22 said I saw R60 grab the food. V22 said I did not get up the Mental Health Tech was walking towards R29 and R60. On 1/11/23 at 10:31AM V2 (Director of Nursing) said residents should not be hitting other residents. V2 said that is considered abuse. V2 said the residents should absolutely be safe in the facility. C. R96's diagnosis including, but not limited to Epilepsy, Schizophrenia, Depressive Disorder, Anxiety Disorder, Insomnia, and Tremor. R167's diagnosis including, but not limited to Schizoaffective Disorder, Bipolar Type, Vitamin D Deficiency, Cannabis Dependence, Nicotine Dependence, Delusional Disorder. R167's care plan initiated on 9/20/22 notes he has the potential to be aggressive. On 11/8/22 R167 was in a physical altercation with a peer due to hallucinations. R167's Aggressive Behavior assessment dated [DATE] notes R167 has a history of aggressive/agitated behavior or noncompliance with medications, treatment, regimen, or resisting care. R167 was involved in a physical altercation with a peer as he admitted to being the aggressor. Due to his hallucinations, he mistakes peer saying something disrespectful to him, resulting in physical aggression. Progress note dated 12/12/22 notes a peer(R167) entered R96's room and became physically aggressive towards R96. Incident report dated 12/12/22 documents physical abuse allegation. Summary of interview witness documents V19 said he observed R167 becoming physically aggressive towards R96. R167's statement was R96 was peeing on my bed. R96's statement was I didn't do anything. Investigation Findings states R167 has a history of physical Aggression, hallucinations, and confabulations. R167 was having hallucinations at the time of the incident believing R96 had urinated in R167's room. R167 approached R96 and struck him. On 1/9/23 at 1:17 pm V15 (PRSC) said she followed up with R167 following the incident with R96. V15 said I was not in the facility the day of the incident. V15 said when she spoke with R167 he would not give me more information. V15 said I spoke with R167 about better ways to cope with his anger. V15 said I think R167 has a history of behaviors, he has shown aggression in the past. V15 said R167 can be aggressive with staff and residents, he was yelling at me the other day. On 1/9/23 at 2:01 pm V9 (Social Services) said R167 was hallucinating and thought that R96 had gone into his room and peed on the towels. V9 said R167 is known to be delusional. V9 said R167 was the on schedule for anger management group. V9 said the goal of programs is to maintain safety. On 1/10/23 at 1:22 V19, (Mental Health Tech Supervisor/MHT) said on 12/12/22 R167 struck R96. V19 said I did not see R167 hit R96. V19 said I went into the resident room to break it up. V19 said R167 said it was because R96 peed on his stuff. V19 said R96 had not been up that night shift, he was in his room, in his bed. V19 said I believe he (R167) just wanted to get him (R96). V19 said he checked both resident's rooms and didn't see anything wet with urine. On 1/11/23 at 10:31 am V2 (Director of Nursing) said resident should not be hitting other residents. V2 said that is considered abuse. V2 said the residents should absolutely be safe in the facility. The facility policy titled Abuse Prevention and Reporting revised 4/29/22 states as follows: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 41758 IV. Based on interview and record review the facility failed to prevent a resident-to-resident sexual assault. This failure affected 4 (R39, R74, R171, and R427 ) residents reviewed for sexual assault. This failure resulted in R39 being sexually attacked by R427 and R74 to pull R171's pants down and attempt to provide R74 with oral sex. Findings Include: A. Police report dated 11/3/22 documents: while in R39's room, R427 used forced to push R39 backwards onto her bed. While lying on her back R427 laid his body on top of R39. R427 place his hand on R39's mouth, place his ot [TRUNCATED]

I.Based on observations, interviews, and record reviews, the facility failed to adequately supervise/monitor and implement effective interventions for one male resident (R33) with a history of having sexually inappropriate behaviors. The facility failed to prevent an incident of sexual assault of three female visitors as well as inappropriate exposure of himself. The lack of the adequate supervision and effective interventions upon the onset of R33's behaviors had the immediate potential to affect all 59 female residents who has the potential to encountered R33. The Immediate Jeopardy began on 1/8/23 V1 (Administrator) was notified on 1/11/23 at 2:11 pm of the Immediate Jeopardy. The facility presented an initial removal plan on 1/11/23 at 4:08 pm. The plan was accepted, and 1/18/23 the surveyor conducted an onsite record reviews and interviews and could not confirm the removal plan was implemented. The facility presented a modified removal plan on 1/20/23 at 8:18 am. The surveyor conducted an onsite record reviews and interview on 1/20/23 to confirm the removal plan was implemented. V3 (Assistant Administrator) was informed the Immediate Jeopardy was removed on 1/20/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: 1. R33's medical record notes R33 with diagnoses including: paranoid schizophrenia, bipolar disorder, and major depressive disorder. R33's MDS (minimum data set), dated 12/14/22, notes section E for behavior shows R33 has hallucinations, delusions, verbal symptoms directed towards others (threating others, screaming at others) that occurred 1 to 3 days, other behavior symptoms not directed towards others (physical symptoms such as hitting or scratches self, pacing rummaging, public sexual act, disrobing in public, throwing or smearing food or bodily waste or verbal/ vocal symptoms like screaming, disruptive sounds) behavior of this occurred 1 to 3 days. R33 has behaviors of wandering, behavior of this occurred 1 to 3 days. Section E1100 shows R33 current behavior status in comparison to prior assessment is the same. R33's behaviors care plan, initiated 2/7/22, notes R33 exhibits sexually inappropriate behavior towards staff and co-peers. This care plan was last updated on 5/20/22. It has a target date 3/20/2023 denotes I (R33) exhibit sexually inappropriate behavior toward staff & co-peers. These behavioral symptoms are manifested by making crude, sexually orientated, profane, or suggestive remarks, and co-peers displaying sexually inappropriate behaviors. On 6/26/19- I was verbally displaying sexually inappropriate behavior towards female peer. On 8/13/19- I was displaying sexually inappropriate toward staff (nurse practitioner). On 2/6/2020: I allegedly displayed sexually inappropriate behavior toward female co-peer. On 9/30/21: I touched a female staff on the behind. On 10/30/21: I touched two female staff inappropriately on the behind and breast. On 12/1/21 & 2/16/22: I touched a female staff on the behind. On 12/7/2021: I attempted to grab a female staff's chest inappropriately. On 5/20/22: I touched a female staff on her behind. I will accept redirection, behave in a safe and respectful manner, and refrain from displaying sexually inappropriate behave. I will refrain from making sexually inappropriate remarks and displaying sexually inappropriate behavior through next review. Administer PRN medication as ordered. Implement limit setting with me. Specify appropriate versus inappropriate behavior. If I attempt to touch inappropriately place your hand over mine and gently (but firmly) push it down and away, clarifying it is not appropriate. R33 redirected to maintain appropriate boundaries w/ staff & peers - 5/13/22. R33 will be placed on 1:1 monitoring. Staff will intervene and redirect me when sexually inappropriate behavior is observed - 2/16/22. I (R33) have a behavior problem touching others inappropriately, as evidenced by it has been reported by staff that resident has tried and/or touched their butt or chest area. 8/17/2021: I inappropriately grabbed activity staff on her buttocks. I will display minimal episodes of touching others inappropriate behaviors related to grabbing at staff's chest or behind through next review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with others. Encourage the resident to express feelings appropriately. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss R33's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Maintain an appropriate distance from resident when interacting. Per PAS/MH Level II Notice of Determination, I (R33) may be able to benefit from: medication monitoring/ management; - ADL (activities of daily living) training/reinforcement; - mental health rehabilitation; illness self-management; - incentive program to improve participation in treatment and community re-integration activities. I will meet with my PRSC as needed to address symptom management issues as well as negative behaviors through next review date. Encourage group attendance, encourage resident to participate in mental health treatment. PRN one on one sessions with PRSC to address behaviors and symptom management. 2. On 1/8/23 around 9:45am, R33 was observed in the common hallway near the central nursing office approach V43 (surveyor) from behind and touch her breast. V7 MHT (Mental Health Tech/MHT) and other residents were present. V7 re-directed R33 away and into an area between the dining room and hallway. On 1/8/23 around 10:00 am, V44 (surveyor) was walking through the central station area after leaving the dining room. R33 was observed approaching V44 from the opposite direction and touch her right breast. Staff's back was turned while this happened. About 15 minutes later, V44 was speaking with R2 and R113 in the hall when R33 came up and pulled his penis out. V44 attempted to redirect R33 back to his room but was unsuccessful. R33 then began making inappropriate comments and abruptly walked away. No staff witnessed these incidents. On 1/8/23 at 2:58pm, R113 was interviewed about the incident with R33 that occurred on 01/08/23. R113 stated. He took out his private parts while we were standing here talking. He will show it to people for no reason. When I see him in the halls, he is always bothering people. I would say he pulls out his penis about once or twice a week that I see. He shows it to all different people. Sometimes staff is there and see him do it. They will just tell him to put it away. Sometimes he listens and other times they have to give him a shot because he won't calm down. They don't do much more than that. I do see him touching people. I don't really see how many times he does that, but he grabs at girls' breasts and their butts. He does it to staff and other residents. On 1/8/23 at 10:20am, R33 was observed walking past V45 (surveyor) and touch her right buttocks. At 10:30am, V45 was speaking with R169 in the hallway. R33 was observed approaching V45, leaning forward, and touching her left breast. R33 then abruptly walked away. A few minutes later, R33 approached V45 and attempted to touch her lower abdomen. There were no staff present during these incidents. On 1/9/23 around 10:15am, V44 was observed in the dining room speaking with a resident. R33 was observed approaching female visitor touching her buttocks and making inappropriate comments. V44 re-directed R33 not to touch her. R33 quickly walked away. On 1/9/23 12:34pm, V7 (MHT) stated V7 heard the residents say R33 just touched a female visitor. R33 walked and sat down. V7 asked R33 if he touched the visitor, R33 just said [NAME], [NAME]. V7 told R33 about personal space and he sat in central area for about 5 minutes and then left. According to V7 there were only two mental health techs working day shift for 174 residents. V7 texted V13 (mental health supervisor) at 12:13pm about the incident with R33 and the visitor. V7 stated that V13 telephoned V7 and acknowledged that he received her text message. 3. Additional interviews were conducted regarding R33's behavior and planned intervention for recognized behaviors as follows: On 1/9/23 at 2:00pm, V9 (Psychiatric Rehabilitation Services Coordinator/PRSC) stated that at this time, there is no facilitator for group therapy programs. V9 reported, the PRSC staff are doing 1:1 session with each resident. V9 stated, social services discuss with the resident the behaviors identified in group therapy. V9 stated, there is no PRSD (psychiatric rehabilitation services director). On 1/10/23 at 9:55am, V9 reported R33 exhibits sexually inappropriate behaviors, R33 touches the buttocks and breasts of female staff. V9 stated R33 was on V28's (former PRSD) caseload until she resigned in early December 2022. At 3:00pm, the surveyor reviewed with V9, V9's documentation on 12/17/2022 of R33's inappropriate behavior. V9 reported, she does not recall which staff or residents R33 touched. V9 stated that if she documented it, then it happened. V9 stated she does not recall reporting this incident to any staff other than the MHT staff. V9 stated, R33 does not exhibit sexually inappropriate behaviors daily, possibly weekly. V9 reported to the surveyor, right before she came to speak with this surveyor, R33 attempted to touch her inappropriately. V9 stated that staff are expected to report all behaviors to the PRSCs On 1/10/23 at 9:00am, V1 (Administrator) stated that the group facilitator and PRSCs should be doing 1:1 session with every resident. V1 stated that the group facilitator resigned in early December. V1 stated that the last day for group programs was on 12/9/22. V1 stated 1:1 session with residents should be weekly same as the frequency group meetings were held. V1 stated that V1 can't recollect if he told staff right away to start doing 1:1 session with residents after the group facilitator resigned. V1 stated 1:1 session is documented in the resident's progress notes. On 1/10/23 at 10:30am, V15 (PRSC) stated that V15 has been covering R33 since PRSD left in December, about 2-3 weeks. V15 stated that R33 is receiving 1:1 session. V15 stated that R33 is not receiving any group therapy programs. V15 stated that she is not aware of R33 exhibiting any behaviors since R33 was readmitted to facility in December 2022 when R33 was hospitalized for aggressive behaviors. On 1/10/23 at 2:40pm, V13 (Mental Health Supervisor) stated that V7 (MHT) notified V13 of an incident of inappropriate behaviors with a female, possibly CNA (certified nurse aide). When questioned if V13 reported this incident to V1 (Administrator), V13 responded 'no'. V13 stated I guess I should have reported it to V1. When questioned if V13 reported it to V1 on 1/9/23, V13 responded 'V13 did not work yesterday. When questioned if he notified V1 today, V13 stated that he thought it was resolved. On 1/13/23 at 10:15am, V7 (MHT) stated R33 exhibits sexually inappropriate behaviors daily. V7 stated that all of the staff are aware of R33's inappropriate behaviors. V7 stated that R33 frequently pulls his pants down in front of staff/residents or pulls penis out. V7 stated on 1/8/23, R33 was calm and walking at a normal pace. V7 stated the behaviors R33 was exhibiting were level one behaviors. V7 stated that R33 does not get sent out to the psychiatric hospital until he is exhibiting behaviors at a level 5, such as running through hallway, cursing staff and other residents, and destroying property. On 1/13/23 at 11:25am, V9 stated that the PRSCs talk to residents 1:1 as needed, not once a week. V9 stated that the expectation is for the PRSC to document in the resident's care plan and progress notes. V9 stated that the PRSCs should be documenting every 1:1 session with a resident in his/her progress notes. V9 acknowledged that these 1:1 session should be occurring routinely, not after the resident exhibits inappropriate behaviors. V9 acknowledged that if it isn't charted, it didn't happen. On 1/17/23 at 10:20am, V46 (Psychiatric Doctor) stated that R33 should have been placed on 1:1 supervision after the first incident on 1/8/23, to prevent the second and the third incidents of inappropriate touching. A behavior contract should have been created. V46 stated that V46 was not informed about R33 touching the staff the first time. V46 stated that V46 would have sent R33 to the nearest hospital at that time. 4. R33's medical record documented the following regarding R33's negative behaviors R33's Social Service Progress Review dated 7/28/22 by V28 (former PRSD /psychiatric rehabilitation services director) noted: V28 witnessed R33 displaying inappropriate behaviors, including exposing himself while in the central area in front of peers. Staff immediately re-directed R33's behavior. Progress note dated 8/23/22 by V2 (DON /director of nursing) noted: R33 is increasingly agitated and socially inappropriate. R33 is slamming items in the facility to the floor, R33 is exposing himself to staff, and threw water pitcher at floor nurse, and is not receptive to re-direction, an as needed medication administered and ineffective. R33's petition for involuntary admission, dated 8/23/2022, notes R33 increasingly agitated and socially inappropriate. R33 was slamming items on the floor and exposing self to staff. R33 is not receptive to re-direction. These behaviors were witnessed by V2 DON and V13 (mental health supervisor). R33's hospital admission record, dated 8/23/22-8/30/2022, notes R33 to continue the following therapies: assertive community treatment, cognitive behavior therapy (therapy to help change certain behaviors), illness-management skills, and social skills training. R33's medical record, dated 7/28/22 - 1/10/2023, does not note R33 was receiving group therapy or 1:1 session with PRSCs. R33's medical record, dated 11/14/22 and 11/30/22, R33 was sent to the hospital each time for exhibiting verbal and physical aggression. R33's medical record, dated 12/17/22, notes V9 noted: R33 noted to be increasingly socially inappropriate. R33 noted to be walking down the hall attempting to touch female staff and female residents on their breasts and behinds. V9 counseled R33 on keeping hands to himself. Male MHT (mental health tech) staff also redirecting R33. Staff will continue to monitor and redirect to ensure staff and resident safety. On 01/20/23 the surveyor verified by observations, record review and interview that the facility implemented the following to remove the immediacy: 1.R33 is no longer at the facility. Psychiatrist ordered a discharge to the hospital for a psychiatric evaluation on 1/10/23. Resident was placed on supervision prior to transfer to hospital. Facility will re-evaluate R33 after completion of treatment. Upon return, resident will be placed on increased staff supervision, provided a room change closer to the nurses' station, evaluated by the psychiatrist, and assessed for appropriate therapeutic programming. 1/10/23 started and ongoing. 2.Staff were in-serviced/trained on how to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to other residents. All staff will be re-educated prior to next scheduled shift including staff that are on leave and are on vacation. Administrator and Assistant administrator are conducting the training. The training includes the Abuse prevention reporting policy, specifically the definition of abuse, Sexual abuse, sexual assault, rape and internal reporting requirements and identification of allegation and protection of residents. Staff acknowledged information via signature. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. The abuse prevention training program posttest questionnaire is the material utilized. No revision of the current abuse policy has occurred. The noncompliance was a failure to follow current policy IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. 1/10/23 started at 2:45pm. 3.Residents that have been identified for being at risk for sexual abuse have had their care plans updated to reflect interventions to prevent abuse. List of identified residents was provided to survey team. Intervention implemented 1/10/23 . 4.Resident identified with sexually inappropriate behavior was counseled and placed on close staff supervision, was educated on symptom management, maintaining boundaries and importance of utilizing coping skills to manage symptoms, and will be followed up with by staff and/or psychiatrist regularly. QA tool titled Abuse reporting, interventions and investigation will be completed weekly by the Administer or Assistant Administrator. Observations noted during regular rounds will be discussed at the QA Committee. Concerns will be discussed among the members, a plan of action is devised, and past plans of actions evaluated. Intervention implemented 1/10/23 39340 II. Based on interview and record review, the facility failed follow the physician order to monitor and conduct neuro checks after a head injury. This failure affected 1 resident R43 reviewed for post injury monitoring. Findings include: R43 was admitted to the facility on [DATE] with a diagnosis of schizophrenia and hypertension. Progress note dated 1/8/23 at 3:08 pm: Resident walked out of his room and was sleeping walking towards the exit door. He was bumping his forehead into walls and doors. Laceration with dried blood noted to his forehead with minimal swollen. On 1/8/23 at 4:20 pm, R43 was observed with dried blood on his forehead and swelling noted to the bridge of nose and forehead. R43 was unable to say what happened. On 1/8/23 at 4:22 pm, V4 (Nurse) said she observed R43 wandering, and staff reported that he bumped his head into something. V4 said R43 had dried blood on his head. V4 said she did not notify the doctor or conduct neuro checks on the residents. V4 said R43 was placed on one-to-one monitoring with staff. On 1/8/23 5:30 pm, V34(Nurse) said R43 head was swollen. V34 said she did not call the doctor or the family about change in condition and the nurse who was assigned prior should have completed notification. V34 said they were not conducting any neuro checks at this time. On 1/11/23 at 10:30AM, V2(Director of Nurse) said any resident that experiences a head injury the doctor should be notified, and neuro checks should be initiated, documented in the resident chart. V2 unable to provide any further monitoring for R34. R43's progress note dated 1/11/23 11:51 am documents: R43 was sent to local hospital. On 1/11/23 at 6:00 pm documents resident returned with a diagnosis of head trauma and abrasion. On 1/12/23 at1 12:35 pm, V36(MD) said he was notified of incident with R43 but unable to recall who contacted him and instructed staff to conduct neuro checks. V36 said he would expect staff to follow orders. III. Based on observation, interview, and record review, the facility failed to monitor residents during smoking breaks to prevent resident from bringing in smoking materials and smoking in an undesignated area. This affected 1 resident R98 reviewed for inappropriate smoking in the sample of 35. Findings include: R98 was admitted to facility on 5/2/22 with a diagnosis of schizoaffective disorder, alcohol abuse, major depressive disorder, nicotine dependence. R98 smoking risk assessment dated [DATE] documents: minimal problem for potential risk recommended require supervision only not able to store smoking materials. On 1/8/23 at 10:04 am, R98 was observed smoking in her room. R98 said she took cigarettes in from smoke break this morning. R98 had a pop bottle on nightstand with 5 cigarette buds in it and verified with V7 (Mental Health Tech). R98 denied having a lighter. On 1/8/23 at 10:40 am, the East smoking area was observed with multiple cigarette buds scattered on the ground. R98's care plan revised on 7/11/22 documents: I am an inappropriate smoker with following interventions dated 5/2/22: Resident will keep smoking materials in a secured location. Resident requires supervision while smoking; intervention dated 7/11/22. Resident will watch a smoking cessation video. R98's care plan and progress notes did not document any smoking violations on 1/8/23. Smoking Policy documents: Staff responsibilities: staff will monitor residents removing cigarette buds from ashtrays or form the ground. Staff will empty and sweep before leaving the smoking areas as needed. All reports of residents who have smoking violations must be reported, documented, and followed up. IV.Based on observation, interview and record review, the facility failed to develop and implement effective fall prevention interventions for 2 residents (R68, R327) with a history of falls. This affected 2 residents (R68, R327) reviewed for fall prevention in the sample of 35. This failure results in R327 sustaining a fall requiring 6 sutures to her lower lip and R68 falling and sustaining bruising to his left eye. Findings include: 1. R327 was admitted to the facility on [DATE] with a diagnosis of epilepsy, unsteadiness on feet and schizophrenia. R327's Minimum Data Set, dated dated dated [DATE] documents under balance during transitions a score of one which indicates not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Under mobility device it indicates a walker. R327's therapy notes 9/24/22 under fall assessment documents: does patient feel unsteady when standing-Yes; Does patient feel unsteady when walking- Yes; Does patient worry about falling- Yes. Under ambulation documents walk 10 -50 feet requires partial to moderate assistance. R327's progress note dated 9/26/22 at 5:30 pm, Narrative: Writer notified by Mental Health Tech resident had fallen as she was coming out her room. Resident assisted to her bed. R327's Progress note 10/2/22 at 9:07 am documents: Nurse was informed by residents' roommate that she found her on the floor after coming in from breakfast. Full body assessment was preformed, vitals were checked and were within normal limits. Resident states that she hit her head and busted her lip on the nightstand. R327's hospital record dated 10/2/22 documents: R327 states she tripped on something and fell on her face. 6centimeter laceration to lower lip down to subcutaneous tissue. Six sutures placed to lower lip. R327's fall care plan dated 1/9/23 documents: 9/26/22 Physical therapy consult for strength and mobility; assessed for injury. 10/2/22 documents: continue with physical therapy for strengthening and mobility; neuro checks for 72 hours; refer to pharmacy for medication review. On 1/10/23 at 12:30 pm, V17(Restorative Nurse) said she was unsure if R327 was on therapy prior to first fall. V17 said the interventions were to continue therapy for strength and mobility. V17 said they offered R327 a walker after the second fall, but she refused. V17 said she was unable to provide any documentation related to medication review or neuro checks performed. V17 was unable to provide another care plan with initiated dates for care plan interventions. On 1/13/23 at 3:56PM, V21 (Mental Health Tech) said he recalls R327 falling a couple of times but unable to recall exact dates. V21 said R327 could not stand by herself, and he would sit outside her room to assist with getting things for her. R327 needed to hold on your arm or side rail to keep herself up when walking. R327's fall risk assessment dated [DATE] documents not at risk for falls. Under gait/balance documents: balance problem when walking. Facility fall prevention program reviewed 1/22 documents: care plan incorporates identification of all risk/issue, addresses each fall; interventions are changed with each fall; preventative measure. Resident environment will be kept clear of clutter which would affect ambulation and remove hazards. 40066 2. R68's diagnosis includes but not limited to Epilepsy, Schizoaffective Disorder, Dementia, Psychotic Disturbances, Mood Disturbances, and Anxiety, and Severe Intellectual Disability. Incident report dated 11/26/21 notes R68 noted running in the hallway when he slipped and fell . Progress Notes dated 10/22/22 documents maintain fall/safety precautions. Incident report dated 1/2/23 notes R68 was running in the hallway and fell . Report noted R68 was unable to provide description. Nothing was cited on precipitating and contributing factors. Report notes R68 sustained a swollen eye. Fall Initial Occurrence for R68 dated 1/2/23 documents a fall occurred in the hallway. Description notes R68 was running in the hallway and fell . It is documented R68 was unable to provide a description. Precipitating and Contributing Factor has nothing selected. [NAME]-checks notes the this was witnessed and R68 struck his head. Orientation of R68 notes e is alert and oriented to time, person, place, and situation. New injury observed swollen eye. Report completed by V20 (Licensed Practical Nurse/LPN). On 1/8/23 at 9:58 am, the surveyor observed R68 walking in the hallway without socks or shoes. On 1/8/23 during initial round approximately 10:00 am R68 was observed ambulating without shoes or socks on in the hallway. On 1/8/23 between 10:30 am-11:00 am R68 was walking barefoot, no shoes or socks on in the hallway. R68 was observed with dark bruised, black eye, to left eye. On 1/9/23 between 10:30 am-11:00 am R68 was observed by the surveyor walking from the west unit to the central unit with no socks or shoes on. The surveyor did not observe any staff offering him socks, grip socks, shoes, approach, or redirect R68 for footwear. On 1/9/23 at 12:00 pm V6 (Registered Nurse) said they told me R68 fell . V6 said she was told R68 fell face down and got a black eye. V6 said R68 goes running in the halls. V6 said she saw R68 running in the hall on 1/2/23 and I told his nurse to do something. On 1/9/23 at 12:24 pm V20 (Licensed Practical Nurse/LPN), said I was told earlier that R68 was running up and down the hall (V20 unable to say who told her or when). V20 said V21 (Mental Health Tech/MHT), called me and said R68 fell in the hallway. V20 said I didn't see him on the floor. V20 said R68 had been at baseline before he fell . V20 said after the fall I assessed R68. V20 said R68 is not verbal, he just made his noises, his vitals were normal, and the bruising and swelling started later that day. V20 said the bruising and swelling progressed overnight. The surveyor asked V20 if R68 was at risk for falls and V20 said R68 doesn't have falls. V20 said I think R68 was running, and he fell . On 1/9/23 at 12:36 pm V21 (MHT), said he saw R68 was running in the halls on 1/2/23. V21 said when R68 is running we usually redirect him. V21 said he told R68 to stop running and then R68 fell . V21 said he saw R68 tripped and hit the wall or the floor, and then bounced up like nothing happened. V21 said it was loud when he fell , you heard it. The surveyor asked what footwear R68 was wearing when he fell , V21 responded he is almost positive barefoot. On 1/9/23 at 12:46 pm V7 (MHT), said I have seen R68 running in the halls. On 1/10/23 at 9:57 am V22 (Certified Nurse Assistant/CNA) said R68 is compliant. V22 said R68 gets the zoomies, fast running like he is doing the track. On 1/10/23 at 10:20 am the surveyor observed R68 sitting in his bed with regular socks on. The surveyor asked V32 (CNA) to show the surveyor R68's shoes. V32 said R68 doesn't have any shoes. 1/10/23 at 12:52 pm V17 (Restorative Nurse) said when a fall occurs, we do team root cause analysis. V17 said I will enter the intervention in the care plan once determined. V17 said I would expect staff to carry out the interventions listed on the care plan. V17 said R68 is complaint with care. On 1/11/23 at 10:31 am V2 (Director of Nursing) said on 1/2/23 R68 was observed by staff running in the hall and fell and hit his face on the floor. V2 said running is not a new behavior for R68. V2 said when R68 is observed running staff can redirect him. V2 said most of the time R68 responds to redirection, is cooperative, and I don't think he has fallen before. V2 said I do not think he was wearing footwear when he fell on [DATE]. V2 said R68 is notorious for walking barefoot. V2 said staff should be offering to apply footwear if R68 has no shoes on. V2 said if R68 refuses then the staff should let the nurse know that they offered footwear and R68 said no. V2 said interventions for R68 can be trying to walk with him, offer a snack, and offer nonpharmacological interventions. V2 said R68 responds fairly well to nonpharmacological interventions. V2 said when R68 is running back and forth, it is not every day, and I would have someone with him to monitor him. Care plan initiated on 4/5/17 notes R68 has impaired cognitive function and impaired thought process related to impaired decision making related to Dementia. On 11/16/21 a care plan was initiated for potential for falls related to use of psychotropic medication and seizure disorder Intervention dated 11/16/21 noted appropriate footwear. No intervention is documented on the care plan following R68's fall on 1/2/23. No behavior of R68 running while inside the facility is documented. Additional, care plan initiated on 11/30/21 notes I am at risk for fall/injury related to wandering/poor safety awareness. The facility Fall Prevention Program revised on 11/21/17 states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporates identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. Footwear will be monitored to ensure the resident had proper fitting shoes and/or footwear is non-skid.

Based on interview and record review, the facility failed to monitor and supervise a resident that is known to respond to internal stimuli to prevent an avoidable accident. This affected 2 of 3 residents (R2, R3) reviewed for supervision, accident, and incidents. This failure resulted in R3 spontaneously throwing a chair resulting in R2 being hit in the face with the chair sustaining a laceration which required 4 sutures. Findings Include: R2's diagnosis: [CONDITION(S)] disorder and auditory hallucinations. R2 admitted to the facility 2/17/22. R3's diagnosis: [CONDITION(S)], [CONDITION(S)] disorder, and [CONDITION(S)]. R3 admitted to the facility on [DATE]. A Behavior note dated 9/27/22 at 7:24AM documents R2 was hit by a chair on the forehead in the day room by another resident. Bleeding to forehead was noted with a deep laceration. 911 was called for immediate transfer to the hospital. R2 is alert oriented times 3 and conscious to the situation. No distress was noted. A Nursing note dated 9/27/22 at 10:32 AM documents R2 returned to the facility from the hospital with 4 sutures to the forehead. An IDT note dated 9/28/22 documents the summary of the IDT meeting is that R2 was injured as a result of R3's non-targeted outburst. R2 was struck by a chair. R2 will be assisted by intervening when R2 is observed in the vicinity of peers responding to internal stimuli. The Hospital Records dated 9/27/22 document R2 presented to the emergency room with a facial laceration. R2 reported being struck by a chair this morning when another resident threw the chair. R2 denied loss of consciousness, [CONDITION(S)], pain, or uncontrolled bleeding. R2 was seen for a laceration repair and was sent back to the facility. The Final Incident Report of all dated 10/1/22 documents R2 was accidentally hit by a chair while sitting in the TV room. An open area to the forehead was noted. Four sutures were noted to the forehead upon return from the hospital. R3 was placed on behavior management skills program. No abuse was identified as this was a non-targeted outburst from R3. On 10/28/22 at 12:22PM, R2 had a laceration to the left upper forehead about 3 inches long. The laceration was glued and is healing. When asked what happened to R2's head, R2 stated, R3 hit me with a chair one morning. R3 just picked up the chair and threw it across the room. We were in the TV room. It was an accident. R3 didn't act mad before the threw it. R3 was just sitting down then R3 stood up and threw the chair. R3 was strong enough to throw it far enough to hit me. R3 didn't say anything to me. I never talked to R3 before. R3 is usually very quiet. I know R3 has some problems with R3's brain. No one was in the TV room that was staff. It was only 3 or 4 residents in the TV room early that morning. During this investigation, no staff were noted supervising the residents in the TV room. The number of residents ranged from 2 - 10 people at one time. Staff would look into the TV room as they walked down the hall, but no staff ever entered the TV room to check on the residents. On 10/30/22 at 11:33AM, When asked about the incident when R3 threw the chair at R2, R2 stated, Yes, I threw it. I don't remember who got hit. I didn't mean to hit anyone. I don't remember why I threw it. I don't have any problems with anyone here. R3 had a very flat affect and would not respond to most questions. On 10/30/22 at 12:51PM, V11 (Nurse) stated, I didn't see this happen, but they were both in the TV room when staff started calling for me to come down there. R2's head was bleeding. It was not gushing but R2 did have blood dripping down R2's head. I called 911 right away and got R2 sent out to the hospital. I was told that R3 hit R2 in the head with a chair in the TV room. No, there was no one (staff) in the TV room when R3 did that. I don't know who was supposed to be in there but when this happened it was just the residents. When I asked R2 what happened R2 said that R2 was in the TV room and R3 was in there with R3 and just picked up the chair and threw it. R2 said R3 didn't say anything before R3 threw it. R3 didn't even talk to R2. R3 just picked up the chair and threw it across the room. On 10/30/22 at 2:18PM, V1 (Administrator) stated, That incident R3 was responding to some internal stimuli while R3 was in the TV room. R3 picked up the chair and threw it across the room which ended up hitting R2. There was no screaming or any other behaviors before R3 picked up the chair and through it. He never really has aggressive behaviors. I know the maintenance man was walking down the hall and heard a chair fall over, so he went into the TV room to see what was going on and saw that the chair was on the ground next to R2 and R2's head was bleeding. On 11/1/22 at 9:11AM, V16 (Nurse) stated, The other resident (R2) that was hit said that R3 just stood up from the chair R3 was sitting in and picked it up and threw it. R2's head was bleeding, and we could not get it to stop so R2 had to be sent out for sutures. No other staff saw it. No one was monitoring the TV room at the time this happened. Someone should be monitoring this area, but I don't know where they were at. When I asked the tech what was happening, she said she was busy doing something else. I told her that someone always needs to be monitoring them. On 11/1/22 at 9:57AM, V18 (Nurse) stated, I later found out that morning that R3 threw a chair. R3 must have just been responding to some stimuli that let R3 to have that behavior. I was not here so I do not know if anyone is monitoring the TV room. I don't know who monitors the TV room. On 11/1/22 at 1:13PM, V5 (Maintenance Director) stated, It was maybe around 6:30 in the morning, I was walking down the hallway and I heard a chair fall over in the TV room. I went into the TV room and saw a resident (R2) who had blood coming from R2's head and the chair was on the floor next to R2. I tried asking what happened, but no one was answering me at first. I came back down, and another resident was telling me that R3 threw the chair. I know R2 had a laceration on R2's head but I don't know about anything else. R2 did have some blood coming down R2's forehead but it wasn't spraying out or anything. There was no screaming or yelling or anything before I heard the chair fall. The only thing that made me go look in the TV room was the sound of the chair hitting the ground. There was no staff in the TV room when this happened. It was only the residents. I think there was 3 or 4 of them in there. I don't know who is supposed to be watching the room. The Psychosocial assessment dated [DATE] documents R2 is injured as a result of R3's non-targeted outburst. R2 reported being hit by a chair thrown by R3. R2 has not had any prior negative interactions with R3. R2 was not interacting with R3 at the time of the incident. R2 was observed to be calm immediately following the incident and did not express being in much pain. The Care Plan dated 7/12/22 documents R2 is at a potentially moderate risk for abuse/neglect related to depression and mental illness. On 9/27/22, R2 was injured due to a peers non-targeted outburst. A Nursing note dated 9/27/22 documents it was reported R3 had a physical altercation with R2. R3 refused to give account of the incident. Both residents were separated and 1:1 monitoring was implemented. Education was provided to R3 to keep R3's hands to self and report issues or concerns to staff. A doctor's order was given to send R3 to the hospital for psychiatric evaluation. R3 left the facility in a calm and cooperative demeanor. An IDT note 9/28/22 documents R3 displayed a non-targeted outburst resulting in an injury to R2. R3 reported R3 had no intention of harming R2. R3 was responding to internal stimuli. R3 was counseled to seek staff to utilize the sensory room when feeling negative urges. There is no other documentation of R3 having any physical altercations or aggressive outbursts with other residents since R3 was admitted . The Behavior/Mood Charting dated 9/27/22 documents R3 was physically aggressive as shown by throwing a chair across the room that hit another resident. R3 had no triggers to this behavior. R3 was educated during 1:1 monitoring. The Psychosocial assessment dated [DATE] documents R3 displayed a non-targeted outburst resulting in R2 being injured. R3 reported feeling angry and had an urge to act on it. R3 threw a chair blindly that hit R2 by mistake. R3 has partial recollection and awareness of the event. R3 was observed to be somewhat remorseful as mentioned R3 was responding to internal stimuli and had no intention of harming R2. R3 has no indicated triggers that would set off a physical altercation. R3 is known to respond to internal stimuli. The Care Plan dated 4/27/22 documents R3 has a potential to be verbally and physically aggressive related to history of aggressive behavior. On 9/27/22, R3 displayed a non-targeted outburst resulting in a female peer's (R2) injury. Interventions include the educating and counseling R3 to develop insight into aggressive behavior. R3 was encouraged to seek staff to utilize the sensory room when feeling negative urges. The Minimum Data Set Section E dated 10/3/22 documents R3 experiences hallucinations and delusions. There is no documentation of R3 having any physically aggressive behaviors.

Based on record review and interview the facility failed to protect residents from being abuse by physically aggressive residents and failed to immediately intervene in situations before residents became physically aggressive towards their peers for ten (10) of twelve (12) residents (R2, R3, R6, R7, R8, R9, R10, R11, R12, R13) reviewed abuse. As a result, R8 was physically assaulted by R9. R8 sustained a partial dislocation of the C1-C2 to R8's neck and head abrasions. R3 punched R2 in the nose several times causing R2 to have a nosebleed and some facial swelling. R7 walked into R6's room uninvited and R7 began to hit R6 causing a skin tear and some scratches to R6's right arm. R10 and R11 were arguing and subsequently R11 slapped R10 on the leg. R12 and R13 were arguing and R13 slapped R12's face causing some redness to R12's eye. Finding Include: Facility's abuse prevention policy denotes the residents have the right to be free from abuse, neglect, misappropriation of resident property exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility desires to prevent abuse, neglect, exploitation, and mistreatment. This will be accomplished by Staff supervision. Situations such as inappropriate language, incentive handling, or impersonal care will be corrected as they occur. 1. R8's Nurses Note Narrative for 3/22/2022 5:40 PM documents resident escorted to the nursing station c/o (complain of) peer (R9) being physically aggressive. Upon assessment resident has approximately 6 superficial scratches to the right side of head, 5 on the scalp and 1 on the forehead. Site cleansed with normal saline and [MEDICATION(S)] applied. MD to be notified. Resident reports being hit by a white man. States he was hit with an unknown object. Area was cleansed and pressure applied to stop bleeding. Administration notified of incident. Dr. notified and gave orders to send resident to ER for head evaluation. Attempted to contact resident's father, however unable to contact. Neurology assessment initiated. Resident sent to hospital via ambulance. Resident alert & oriented. Verbally responsive. Vital signs obtained. R8's Nurses Note Narrative for 3/23/2022 1:05 AM documents resident returned from hospital, O/F with a neck collar. Vitals-1136/82 (SIC), 97.3, 80,18. Sp02 (blood oxygen) 97% on room air. Resident denies pain at this time. Resident in bed, call light with reach. Resident needs to stay in his neck collar until he follows up on appointment. Follow-up appointment with Dr., neurosurgeon. No apparent distress noted. Will cont. to monitor the resident. R8's Nurses Note Narrative for 3/23/2022 1:15 AM documents resident returned with dx: Subluxation (partial dislocation) of C1-C2 cervical vertebrae, initial encounter. CT head/brain and CT spine cervical carried out during hospital visit. No new orders received. R8's hospital records dated 3/23/23 denotes reason for visit head injury; Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's care plan denotes R9 has potential to be verbally aggressive while experiencing mood swings. Ineffective coping skills. Interventions included, monitor behaviors every shift. Document observed behavior and attempted interventions. R9s' Behavior Late Entry: Note Text for 3/22/2022 5:10 PM documents it was reported to management that resident is allegedly being physically aggressive towards a male peer. Resident will not disclose any information regarding this incident. A complete body assessment was rendered and no physical signs of injury. Emergency contact and psych MD notified. Will continue to monitor. R9's SOCIAL SERVICE NOTE Text 3/23/2022 10:30 AM documents writer spoke to resident in regard to an altercation he got into with peer. Resident admitted to becoming physically aggressive with peer last night but alleged that he threatened to stab me with a pen, and I am the police, so I stopped him. Writer discussed with resident that he should always come to staff instead of becoming physically aggressive. Resident stated he understood. Staff will continue to monitor to ensure safety of resident and others. R8 stated on 5/5/22 at 3:10 PM that he was in a car accident a few weeks and his neck got hurt. R8 stated he wore the C-collar around his neck, but it is still sore sometimes when he turns his neck. R8 stated he feels okay and feels it is safe to stay in the facility. On 4/27/22 at 5:30 PM V8 (Mental Health Technician) stated R8 keeps to himself but likes to joke and be sarcastic. V8 stated not seen or heard of R8 being aggressive. V8 stated R8 came out of his room for dinner and saw a laceration on R8's head. V8 stated V8 asked R8 what happened and R8 told them he did not want to talk about it. V8 stated V8 told the nurse. They investigated it and discovered that R8 was in an altercation with R9. On 4/27/22 at 5:00 PM V13 (Mental Health Technician) stated V13 was working when around dinner time when R8 came to eat and noticed R8 was bleeding from several scratches on his head. V13 stated the Administrator came to the dining room and talked to R8 and found out that R9 had attacked him. V13 stated V13 had seen R9 have in the past verbal altercations with other residents but this is the first time he seen/heard R9 have a physical altercation another resident. V13 stated they sent R8 out to the hospital right away and R9 was sent to the hospital later. V13 stated because R8 and R9 were roommates, their rooms were changed. On 4/21/22 at 4:15 PM V4 (Administrator) stated staff reported to him that R8 had a small abrasion on the side of his head. V4 stated R8 would not say or tell them what happened. V4 stated V4 interviewed R8's roommate who was R9 at that time and R9 denied doing anything. V4 stated V4 interviewed a resident that saw the incident and saw R9 sitting on R8's head then walked away. V4 stated during course of the investigation it was discovered that R8 had a neck injury. V4 stated R9 was sent out to the hospital that day when they found out what had happened and R9 has not returned to the facility. On 4/27/22 at 5:15 PM V15 (Psyche Social Rehab Coordinator) stated she has been working at the facility and R9 was on her case load. V15 stated R9 was alert to self and believed he was a police officer or the president. V15 stated R9 had flight of ideas and delusions of Grandeur. V15 stated R9 was invited to attended groups but refused to go sometimes. V15 stated when R9 did go to group he would do the assignments. V15 stated R9 was seen talking to himself and responded to others aggressively. V15 stated R9 did have in the past of aggression towards other residents, which from what they saw were unprovoked. V15 stated the best way to handle R9 was to intervene or redirect R9 before or when he is getting upset. V15 stated R8 is very timid but has delusions at times. V15 stated R8 interacts with select peers but mainly keeps to himself. V15 stated R8 did not have a history of being an aggressor of any type. V15 stated R8 can report if something happened to him and if asked right away or a few weeks later. V15 stated R8 internalizes and have flight of ideas and trouble verbalizing the exact details on the incident he had with R9. On 5/5/22 at 4:00 PM V19 (Doctor) stated subluxations mean the vertebrae of the neck is out of alignment or slightly off. V19 stated the C-collar was given to R8 and it helped to put the vertebrae back into alignment. V19 stated it seemed that R8 sustained an injury but because R8 did not require surgical interventions nor display any neurological damage he and others in the health care field classify it has a minor injury. V19 stated R8's injury would only been a major injury if R8 had displayed some neurological deficit/injury and/or required surgical intervention. V19 stated has seen R8 and he is healing, doing well and showing no neurological deficiency. V19 stated there are several causes of subluxation but one cause is if a person sits on another person neck that can cause a subluxation. On 5/5/22 at 4:45 PM V18 (Psyche Rehab Service Director) stated she is over the case managers and mental health technicians. V18 stated the mental health tech (MHT) should be able to intervene in a situation when they see a resident getting upset or aggressive and attempt to redirect that resident from the situation. V18 stated the MHT are also trained in crisis prevention intervention so they and the residents do not get help and last option to use when the resident might be a danger to themselves or others. V18 stated the MHT are to make rounds frequently during their shift making sure residents are where they are supposed to be. 2. R3's Nurses Note Narrative for 2/24/2022 10:07 PM documents writer was responding to code yellow, when MHT informed staff that two residents had been involved in a physical altercation. The MHT staff separated the two residents. Body assessment rendered to the above resident, it was noted that resident had slight swelling to right side of face, lips, and nose with moderate blood loss(from nose). First aid administered. Resident denies pain, however, resident received prophylactic pain medication. MD was called and orders carried out. The administrator was informed of incident. Writer left non- emergency message for Contact. DON, also informed of incident. Resident to be monitored for 72 hours. On 5/5/22 at 2:50 PM, R3 stated a few weeks ago I was in the hall walking going down the corridor and saw R2 come out a room. R3 stated, R2 approached him and punched him in the face and nose a few times. R3 stated staff came and grabbed R2 and took R2 to a room. R3 stated the nurse looked at his face and gave him some ice for his nose. R3 stated his nose was not broken just sore at that time but is fine now. On 4/21/22 at 4:00 pm V3 (Psyche Social Rehab Coordinator) stated R2 was on his case load for three months and did not attend groups like he was supposed to and had to meet with R2 for 1:1 counseling. V3 stated some days R2 is normal and other days his delusions/hallucination became heightened, and he would be unpredictable. V3 stated V3 would get reports of R2 getting physical/aggressive and counseled him on keeping his hand to himself. V3 stated a lot of R2's behaviors happened in the evening time when he was not there physically at the facility. V3 stated if staff see that R2 is upset or that his symptoms are heighten staff should intervene. V3 stated interventions are in R2's plan of care that they should do before or when R2 was getting upset. V3 stated R2 did not take his medications like he should and when they asked R2 why he did something inappropriate his thought process was so disorganized he could not explain why he did what he did. V3 stated R2 was sent out of the facility the hospital and not expected to return to the facility. On 4/21/22 at 4:30 PM,V9 (Licensed Practical Nurse) stated she has worked at the facility for ten years. V9 stated R2 was tall resident that tried to bully residents if he could. V9 stated R2 was non-compliant with meds and ADL's. V9 stated was working and heard some commotion and saw R2 punching R3 several times in the face. V9 stated, I called code yellow which means residents are having altercation or behavior issues. V9 stated, staff came, and they separated both residents. V9 stated , she assessed R3 face and noted blood on his nose. V9 stated notified the doctor and he gave order first aide to R2 and monitor. V9 stated tried to give R2 [MEDICATION(S)] shot but he refused, and they called the 911. V9 stated the police came and paramedics arrived but they had to get more officers because R2 was acting belligerent. V9 stated the police and paramedics restrained R2 to a stretcher and took him to the hospital. V9 stated asked R3 what happened and told them that he did not say anything to R2 and that R2 just attacked him for no reason. On 4/21/22 at 4:45 pm V7 (Mental Health Technician ) stated, V2 was working the second shift at the desk monitoring the cameras and checking on the residents. V7 stated V2 was standing by another resident that needed assistance and saw R2 swinging his arms in R3's in direction. V7 stated he ran towards R2 and R3 and they separated them and saw R3 had a blood on his nose. V7 stated R2 was offered shot but he refused so he was on 1:1 until the ambulance arrived. V7 stated asked R2 what happened but refused to talk about it. On 4/27/22 at 5:00 pm V13 (Mental Health Technician) stated a nurse called a code yellow and arrived. R2 and R3 had been separated and saw R3 with blood on his nose and shirt. V13 stated R2 had his good days and bad days. V13 stated R2 always refused his medicine before and had to physically pull him away from attacking other residents in the past. V13 stated R3 was quiet and kept to himself. On 4/21/22 at 5:00 pm V6 (Licensed Practical Nurse) stated she was working when R2 had an altercation with R3. V6 stated from what she recalled the residents were separated and noted small scratch on R3's nose that was bleeding. V6 stated asked R2 what happened, and he replied that he was tired of R3 coming by his room and hit him. V6 stated residents were separated and R3 sent out psych evaluation. V6 stated R2 refused to go out to the hospital and told them he was okay and to leave him alone. On 4/21/22 at 4:15 pm V4 (Administrator) stated staff reported to him that R2 and R3 were in an altercation. V4 stated R2 had history on being noncompliant with his medications. V4 stated from their investigating R2 was walking down the hall, became delusional and struck R3 in the face. V4 stated staff intervened and separated both residents. V4 stated that R3 had no significant injury just scratches on his nose. V4 stated R2 is no longer in the facility. 3. R6's Nurses Note Narrative 3/17/2022 21:57 (9:57pm) : resident observed in physical altercation with male peer (R7). Resident stated peer just walked to her room and started an altercation. Assessment shows skin tear to right arm. Cleansed area with saline and applied antibiotic ointment MD made aware of incident. Neuro checks initiated. Will monitor. R6's social service note text 3/18/2022 8:15am: Writer met with resident to follow up after her incident with a male staff the night prior. Resident reported that she was feeling fine and expressed gratitude for writer checking on her. Writer encouraged resident to stay away from her male peer, as well as to speak w/ staff when she has any further conflicts with peers. Resident verbalized understanding. R7's care plan denotes the potential to be verbally and/or physically aggressive, experience auditory hallucinations and demonstrate an unstable mood r/t [CONDITION(S)] diagnosis. Interventions include when the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation, If response is aggressive, staff to walk calmly away, and approach later. 3/5/2022 9:00 am R7s' social service note text: Writer responded to a code yellow that resident was involved in. There was a verbal altercation between resident and peer, resident attempted to get physical, but staff was able to intervene prior to physical contact with peer. Writer brought resident into the office to counsel and separate from peer. Resident expressed that he was upset that peer had called him the N word and he was also trying to get in his room. It is my room and not his, he cannot have my stuff or their stuff. Writer verbalized understanding of his feelings of agitation but went over with resident better ways to handle this situation, i.e., seeking out staff. Resident stated he understood. Resident then showed writer his nail which he stated, I think I split my nail on the wall Writer brought resident to the nurse who attended to his nail. Staff will continue to monitor. 3/13/2022 7:00 pm R7's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . NOD reports occasional agitation. Can be redirected with non-pharmacological approach at this time. Upon encounter no s/s of depression, anxiety or agitation. No active [CONDITION(S)]. Patient denies SI, HI, AVH at the time of my evaluation. 3/17/2022 9:26 pm R7's nurses note narrative: Resident observed in physical altercation with female peer in her room. Resident was observed leaving the scene staff intervention. No injury or distress noted upon assessment. MD and family notified of incident. Orders received from MD to send out to hospital for psych evaluation. 3/18/2022 9:00 am R7s' social service note text: Writer along with PRSD spoke to resident in regard to altercation with peer that had happened last night. Resident apologetic and states, I are sorry I don't know what happened I just lost control. Resident counseled on appropriate ways of handling feelings of anger or loss of control, such as seeking out staff and asking for help. Resident verbalized understanding. Explained to resident that he will be sent out help him understand why he lost control. Resident is being sent out for psychiatric evaluation. On 5/5/22 at 3:05 pm R6 stated a few weeks ago R6 was in her room watching TV minding her own business when suddenly R7 came in her room grabbed her by her arms shook and hit her on the head a few times. R6 stated staff came escorted R7 out of her room. R6 stated nurse looked at saw her and cleaned the scratches on her arm that R7 had did with an alcohol pass. R6 stated since the incident R7 has not bothered and not seen R7 since the incident. V15 (Psyche Social Rehab Coordinator) she stated on 4/27/22 at 5:15 pm been working at the facility for a year and R7 was in her case load. V15 stated R7 responds to internal stimuli and at times gets aggressive talking in third person. V15 stated R7 had episodes in the past with other residents being aggressive or attempting to be aggressive. V15 stated V15 would counsel R7, and he always responded that he did not know why he did what he did. V15 stated the best way to handle R7 is to intervene or redirect R7 before or when he is getting upset. V15 stated V15 heard that R7 had grabbed R6, and he was sent to the hospital. V15 stated R7 has not returned to the facility and R7 not been in the facility several weeks. V6 stated R6 can tell you what happen to her and capable of verbalizing to staff if something had happened to her. V15 stated R6 is delusional at times and respond to internal stimuli but there are times but not all the time. V15 stated is not one that would become physical maybe verbal with others when she is having delusional moment. On 4/21/22 at 4:30 pm V9 (Licensed Practical Nurse) she stated was working on the unit and recalled R6 was in her room. V9 stated heard a noise from R6's room and went into R6's room and saw R7 on top of R6 hitting her. V9 stated R6 and R7 were immediately separated. V9 stated R6 was assessed and noted scratches on her arm and R6 did complain that her head was hurting. V9 stated R7 was monitored until he was sent to the hospital. V9 stated in the past with R7, and his roommate got into an altercation it and staff had to separate them. On 4/27/22 at 5:00 pm V13 (Mental Health Technician) stated he was working, and nurses called a code yellow regarding R6 and R7. V13 stated when arrived to R6's room R7 had already been escorted out and noticed that R6 had a couple of scratches on her arm. V13 stated the nurse gave R6 some pain medicine and heard R6 tell them she was okay. V13 stated not seen or heard of R7 attacking other residents before. On 4/21/22 at 4:15 pm V4 (Administrator) stated staff reported to him that R7 was delusional and got into an altercation with R6. V4 stated R6 does have verbal outburst for no reasons but none were witness that day. V4 stated after interviewing R7 he told them that R6 was yelling and that got him upset and ran into her room and grabbed her arm and in the process scratched R6's arm. V4 stated staff did intervene afterwards and separated both residents. V4 stated R7 was send out to the hospital and has not returned. 4. 2/22/2022 3:45 am R10's nurses note narrative: As per MHT, he said he witnessed resident and roommate having physical altercation. Writer assessed resident; no injury observed. Denies pain and discomfort. Resident is responsible for herself. MD paged. Will continue to monitor. 2/22/2022 12:27 pm R10's social service note text: Writer spoke with resident in regard to altercation she got into with peer. Resident states it is over I am good. Resident states that other peer slapped her but she is not scared of her. Writer encouraged resident to come to staff if she was having issues and not to exchange words with others. Resident verbalized feeling safe and secure at this time. R11's Care plan denote potential for behavioral events, physical aggression. I use [CONDITION(S)] medications R/T diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2/22/2022 3:45 am R11's nurses note narrative text: As per MHT said he witnessed resident and roommate having physical altercation. Resident denies having altercation with roommate. Writer assessed resident; no injury noted. No bruise or redness noted. Resident denies pain and discomfort, no distress noted. Resident does not have any contact on face sheet and MD paged. Will continue to monitor. On 4/27/22 at 5:00 pm V13 Mental Health Technician) stated R10 and R11 were having a verbal argument when V11 suddenly slapped V10 on her leg/foot. V13 stated residents were separated, administrator notified, and a room change was done. On 4/27/22 at 5:30 pm V8 (Mental Health Technician) stated R10 is middle aged woman that likes to keep her rooms cleans. V8 stated R10 will follow directions and take her medicine. V8 stated R11 has verbal outburst and likes to scavenge in the garbage or seek food. V8 stated V8 has never seen R11 attack other residents, the most seen R11 do is scream and make outburst at no one in particular. On 4/21/22 at 4:15 pm V4 (Administrator) stated staff reported to him that they (R10, R11) were having a verbal argument and then V11 slapped V10 on her leg/foot. V4 stated R11 denied the incident took place and never admitted to hitting R10. V4 stated staff witnessed R11 hitting R10 on her foot while she was lying in her bed. V4 stated R10 told them that R11 got mad at her because she was eating her food too loudly. V4 stated they were roommates at that time and since the incident are no longer roommates. V16 (Psyche Social Rehab Coordinator) she stated on 4/27/22 at 5:20 pm has worked at the facility for over a year and R11 was in her case load. V16 stated R11 was sweet and not typical for her to hit another resident. V16 stated R11 is in the process of trying to move out of the facility back into the community. V16 stated when told that R11 hit R10, that hitting anyone is not allowed and next time to come to the staff feel their upset or if they have any issues or concerns. V16 stated since R11 hit R10 not aware of any other incident like that taking place since then. V16 stated R11 is supposed to go to groups and does not attend them on a regular basis so they have to do more 1:1 therapy and sit down talk to her about different topics and educate her on life issues. V16 stated they do coping skills or stress management exercise with R11. V16 stated regardless of the what the residents go through they do not have the right to hit/strike another resident. On 5/5/22 at 3:15 pm R10 stated she did not want to discuss any altercation that she had with R11 or any other resident. On 5/5/22 at 3:18 pm R11 stated she did not know who R10 was and did not hit R10. 5. 2/19/2022 11:34 pm R12's nurses note narrative: Resident physically attacked by peer (R13); resident assessed for LOC and apparent injuries; redness to right eye noted. Ice compression given for redness all appropriate parties notified. Will continue to monitor. R13's care plan denotes R13 has the potential to be physically aggressive r/t (related to) ineffective coping skills interventions included When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away, and approach later. 2/19/2022 11:30 pm R13's nurses note narrative: Resident physically attacked peer (R12); Resident unable to recall incident when asked by writer. Resident placed on 1:1 behavior monitoring; Resident became increasingly combative with staff attempting physically attack staff and peers; 911 called to facility. Resident taken to hospital via fire department. All appropriate parties notified. On 4/21/22 at 4:15 pm V4 (Administrator) stated staff reported to him that R12 and R13 were in line for medication pass. V4 stated R13 was banging on the nurse's window when R12 asked R13 to stop hitting the window. V4 stated R13 and R12 exchanged words then R13 slapped R12 in the face. V4 stated they were immediately separated and R13 taken to the hospital for psych evaluation. V4 stated R12s' doctor notified, no orders to send to the hospital but for staff to apply ice to her face. On 4/21/22 at 4:00 pm V3 (Psyche Social Rehab Coordinator) stated R13 was in his case load. V3 stated R13 had some delusions and hallucinations. V3 stated R13 had issues with controlling her temper would verbally/aggressive with other residents and staff. V3 stated they try to intervene before R13 gets physically aggressive or verbally aggressive by counseling her with 1:1 or ask the nurse to give prn meds. V3 stated R12 is sweet residents and does at times make false reports. V3 stated was made aware that R13 had an altercation with R12 and R13 was sent out to the hospital for eval. On 4/27/22 at 5:00 pm V13 (Mental Health Technician) stated he was working and heard that R13 got mad at R12 and slapped R12. V13 stated has seen R13 in the past hit other residents in the past and they would have to intervene, and the nurse give her medicine to calm her down. On 4/27/22 at 5:30 pm V8 (Mental Health Technician) stated R12 was very young,19, energetic and will get into awkward situations with other residents therefore needed to be supervised more. V8 stated R12 felt like people were against her because she was so immature. V8 stated R13 was bi-polar but mentally knew right from wrong. V8 stated R13 got along with some residents and some residents she did not get along well with. On 4/27/22 at 4:30 pm V9 (Licensed Practical Nurse) stated R13 was mentally in and out of it, easily agitated and did not want to follow the smoking rules. V9 stated it is hard to redirect R13 and wanted to do what she wanted to do.

Based on observations, interviews, and record reviews the facility failed to prevent abuse by not following the plan of care for one resident (R130). R130 had an incident with another resident causing R130 to sustain a fall requiring emergency transfer to a local hospital. R130 was diagnosed with right arm fracture and needed 9 sutures to the right side of the forehead. The facility failed to prevent one resident (R119) from attacking another resident (R90) after R119 showed signs of physical and verbal aggression. This failure resulted in R90 to be transfer to a local hospital for emergency services and receiving 4-5 sutures to the left eyebrow. These failures affected three residents: (R90, R119, and R130) in a total sample of 35 reviewed for abuse and had the potential to affect 170 residents currently at the facility. Findings include: A. R130 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R130 who was originally admitted into the facility 7/29/14. On 1/25/22 at 10:44 AM R130 was lying in R130's bed with the right arm wrapped and in a brace. Sutures on the right side of R130's forehead was observed V6 (Licensed Practical Nurse) said R130 had an incident with another resident that led to R130's arm and head being injured. V6 stated I was not present in the facility when the incident occurred. It was reported to me that R130 became confused and wandered into another resident's room. When the resident asked R130 to leave their room, R130 refused resulting in R130 being shoved by the other resident. R130 lost R130 balance after R130 was shoved and fell breaking R130's right arm. R130 also has sutures on the right side of the forehead from the incident. On 1/26/22 at 1:36PM V1 (Administrator) said, an altercation resulted when R130 went into another resident's room. The other resident wanted R130 to leave their room resulting in R130 being pushed. The incident occurred 1/21/22. On 1/26/22 at 3:24PM V2 (Director of Nursing) said she was not aware of R130 having a habit of roaming in and out of other residents' rooms. On 1/26/22 at 3:53PM V3 (Assistant Director of Nursing) said, R130 does not have a history of going into other resident's rooms or roaming/wandering the facility however, she would at times visit with other residents which had not caused any issue in the past. Review of R130's current care plan initiated 5/14/20 reads: R130 wanders and R130 displays poor boundaries. Interventions include counseling R130 individually about the risks of displaying poor boundaries and redirecting R130 to display healthy boundaries. Facility Reported incident report dated 1/21/22 documents it was reported that another resident pushed R130 on the evening of 1/21/22. R130 had a physical altercation with another resident and fell to the floor, sustained a laceration to the right forehead area and was guarding R130's right arm. R130 was sent out to the hospital and returned to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R130 has a history of poor social boundary and went into another resident's room uninvited and unwelcomed. Another resident push R130 out of their room causing R130 to fall in the process. On 1/26/22 at 4:48 PM V1 (Administrator) was not able to provide information, investigation as to how abuse towards R130 specifically could have been prevented. B. R119 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R119 is alert and oriented and based on Minimum Data Set (MDS) R119 was assessed for Brief Interview for Mental Status (BIMS) with score of 15, cognitively intact (12/07/2021). 01/24/22 12:10 PM the surveyor observed R119 displaying verbal aggression towards staff during lunch time. R119 had already been served a plate of food and was eating in the bedroom doorway. R119 began yelling expletives to staff threw the plate onto the floor and charged towards the food cart requesting additional lunch portions and options. V7 (Certified Nurse Assistant) informed R119 that all of the residents would have to be served first before giving R119 extra portions. After V7 confirmed all of the residents ate, V7 removed an extra plate off of the food cart and gave to R119. R119 then took the food into the bedroom. No further redirection was given. The nurse nor any other staff were not informed of the behavior at the time of the event. R119 has a care plan for physical aggression initiated 8/26/20 which was last updated 1/25/22 after R119 had a physical altercation with another Resident (R90). R119 also has a care plan for refusing medication that was initiated 3/27/21 and updated 12/28/21. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R119's Progress note written 1/25/22 read, R119 requested to switch room due to paranoia. Writer attempted to explain to resident that R119's paranoia will be present in any room R119 moves to. Writer offered resident a PRN (medication) but resident declined. Writer spoke with V2 (Director of Nursing) and Mental Health Tech supervisor about possible room change for resident. Mental Health Tech supervisor advised to keep resident in the same room under observation. Writer will monitor the situation and make changes as needed. A note written on 1/25/22 reads, Writer counseled resident after R119 attempted to become physically aggressive towards peer. Writer asked resident what happened, and resident stated Paranoia Resident would not elaborate instead began jumping from subject-to-subject verbalizing delusional thought about the food and wanting a liquid diet. Writer encouraged resident to take R119's medication and states R119 does not need medicine. On 1/25/22 at 9:11PM a Nurse notes reads Writer made aware of resident's physical aggression toward female peer. Resident noted with auditory hallucination, hostile and threatening toward self and peers. R119 is non-compliant with medication. MD notified, order received to transfer resident to (local hospital) for psych evaluation and treatment. On 1/25/22 at 11:52 PM R119 was transferred to the hospital and admitted for aggressive behavior. R90 was admitted to the facility 5/10/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) with a Brief Interview for Mental Status (BIMS) results reads: score 10, indicating moderate cognitive impairment. On 01/25/22, R90 was physically abuse by another Resident (R119) and sustained a laceration that resulted in R90 going to the local hospital for emergency services to getting sutures to the left eyebrow. On 1/26/22 at 12:02 PM, R90 was observed in the hallway wearing a white t-shirt with stains that appeared to look like dried blood. R90 was alert and ambulating and was not able to be re-directed when surveyor asked to speak. At 1:30 pm, surveyor went to see R90 again, and R90 was seen wearing a clean white shirt. Black sutures are seen to the left eyebrow. R90 said, I got into a fight with another resident last night and I had to go to the hospital to get some stitches in my face. I'm not hurting anywhere else, and I'm okay now. On 1/26/22 at 4:30PM, V1 (Administrator) said, I wasn't aware that R119 had been expressing some aggressive behaviors prior to the altercation with R90. We sometimes have residents who refuse medications and treatment, and we do the best to re-direct them if we can. But ultimately, we cannot force the residents to take medications or do anything else. I expect the nursing and Mental Health Team to take the appropriate measures to address behavioral concerns that a resident may exhibit right away for the safety of the other residents and staff. R90's medical record review reads on 1/25/2022 at 6:24PM the nurse was made aware of physical aggression received by R90 from male peer. R90 was noted with a laceration to the left side of face. The nurse called 911, R90 was transferred to a local hospital for medical evaluation and treatment. R90 returned to the facility on [DATE] at 1:11 AM with 4-5 sutures to the left eyebrow and no further injuries confirmed. R90's medical record has an Abuse Risk Assessment (dated 1/26/22) with score of 6 which indicates R90 was at a high risk of abuse. Facility did not provide Abuse Risk Assessment for R119 upon request. Facility did not provide incident report for R119 and R90 upon request. The facility's Abuse policy reads: The resident has the right to be free from abuse. Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of the residents, including that assigned staff have knowledge of individual resident care needs.

Noncompliance resulted in two deficient practices. I. Based on interview, and record review, the facility failed to monitor and supervise three residents (R1, R11, and R12) that were at high risk for elopement for four residents reviewed for elopement in a total sample of sixteen. This failure resulted in R12 eloping from the facility during smoke break on [DATE] and was found deceased on [DATE]. This was identified as an immediate jeopardy situation that began on [DATE] and was removed on [DATE]. V1 (administrator) was informed of the immediate jeopardy on [DATE]. The immediacy was removed on [DATE], but the deficiency remains at a level 2 harm, until the facility can be evaluated for the effectiveness of the interventions implemented. Findings Include: R12 R12's diagnosis: type 1 diabetes mellitus with [CONDITION(S)], patient's noncompliance with medication regimen, and [CONDITION(S)] episode with psychotic features. R12 was admitted to the facility on [DATE]. The Admission Hospital Records dated [DATE] documents R12 is an elopement risk due to R12 attempting to run away from the hospital on this day. The Discharge Records document R12 has type one diabetes with poor compliance with insulin. R12 needs a more structured setting for managing the diabetes. A Nursing note dated [DATE] documents R12 fled facility on foot, wearing all white, including a white baseball cap. Code was enacted, and staff search the area to no avail. Non-emergency police were informed as well as R12's guardian. The Police Report dated [DATE] documents police assisted in a wellness check of R12 when R12's family member could not get an answer at the door of R12's apartment. When the police officer entered the apartment, R12 was noted on a mattress and deceased . R12's body was stiff and had what appeared to be dry brown vomit coming out of R12's mouth. The Police Report dated [DATE] documents officers were at the morgue on [DATE] during an autopsy in a death investigation for R12. R12's blood sugar was tested and was 1500 (normal blood sugar range is ,d+[DATE] mg/dL). The doctor performing the autopsy told the office that R12 had lethal levels of blood glucose and [MEDICATION(S)] glucose. [MEDICATION(S)] glucose means the glucose level is greater than 200 mg/dL. Because glucose levels decline rapidly after death, a postmortem [MEDICATION(S)] glucose level greater than 200 mg/dL is indicative of diabetes mellitus, diabetic ketoacidosis (a serious complication of diabetes that causes a build-up of acids in the blood when blood sugar levels are too high), or nonketotic hyperosmolar coma (coma resulting in person with a very high blood glucose level). On [DATE] at 12:07PM, V7 (Nurse) stated, That day (R12) was talking on the phone with his mom and yelling. I heard him say he wanted to go home. (R12) seemed to calm down. I didn't hear anything else from him. Then I heard he left out the gate during smoke break. I didn't think he was an elopement risk. If they have a prior elopement, then that makes them an elopement risk automatically. I was never told anything about him eloping. On [DATE] at 3:55PM, V3 (DON) stated, I was called and told (R12) left during smoke break. They told me (R12) left out the gate. The nurses go over the admission paperwork and then myself and the admissions department will go over it again the next day. I don't remember him having an elopement history. On [DATE] at 10:35AM, V14 (family member) stated, I was called around 4PM that day and was told by the nurse that he eloped. He had called me an hour or two before on his cell phone. I was concerned when I was talking to him because he was starting to yell and argue over little things with me again. I called the place back to talk to the nurse to tell them I thought he might need a high level of care because of how he was acting when I was on the phone with him, but I never got answer. It was later they called to tell me he left, and they tried to look for him, but they couldn't find him. He called me a couple days later saying he had made it to Chicago near 95th by the train and was taking the train home. I know he was staying at a Dunking Donuts and they would give him all the day old donuts and juice. Without insulin, I'm sure that was not good for his diabetes at all. We are in Carbondale. He told me he was going to stay with a friend for a while, but he wouldn't tell me exactly where. I tried telling him to come home because he needed his insulin. He would get upset when I would mention it and kept telling me he could do it on his own. I just kept encouraging him to at least go to the pharmacy and get his insulin. I heard from him a couple days later and he said he broke into his old apartment and had his insulin. This was on Saturday ([DATE]). He asked us to bring him somethings and we did and left it there for him. The next day we got a text from him saying he was feeling good and had a sore throat. We told him to go to the hospital because all the clinics were closed. We didn't hear from him that day and thought he went or must have felt better. We called again on Monday to see how he was and had no answer on his phone. My husband called again on Tuesday and it went straight to voicemail, so we knew something was wrong. My husband went over there and knocked on the door, but he did answer. He called the police and go the landlord to come open the door. When they went into his apartment, he was deceased . We had to send his body to the coroner for testing and the coroner called me to tell me the final report was still pending but R12's blood sugar was 1500. When the police searched his house, he did have insulin and the supplies in the fridge, but I don't know if he took any of it like he was supposed to. I called and spoke with a nurse a day after he was admitted and told them he tried to escape from the hospital, and he needed to be watched closely. I told the staff he was a high elopement risk and he still got out. On [DATE] at 11:13AM, V15 (PRSC) stated, We are supposed to do an L formation outside. All the staff members get in the shape of an L so we can see all sides. I don't remember him being an elopement risk. We have a binder of people that are elopement risks that we update when there is an elopement. I don't know how often it is updated. No, we don't take this outside with us. On [DATE] at 12:52PM, V16 (Mental Health Technician) stated, When a resident is an elopement risk, you have them sit near you or away from the gate. I don't remember this resident but if he got out, he probably just opened the gate. The gates aren't locked and when it's two staff members trying to watch thirty or more people things can happen. I don't think there is a certain formation we can make to watch. You just pick a spot where you can see as many people as possible. On [DATE] at 11:58AM, V17 (Primary Physician) stated, If you don't take your insulin, you can go in diabetic ketoacidosis because your sugars will be so high. It is not a good thing to do. If it is left untreated, you will go into a diabetic coma and can die. On [DATE] at 11:10AM, V19 (Psychiatrist) stated, We get residents all the time that attempt to elope. Some are successful in eloping and others just talk about leaving all the time. Then there are residents who don't show behaviors initially then start to show signs after a few days. If someone was an elopement risk, I would expect an extra person be with that resident if they are outside the building. The Elopement/Unauthorized Leave Risk review dated [DATE] documents R12 is not at risk for to elope at this time and placement on the Elopement Risk Protocol is not indicated. The question on the form Is there a prior history of wandering/elopement and/or does the resident verbalize a strong desire to leave? is documented as no. The Community Survival Skills assessment dated [DATE] documents R12 does not appear capable of unsupervised outside pass privileges as this time. Per facility policy and due to COVID, R12 is not eligible for independent pass privileges at this time. The Elopement/ Unauthorized Leave Risk review dated [DATE] documents R12 is at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. The Care Plan dated [DATE] documents R12 is an elopement risk/wanderer related to exit seeking, history of attempts to leave the facility unattended, impaired safety awareness, and R12 wanders aimlessly. R12 has type 1 diabetes mellitus and is insulin dependent. The Minimum Date Set (MDS) Section E dated [DATE] documents R12 does have a behavior of experiencing delusions. R1 R1's diagnosis: [CONDITION(S)], [CONDITION(S)] disorder and chronic [CONDITION(S)] C. R1 admitted to the facility on [DATE]. The Admission Hospital Records dated [DATE] document R1 was hospitalized for safety and stabilization after escaping from nursing home multiple times. Intake reports document R1 was found in the cellar of a house after being heard talking to self. A Social Service Note dated [DATE] documents per the hospital records, R1 escaped from the previous facility several times and will be placed on elopement risk protocol. A Social Service note dated [DATE] documents R1 was previously at another facility and left unauthorized from there six times in eight months. A Nursing note dated [DATE] documents R1 left the facility unauthorized during smoke break and was brought back in by staff. 72-hour behavior monitoring initiated. A Social Service note dated [DATE] documents R1 left unauthorized during smoke break and was picked up by staff down the street. R1 requested to go to the hospital and reported will attempt to leave again in not sent. R1 continues to be on elopement risk protocol. During the smoke break on [DATE] at 1:15PM, 67 residents were outside with four staff members, on [DATE] at the 3:15PM, 54 residents were outside with five staff members, and on [DATE] at 11:15AM, 71 residents were outside with four staff members. R1 sat on a bench or on the ground each smoke break. Staff was not within close proximity of R1 for the entirety of the smoke break. There was no closer monitoring noted for elopement risk residents. On [DATE] at 11:24AM, V5 (PRSC) stated, She eloped from the previous facility and the police brought her to the hospital. Her family had her transferred here because they were concerned about her escaping the other facility so many times. She walked out the gate both times. When I did her assessment, I put her at high risk. We tell the staff verbally when there is a new admission that is a high risk. There is also a list at the nurse's station and in the offices. I don't know how often that is updated. The staff should be passing on in report who is high risk if they are new. On [DATE] at 2:05PM, V10 (Nurse) stated, I was her nurse the first time she left. I don't think she was on the elopement list then. I wasn't told she was a high risk. I didn't know she left the other facility that many times. On [DATE] at 2:54PM, V11 (CNA) stated, She just walked out the gate that I know. That was her second time leaving. I was standing by the gates by the basketball gates, so I didn't see her leave. At that time, she was an elopement risk so whoever was on that side should have been watching her. On [DATE] at 3:07PM, V12 (Activity Aide) stated, This time she just walked out the gate. It isn't locked and she jumped over the other fence. I was passing out cigarettes and saw her leave. There was one or two other people out there I think but I can't remember. No one was standing by that side she left one. I don't know of any list of elopement risk. I just know who to watch for and if people are looking suspicious you watch them. I have another resident that I trust stand over by the gate now. I couldn't watch everyone and pass out the cigarettes at the same time. On [DATE] at 3:20PM, V18 (Mental Health Technician) stated, I was outside, and I was standing over by the area where I can see both sides. This was on the East side. I didn't see her leave. I just saw her bag going over the fence. The girl (V11) said she opened the gate and then jumped the other fence. I ran through the building and left outside through the West side doors and caught up to her. We just get report from the shift before us on who to watch. I think I was told to watch her. It was my first day alone so I was watching everyone, and she must have just left when I was watching someone else. On [DATE] at 3:55PM, V3 (DON) stated, She made attempts to leave on both sides. The West side area was closed down and all residents go to the East side now so staff can watch them all in one area. We have elopement risk list at each nurse's station. She is an elopement risk now. Signs of elopement are pacing, checking the doors, voicing they want to leave, and attempts of leaving the facility without staff being aware. She wasn't on the list when she was first admitted . She was put on after the first elopement. I believe her family called admissions to let them know she eloped from the previous facility. The elopement risk list is updated quarterly or when there is a new elopement. The Elopement/ Unauthorized Leave Risk review dated [DATE], [DATE], and [DATE] document R1 is at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. The Care Plan dated [DATE] documents R1 is an elopement risk related to history of elopement at previous facility. On [DATE] and [DATE], R1 left the facility unauthorized during smoke break. The Community Survival Skills assessment dated [DATE] documents R1 does not appear capable of unsupervised outside pass privileges as this time. R1 is not appropriate for outside pass privileges based on reported history of socially inappropriate behavior and unauthorized leave from other nursing home. The MDS Section E dated [DATE] documents R1 does have a behavior of experiencing delusions. R11 R11's diagnosis: [CONDITION(S)] disorder, psychotic disorder, and type 2 diabetes. R11 admitted to the facility on [DATE]. A Code Pink was called at approximately 2:43PM on [DATE] in the central wing. R11 was accompanied by staff returning to the building around 2:45PM. It was reported R11 exited the facility during an activity. V20 (Activity Aide) was running a music activity and had about twelve residents inside and seven or eight residents outside. R11 opened the gate and left. The video was replayed by V2 (Assistant Administrator). The video showed R11 open the gate and walk on the path to the west side of the building. Staff found R11 about three minutes after R11 exited the gate. R11 was brought back to R11's room. R11 was agitated at this time and refused to talk with surveyor. On [DATE] at 3:05PM, V20 stated, I was doing an activity by myself. I had about 12 residents inside and maybe seven or eight outside. I kept going back-and-forth from inside to outside to keep checking on everyone. I was inside and one resident came in and tapped me on the shoulder and told me R11 left out the gate. I called the code pink and asked for the other residents to come inside. R11 was found on the employee smoke patio and R11 had walked over to the west side door. No, she's not an elopement risk we were doing a music therapy where I play music and I just kind of let the residents do whatever they want. Some play basketball and some play cards and others just sit there and listen to the music. I don't take more than 20 residents for an activity by myself. Normally I have a mental health tech with me but I know some of them are training today and their schedules are a little different because we just hired a bunch of new people, so it was just me today doing the activity. A Social Service Note dated [DATE] documents R11 tried leaving the facility on the west pavilion. R11 escorted back into the building. R11 reported trying to leave due to breakfast being late. Staff reminded R11 breakfast was at 8AM and it was now 9:30AM. A Nursing note dated [DATE] documents R11 left the building and was found sitting just out the building. R11 agitated and cursing at staff. R11 is threatening to leave again. A Nursing note dated [DATE] document R11 exhibited an unauthorized exit and was immediately brought back into the building. R11 placed on behavior monitoring for 72 hours. The Elopement/Unauthorized Leave Risk Review dated [DATE] documents R11 is at risk and should be placed on the Elopement Risk Protocol. The Elopement/Unauthorized Leave Risk Review dated [DATE] documents R11 is at risk and should be placed on the Elopement Risk Protocol. The Elopement Risk List 2021 dated [DATE] does not list R11 as an elopement risk on this day. The policy titled, Elopement Risk Assessment, documents, 2. Risk factors that will be assessed include the following: a. Independent ambulation with or without assistance, b. Pre-admission or history of elopement, c. Purposeful exit seeking, d. Restless, aimless pacing, e. Verbalization of wanting to leave the facility and/or go home, f. Grabbing doorknob or pushing on exit door, g. A cognitive impaired individual who is a follower, h. Inability to differentiate safe from unsafe situations, i. Diagnosis of Alzheimer's, Dementia, [CONDITION(S)], [CONDITION(S)], j. Inability or refusal to follow instructions. 3. Should an elopement risk be determined; interventions will be immediately initiated to protect the resident in a reasonable manner and as approved by the physician 4. The physician and family/sponsor will be notified of the resident assessment findings, and suggested interventions to protect the resident. 6. The Social Service Department will notify Facility Staff and initiate interventions necessary to protect the resident. Interventions include, however, are not limited to the following: a. Relocation to a secure unit, b. Bed alarm and/or chair alarm, c. Use sign in/sign out record, d. Psychological consult, e. Personal alarm arm or ankle bracelet, f. 15 minute to one-hour observations, one-to-one observation, h. Behavior management programs. The immediate jeopardy was removed on [DATE] at 12:28PM with the acceptance of the following plan: Aperion Care Chicago Heights DESCRIPTION OF OCCURRENCE: The facility failed to monitor and supervise residents during smoking breaks to prevent residents from leaving the facility under unsafe conditions, for R1 and R12 that were at high risk for elopement. ACTION TAKEN: R12 is no longer a resident of the facility R1 continues to reside at the facility. There is no current exit seeking behavior noted. If exit seeking behavior is observed, R1 will be provided diversional therapeutic activities that residents will enjoy doing which will keep resident engaged thereby stopping exit seeking behaviors. R1's Careplan will be updated to include staff intervention to address future potential elopement behaviors: Completed on [DATE] 1. Staff were in serviced and trained on procedures of supervising and monitoring residents for elopement utilizing the Elopement Policy and Code Pink Policy/Procedure. The smoking program was updated to reflect increase supervision for those at risk of elopement. There will be a minimum of 3 employees monitoring: 1 will be stationed at the west gate, 1 will be stationed in the middle and 1 will be stationed at the exit door. All residents identified as at risk for elopement will be supervised separately during any outside Activity. Activity staff will be in-serviced on supervision of residents at risk for elopement during outside activities. All staff will be re-educated by V2 DON prior to next scheduled shift. All staff on vacation or on leave will be re-educated prior to returning to work and new hires will be trained during orientation before starting work. V2 DON, verbally conducted in-service initiated at 2pm [DATE]. Staff acknowledge information via signature. Staff competency of policy/ procedure will be assessed with a questionnaire completed with each staff member post in-service Administrator/Managers will continue to monitor all staff for compliance by daily observations of resident smoke breaks. Administrator/Managers will continue to monitor all staff for compliance by observations of Code Pink response if a code response is required: Completed on [DATE] Observation audits will occur daily for three months and any noncompliance will be addressed. If there are concerns noted, reeducation will be provided, and observations will continue. The administrator and or manager on duty will perform the observations on the weekends. 2.Staff will be in serviced/trained on conducting proper elopement risk assessment by Social service consultant: Completed on [DATE] 3.All residents that are at risk for elopement were reviewed for accuracy of their elopement risk assessments. The elopement risk assessments were performed and will continue to be done upon admission, Quarterly, any changes in condition and as needed. Accuracy of the assessments will be audited by the Social service consultant: Completed on [DATE]. Assessment will be reviewed and updated quarterly and as needed. 4.All residents were re-assessed for Elopement Risk. List is updated as of [DATE] Completed [DATE]. Assessments are reviewed and updated quarterly and as needed. 5.All residents assessed at risk for elopement will be supervised during their identified smoking times. Any residents observed or reported with signs of potential exit seeking behaviors will be intervened and addressed accordingly. The smoking program has been revised to 2 separate groups: Group A- residents identified assessed as at risk for elopement. 4 staff will be supervising 24 residents. Group B- residents not assessed as at risk for elopement. 4 staff will be supervising 96 residents 6.All residents at risk for elopement will be monitored 1 on 1 with staff during outside activity. If Activity staff is unable to provide 1 on 1 monitoring, residents at risk for elopement will participate in indoor activities only. Any residents observed or reported with signs of potential exit seeking behaviors will be intervened and addressed accordingly. The Chicago Heights policy elopement policy is updated as of [DATE]. List of residents at risk for elopement is updated. Mental health techs, behavior aides and activity staff will monitor residents who are high risk during smoking and activity. Department heads will ensure that the departments are compliant with monitoring: Completed as on [DATE] for smoking and [DATE] for activities. 7. All residents at risk for elopement that do not smoke will have their care plans reviewed and updated to include diversional therapeutic activities that residents will enjoy doing which will keep resident engaged thereby minimizing/stopping exit seeking behaviors: Completed [DATE] II. Based on observation, interview, and record review, the facility failed to effectively monitor and supervise residents with a known history of inappropriate smoking behaviors 4 of 4 residents (R13, R14 R15 and R16) reviewed for supervision of inappropriate smoking behaviors. This failure resulted in R13 and R14 smoking inappropriately in a resident bathroom causing the fire alarm to activate and the local fire department responding to the facility. Findings Include: On [DATE], the local fire department responded to the fire alarms in the facility. A large amount of smoke was noted coming out of the resident bathroom in room on the resident wing. R13 and R14 were the residents found to be smoking inappropriately at this time. R13's diagnosis: [CONDITION(S)], [CONDITION(S)] disorder, and [MEDICATION(S)] dependence. R13 was admitted to the facility on [DATE]. R14's diagnosis: [CONDITION(S)] and delusional disorder. R14 was admitted to the facility on [DATE]. A Nursing note dated [DATE] documents R13 noted with inappropriate smoking in bathroom and was immediately removed and redirected to central station where a complete body assessment was rendered. While facility rendering their head count protocol, R13 became verbally aggressive and attempting to get physical with staff. The doctor gave an order to transfer to the hospital with a psych petition. A Nursing note dated [DATE] documents R14 noted smoking inappropriately in bathroom and immediately removed from area and redirected into central nursing station. Room was cleared for assessment. R14 verbalized no concerns at this time and has been escorted to the dining area for closer supervision. While waiting in dining area for clearance of our head count protocol, R14 started getting anxious and restless and became verbally aggressive towards staff and peers. The doctor was notified of situation and has given an order for transfer to the hospital with petition for harm to self and others. On [DATE] at 2:30PM while doing rounds with V23 (Mental Health Technician), a strong odor of cigarette smoke was noted in two bathrooms in resident rooms. The staff was unable to identify which resident(s) were smoking in the building. On [DATE] at 12:25PM, V5 (PRSC) stated, I know the fire alarms went off and a code red was called. They were smoking in that bathroom and it set the alarm off. We don't know why they were in that room. That room was searched, and nothing was found. R14 normally doesn't have issues with smoking inappropriately. I have to counsel R14 on it maybe every six months. The first time you are caught it is a verbal warning. The second time your smoke privilege for the next break time is taken away. The third time you are caught is a 24-hour ban. I don't know when the time is reset for the violations. I don't know if it's over a day or a week. On [DATE] at 12:44PM, V21 (PRSC) stated, No residents can keep any smoking materials on them because of safety reasons. They all must be locked up with activities. They can't keep them because they aren't safe to smoke in the building. A lot of residents here have poor safety judgement. I can't really remember R13's behaviors with inappropriate smoking. After they are caught smoking, we counsel them on the policy and update the care plan, but we aren't the only ones who update the care plan. All the other staff can do that too. On [DATE] at 12:56PM, V22 (Mental Health Technician Supervisor), stated, There is a daily list of people who are banned from smoking after their infractions. It changes daily. We don't have a list of any repeat offenders. The staff just kind of knows who to look out for. The MHTs should be checking the people we suspect of bringing in materials. All we can do is have them show us their pockets and check around their waist. We will also do room checks. The daily list is given to the activity aides, PRSCs, and MHTs so we are all aware who can't smoke for today. After their 24-hour ban is up, they can go back to smoke again the next day and then they start back at zero violations. On [DATE] at 2:00PM, V23 stated, The first time is a verbal warning. The second time is they get the next smoke break taken away, but they can go out again after that. The third time they can't smoke for 24 hours. After the 24 hours is up, they start back with no violations. They get a clean slate after they do the 24 hours. We make the repeat offenders open their pockets at the door before they come back in. We just know who they are. We make sure they aren't taking anything off the smoke cart. We don't know how the repeat offenders are getting them in. We don't usually find anything during the searches. We don't know how they are lighting them either. We haven't found any matches or lighters. During the 3:15PM smoke break on [DATE], no residents had their pockets checked by staff before reentering the building. On [DATE] at 3:42PM, V24 (Mental Health Technician) stated, During smoke break, we watch so no one is eloping, and we watch for behaviors. We have the repeat offenders open their pockets in the front and back. I don't think there was any repeat offenders outside. I don't think there is a list. I just know who they are. During the 1:15PM smoke break on [DATE] R15 and R16 were outside smoking even though they were on the smoking ban list for that day. The smoke ban list on the cigarette cart does not list R16 as being on smoke ban. On [DATE] at 2:50PM, V20 (Activity Aide) stated, I have not seen the sheet at all today. I know there are people that have got caught smoking in the building, but I don't know who. V22 is supposed to relay that to us but it doesn't happen. I don't know who is or is not allowed to smoke. There is no communication with the activity department on who cannot smoke. I know the mental health techs sometimes know who is on ban but there is no communication with us, and we are the ones passing out the cigarettes. During the 3:15PM smoke break on [DATE] R15 came outside to smoke and was told to go back in the building by V20. V22 told V20 it was ok for R15 to smoke because R15's smoke ban time limit was over. R16 attempted to come smoke again and was told to go back in the building by V20. On [DATE] at 3:42PM, V22 stated, R15 can smoke now. R15's 24-hour ban is over. R16 cannot smoke though. R16 was just caught earlier this morning smoking in the building. R16 is being sent out for smoking so I didn't bother to update the list and give it to activities. The Care Plan dated [DATE] documents R13 is an inappropriate smoker. R13 was found smoking inappropriately on [DATE]. No new interventions are noted on or directly after [DATE] in regard to this behavior. There is no further documentation in progress notes of R13's inappropriate smoking behavior on this date. The Smoking Safety Risk assessment dated [DATE] documents R13 is minimally problematic with history of hazardous behavior (i.e., smoking in unauthorized areas or careless use of smoke materials, sustaining [CONDITION(S)], fire starting) and begging, borrowing, trading items, and panhandling for smoking materials. R13 requires supervision while smoking and is not able to store smoking materials. The Care Plan dated [DATE] documents R14 is an inappropriate smoker. There is no further description of R14's inappropriate smoking behaviors. There is no further documentation in progress notes of R14's inappropriate smoking behavior on this date. The Smoking Safety Risk assessment dated [DATE] documents R14 is minimally problematic with potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking materials. R14 requires supervision while smoking and is not able to store smoking materials. The Behavior Management Program and Level Program agreement dated [DATE] documents The following are inappropriate and unacceptable behaviors and will result in immediate pass suspension: 1. Smoking in non-designated areas. This endangers everyone who lives and works in this facility . The Smoking Policy Acknowledgement with no date documents All residents are require to turn in smoking materials to the Activity Department, in which those smoking materials will be distributed by the Activity Staff (lighters, matches, pipes, cigarettes, tobacco). Smoking materials are not allowed in resident's possession .Residents who violate the expectation of the smoking program will be subject to progressive interventions. Staff Responsibilities: assigned staff will monitor residents on the smoking program; staff will remain in the designated area, during the entire scheduled smoke time with the residents; staff will monitor for residents removing cigarette buds from ashtrays or from the ground; staff will empty ashtrays and sweep before leaving the smoking area as needed; all reports of resident smoking violations must be reported to the charge nurse, mental health tech, activity director or social services, documented, and followed up. Resident smoking is permitted in the designated area: Patio area. R [TRUNCATED]

Based on interview and record review, the facility failed to supervise smoking breaks to ensure residents properly dispose of smoking material and failed to ensure residents identified as supervised smokers are not in the procession of smoking contraband. These facility failures apply to 5 of 5 (R6, R10, R11, R12 and R13) residents reviewed for unsafe smoking in a sample size of sixteen. As a result, on 6/14/2021 R6 who is assessed as an unsafe smoker could possess smoking materials and smoked in an unauthorized smoking area (resident room) and started a fire in the room with his roommate (R2). This was identified as immediate jeopardy situation that began on 6/14/21 and was removed on 7/1/21. V1 (administrator) was informed of the immediate jeopardy on 6/25/21. While the immediacy was removed on 7/1/21, the facility remains out of compliance at a severity level two until the facility can evaluate the effectiveness of staff training for monitoring residents at risk for unsupervised smoking and disposal of smoking material. Findings include: R6 R6 was admitted with the diagnosis of [CONDITION(S)] Disorders and Homicidal Ideations. Brief interview for mental status dated 5/31/21 documents: R6 has a score of fifteen which indicated cognitively intact. Smoking Safety Risk assessment dated [DATE] documents: R6 had a minimal problem begging, borrowing, trading items and panhandles for smoking material. R6 requires supervision with smoking and is not able to store smoking material. Behavior note dated 6/14/21 documents a fire was noted in R6 room. R6 said, if he couldn't sleep and why should anyone else. Initial Reportable dated 6/14/21 documents: Smoke coming from R6's room. Fire noted on R6's bed sheets. Care plan dated 5/21/21 documents R6 is a smoker, instructed about the facility policy on smoking: locations, times and safety concerns. Change in condition dated 6/14/21 documents: R6 set fire to bed. Behavior changes: Verbal aggression (cursing and screaming) and danger to self or others. Transfer form dated 6/14/21 documents: Reason for transfer: behavior symptoms (agitation and psychosis) R6 had fire setting behaviors. Census dated 6/9/21 document: R6 was in room with the fire. On 6/16/21 at 1:23pm and 1:29pm, multiple cigarette butts/buds were observed on the ground on the East/West wing patios during a smoking break. On 6/16/2021 at 2:46pm, V3 (Maintenance Director) said, it was a small fire in R6's room that was put out pretty quickly. V3 measured the blackened area on the bed frame and floor, both measured 2cm wide by 8 cm long. V3 said, the bedframe blacken area is from the fire. On 6/17/21 at 3:57pm, R6 who was assessed to be alert and orient to person, place and time, said, I was smoking a cigarette in my room. I walked to my bathroom to put the cigarette out but it must have still been lit. I must have dropped some ashes as I walked back from the bathroom. I walked out of my room, then a few minutes later I heard staff yell fire located in my room. The bed sheets and the tile under the bed sheet was burnt. I save the cigarette and lighter, I found on the ground during smoking break to smoke later. On 6/16/21 at 4:19pm, V4 (Certified Nursing Assistant) said, I put out the fire. The bed sheets were on fire and melting to the floor. The fire [NAME] was on the covers that was partly on the floor. R6 was exhibiting verbal and physical aggressive behaviors before the fire. On 6/22/21 at 1:27pm, V6 (Nurse) said, there was a fire on the foot portion of R6's bed. R2 was in the room during the fire, the smoke was too thick to see into the room and we were not able to reach R2. A portion of R6's mattress was burnt. The fire department said, the fire was set on purpose based on the location of the fire. Fire Department report dated (6/14/21) documents: Fire alarm activated: facility reported furniture burning in R6's room. The mattress burned at the foot end. R6 reported, he was smoking in the room. Smoking Safety Policy dated 11-28-12 documents: To provide safe and healthy living environment. The facility will designated area for approved for smoking by resident. The facility prohibits resident from keeping smoking material in his/her possession for health, safety and security reasons. The facility restrict access to smoking products, matches and lighters for person deemed unsafe R13 R13 was admitted with the diagnosis of [CONDITION(S)] Disorder, [CONDITION(S)] type. R13's brief interview for mental status dated 4/12/21 documents a score of ten which indicates moderately impaired. Smoking Safety Risk assessment dated [DATE] documents: R13 has a minimal problems with general awareness and orientation to understand the facility safe smoking policy, potential for causing injury to self or other from smoking in unauthorized areas or careless use of smoking material. R13 has a severe problem with following the facility smoking policy, requires supervision and is not able to store smoking material. Nursing note dated 6/15/21 documents: R13 was caught in another room with male peer smoking weed. R13 was redirected not to smoke that kind of thing again. Progress note dated 6/15/21 documents: R13 was caught in R12's room passing R12 a lit joint to. Care plan initiated on 8/30/18 documents: R13 smoked in an unauthorized area (bedroom) on 1/21/21 and 4/28/21. R13 was caught smoking contraband in another resident's room. Intervention: R13 requires supervision while smoking, smoking supplies stored in the activity room and if behavior occurs address, counsel and remind of facility policy. Inappropriate smoker form dated 6/15/21: Smoking in an unauthorized area: Smoking drugs automatic three day ban. On 6/16/21 at 1:34pm, R13 who was assessed to be alert and orient to person, place and time said, I was not allowed to smoke today, because I got caught smoking in R12's room. R13 refused to elaborate on where the smoking paraphernalia from. Smoking Safety Policy dated 11-28-12 documents: To provide safe and healthy living environment. The facility will have a designated area approved for smoking by resident. The facility prohibits resident from keeping smoking material in his/her possession for health, safety and security reasons. The facility restricts access to smoking products, matches and lighters for person deemed unsafe. R12 R12 was admitted with the diagnosis of Paranoid [CONDITION(S)]. Brief interview for mental status dated 5/27/21 documents a score of fifteen which indicated cognitively intact. Smoking Safety Risk assessment dated [DATE] documents: R12 requires supervision with smoking and is not able to store smoking material. Social service note dated 6/15/21 documents: R12 was caught in the midst of accepting a lit joint of marijuana. Inappropriate smoker form dated 6/15/21: Smoking in an unauthorized area: Smoking drugs automatic three day ban. Care plan date 6/15/21 documents: R12 was caught smoking marijuana in his room. Intervention: Notify the nurse immediately if it's suspected R12 violated the smoking policy. On 6/22/21 at 4:10pm, V15 (PRSC), said, I smelled what smelled like weed (THC/marijuana/ joint) coming from room AAA. I knew it was weed based on the smell. I walked in the room and caught R13 passing a joint to R12. We took the joint and put it out. R12/R13 would not tell me where they got the weed from. I confiscated the lighter. On 6/23/21 at 12:52pm, R12 who was assessed to be alert and orient to person, place and time refused to elaborate on smoking in the room on 6/15/21 or where the smoking paraphernalia came from. Smoking Safety Policy dated 11-28-12 documents: To provide safe and healthy living environment. The facility will have a designated area approved for smoking by resident. The facility prohibits resident from keeping smoking material in his/her possession for health, safety and security reasons. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. R10 R10 was admitted with the diagnosis of [CONDITION(S)]. Social service lookback summary dated 3/24/21 documents R10 was observed receiving smoking paraphernalia from others through a window on 1/5/21. I will not smoke without supervision. Brief interview for mental status dated 5/19/21 documents: R10 has a score of thirteen which indicates cognitively intact. Social service note dated 6/17/21 documents: R10 was observed smoking in another resident's room. Smoking Safety Risk assessment dated [DATE] documents: R10 has a minimal problem with general behavior, seeking out/pursues smoking materials, potential for causing injury to self or others from smoking in unauthorized area or careless use of smoking material, following the smoking policy and a moderate problem with trading, borrowing, begging and panhandles for smoking material. R10 requires supervision with smoking and is not able to store smoking material. On 6/17/21 at 10:41am, ashes were noted on the floor and the smell of fresh smoke was noted in room BBB. Two dark brown cigarettes butts, five light beige cigarettes butts with white dots noted on the filter were observed on the floor. On 6/17/21 at 10:53am, V17 (Mental Health Tech), said, I saw five to six cigarette butts on the floor. On 6/17/21 at 11:04am, V21 (maintenance) said, I smelled smoke in room BBB. R11 was trying to hide in between the closet space and the wall next to the window. I asked, R11 to come out. I notice a pair of jeans behind R11. V22 (maintenance) and myself pulled the pants out and noticed a lite cigarette on the pants. R10 and R11 admitted to smoking in the room. I don't know where they got the lighter or cigarette from. We didn't find the lighter. I only saw the buds and ashes on the floor. On 6/17/21 at 11:15am, a pair of blue jeans with a fresh smell of smoke was noted with a small burned area on the left upper leg near the front pants pocket measuring 5cm. On 6/17/21 at 11:30am, R10 who was assessed to be alert and orient to person, place and time, said, I was smoking. We got caught smoking. R11 got the cigarette off the ground on the smoke patio. On 6/17/21 at 5:18pm/5:19pm, V18 (PRSC)/V19 (PRSC) both said, they did not do a room search for R10/R11. On 6/17/21 at 6:08pm V7 (Social Service Director) said, I didn't directly assign anyone to do a room search. We don't have any resident who are assessed to smoke independently or hold their smoking material. I don't know if staff found the lighter in room BBB. There is no smoking allowed in the building. On 6/17/21 at 6:23pm, V1 (Administrator) said, no one is assessed to smoke independently or to have smoking material. During smoking breaks, staff is observing for residents breaking off filters, smoking difficulties with dumping their ashes or holding the cigarette. I wasn't given anything from the room search. On 6/17/21 at 6:37pm, V20 (Activity Director), said the mental health tech monitors the resident for picking up cigarette butts and pocketing them. We provide the cigarettes with the dark brown filter. On 6/17/21 at 7:30pm, observed over 100 cigarette butts outside the window of room BBB, along with an empty package of cigarettes and a lighter. Cigarettes butts had both light and dark brown filters. R11 R11 was admitted with the diagnosis of [CONDITION(S)]. Brief interview for mental status dated 4/5/21 documents: R11 has a score of fifteen which indicates cognitively intact. Smoking Safety Risk assessment dated [DATE] documents: R11 requires supervision with smoking and is not able to store smoking materials. Nursing noted dated 2/19/21 and 6/17/21 documents: R11 was caught leaving out of the room with a peer smoking cigarettes. R11 was assessed to have a change in skin integrity to the left thumb, index and middle finger which was dark in nature. R11's right hand had a change in skin pigmentation. R11 admits to breaking off the tip/filter of his cigarettes to get the full effect. Care plan dated 6/17/21 documents: R11 was smoking in an unauthorized area. Intervention: staff should monitor R11 while smoking to ensure he properly discard of cigarettes once done. On 6/17/21 at 11:44am, R11 who was assessed to be alert and oriented said, I was smoking. I brought the cigarettes in last night after the 7:30pm smoking break. I didn't smoke all of my cigarette. I put the cigarette out and brought the rest of the cigarette in just in case, I got the urge to smoke later. R11 was noted with light brown burn marks on his right index finger, thumb and left third finger. R11 had thick hard dark brown burn marks on his left index finger, thumb. R11 said, this happened when I smoked on the patio. I break the top of the cigarette off and smoke the cigarette down. I don't throw it away when it gets little. On 6/17/21 at 11:57am, V2 (Director of Nursing) said, R11's fingers are signs of unsafe, inappropriate smoking. R11's left hand is old and healing, the right hand are new [CONDITION(S)]. R11's left hand has the most chard skin on the thumb, index and third finger. On 6/22/21 at 2:52pm, V14 (Mental Health Tech), said after three pm, I am the only person outside to do the 7:30pm smoke break. I have to light the cigarettes then I go out for 5-6 minutes to monitor the residents smoking. Smoking Safety Policy dated 11-28-12 documents: To provide safe and healthy living environment. The facility will designate an area for approval for smoking by resident. The facility prohibits resident from keeping smoking material in his/her possession for health, safety and security reasons. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. Fire Department report dated 6/13/21 documents: smoke detector activated, set off by cigarette smoke. R17 R17 was admitted with the diagnosis of [CONDITION(S)] disorder ([CONDITION(S)] type). R17's brief interview for mental status dated 5/21/21 documents a score of fifteen which indicates cognitively intact. Smoking assessment dated [DATE] documents: R17 requires supervision with smoking and is not able to store smoking material. Progress note dated 6/18/2021 documents: R17 was caught trying to light a cigarette in his bathroom. All smoking contraband was confiscated. R17 was verbally warned about the no smoking rule in the building. Daily Communication dated 6/20/21 documents: R17 was smoking in the room and made a lighter out of two batteries/razor blades. Care plan dated 12/04/20 documents: R17 is physical and psychological addicted to [MEDICATION(S)]/smoking and smoking routines. Intervention: Monitor/report any concerns with non-compliance with smoking safety. On 6/23/21 at 4:20pm, R17 who was assessed to be alert and oriented time person, place and time, said, I made a lighter from batteries and a razor. I took a razor blade, put it on the positive end of a battery and turn the other side of the battery to the negative side, it will heat up, get hot and light like a lighter. I used it to light my cigarettes to smoke in the bathroom. I saved my cigarette from smoke time. I don't smoke all of it. I'll put the cigarette out and in my pocket for later. I do it all the time. I was smoking in my bathroom yesterday, On 6/23/21 at 4:28pm, V7 (PRSD) said, R17 was trying to light a cigarette in his bathroom with an apparatus, a battery and a piece of razor blade from a razor that you shave with. Fire Department report dated 6/20/21 document: tobacco smoke set off the alarm. Smoking Safety Policy dated 11-28-12 documents: To provide safe and healthy living environment. The facility will designated area for approved for smoking by resident. The facility prohibits resident from keeping smoking material in his/her possession for health, safety and security reasons. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. R1 R1 was admitted with the diagnosis of [CONDITION(S)] and [MEDICATION(S)] dependence. Brief interview for mental status dated 4/29/21 documents a score of fifteen which indicated cognitively intact. Smoking safety risk assessment dated [DATE] documents: R1 has a minimal problem with begging, borrowing, trades items, panhandles for smoking material, safely following the facility smoking policy, requires supervision with smoking and not able to store smoking material. Social service noted dated 6/17/21 documents: R1 was caught by V15 (PRSC) and V20 (activity director) in a peers bathroom which was smoke filled with a distinct odor. V7 (PRSD) found additional evidence of unauthorized smoking. R1 admitted smoking weed. Nursing Note dated 6/17/21 R1 was caught smoking weed with another peer. Social service note dated 6/12/21 documents: Staff smelled smoke, asked R1 to leave the bathroom and found a lit cigarette.R1 reported, he just came across the cigarette and denied having any more or a lighter. Care plan dated 6/12/21 documents: R1 was an inappropriate smoker as evidence by possession of smoking materials, smoking in unauthorized area/unauthorized times. R1 was caught smoking in the bathroom. (6/17/21) R1 was caught in peer bathroom filled with smoke of an odd odor. I admitted to smoke weed. Interventions (6/12/21) uphold consequences for inappropriate smoking, (6/17/21) search R1 and immediate area for contraband material if smoking unauthorized is suspected/substantiated. On 6/22/21 at 3:29pm, R1 who was accessed to be alert to person, place and time said, I smell the weed, went in the room and was smoking with the other residents. On 6/22/21 at 4:10pm, V15 (PRSC) said, R1 and R15 were smoking weed in the bathroom of room R12's room. The smoke was fresh and filled the bathroom. R1 and R15 had just finished smoking. We did not find the lighter nor would either resident report where they got the weed. Smoking Safety Policy dated 11-28-12 documents: To provide safe and healthy living environment. The facility will designate an area approved for smoking by residents. The facility prohibits resident from keeping smoking material in his/her possession for health, safety and security reasons. The facility restricts access to smoking products, matches and lighters for persons deemed unsafe. R15 R15 was admitted with the diagnosis of [CONDITION(S)] and Borderline Personality disorder. Brief interview for mental status dated 5/2/21 documents a score of fifteen which indicated cognitively intact. Smoking assessment dated [DATE] documents: R15 has a minimal problem for causing injury to self or others from smoking in unauthorized areas or careless use of smoking material, with hazardous behavior and following the facility smoking policy. R15 requires supervision with smoking and is not able to store smoking materials. R15 has a history of smoking unauthorized. Smoking assessment dated [DATE] documents: R15 admitted to smoking unauthorized. Smoking assessment 6/18/21 documents: R15 was caught smoking unauthorized. Social service note dated 6/17/21 documents: R15 and another peer was found in another peer's bathroom filled smoke with an odd odor. Contraband was retrieved from R1's room. R15 reports, taking a puff off some weed. Nursing note dated 6/17/21 documents: R15 was caught smoking in the room with another peer. Social service note dated 6/18/21 documents: R15 was found smoking weed in his room. Contraband was confiscated. R15's care plan dated 6/17/21 documents: I am a smoker. I have a history of suspected inappropriate smoking evidence by smoking in my room. I was caught in a peer's bathroom smoking. I admitted to taking a puff of peer's weed. R15's care plan dated 6/18/21 documents: I was caught allegedly smoking weed. On 6/22/21 at 3:46pm, R15 who was assessed to be alert and oriented to person place and time, refused to elaborate on smoking or where the smoking contraband came from. On 6/22/21 at 4:10pm, V15 (PRSC) said, R15 was smoking weed in R12's bathroom. The smoke was fresh and filled the bathroom. R15 had just finished smoking. We did not find the lighter nor would either resident report were the contraband came from. Smoking Safety Policy dated 11-28-12 documents: To provide safe and healthy living environment. The facility will designate an area approved for smoking by residents. The facility prohibits residents from keeping smoking materials in his/her possession for health, safety and security reasons. The facility restricts access to smoking products, matches and lighters for persons deemed unsafe. The surveyor confirmed through observation, interview and record review that the following actions to remove the immediacy: 1. Updated/reviewed smoking assessments and care plans. Social Service is responsible for updating assessments and care plans. Residents identified with inappropriate smoking had assessment and care plan updates. Initiated 06-14-21, 6-17-21, 6-18-21 and will continue biweekly x 4 weeks. This will be continued monthly thereafter. Room searches are an update to the removal of resident smoking material. 1. Updated list of inappropriate smokers based on the updated smoking assessments. Activity Director is responsible for updating the inappropriate smokers list on a daily/weekly basis based on assessment of inappropriate smoking behavior and/or new resident admission. Completed 06/14/21 and ongoing 2. List of inappropriate smokers have been placed at the nurses', behavior aid desk, activities department, Social service department. Nursing staff in serviced regarding monitoring inappropriate smokers during rounds. Administrator and/or designee is responsible for in-servicing staff. Staff on leave will be in serviced upon return. New hires will be in-serviced during the staff orientation process. Rounds will be conducted every hour. Mental Health Technicians will be conducting rounds. Room census will be used as an audit tool. MHT will note on the room census which rooms that were entered upon their rounding. MHT's are schedule on a 24-hour basis. Nurse and/or designee will conduct MHT rounding if deemed necessary. PRSD and/or designee will audit MHT rounding. Monitoring for inappropriate smokers is an addition to well-being checks on residents. Initiated 06/14/21 and updated weekly. Inservice was conducted on 6/21/21, 6/22/21, and ongoing to account for staff on leave of absence, vacation, and new hires. How the facility will monitor system: 1) New residents will be assessed upon admission for any inappropriate smoking behavior and the resident may not be admitted if this behavior is identified. New residents will be assessed within 72 hours following entrance into the facility. 2) Staff have been in serviced on 6/14/21 to report any resident noted to have smoking materials to management, so the smoking material can be obtained and stored according to policy. Initiated 06/14/21 and updated weekly. Inservice was conducted on 6/21/21, 6/22/21, and ongoing to account for staff on leave of absence, vacation, and new hires. Staff on leave will be in serviced upon return. New hires will be in-serviced during the staff orientation process. 3) Upon admission, staff will perform a search of the resident/belongings for contrabands including inappropriate smoking materials. 4) Administrator, DON and/or designee will do random inspections of resident rooms for smoking materials and other devices that would be possible methods for residents to set a fire. Initiated 6/14/21, then weekly for 4 weeks. This will be continued monthly thereafter. 5) Mental Health Technicians/Receptionist will inspect all resident packages for any contraband items. Inspection will be done by visual observation of the items. All resident packages will be inspected coming into the facility without specific circumstances. Initiated 6/29/21 with frequency of daily inspections. 6) Maintenance will conduct daily checks on window screens to inspect for tears/repairs needed. Initiated 6/21/21 with frequency of daily inspections. Facility will be identifying a more durable screen material to replace the current screen material within the resident windows. Maintenance and MHT staff will monitor areas when screens are being removed for repair by conducting hourly visual observations of resident rooms. Initiated 7/01/21 and ongoing until completion. 7) Maintenance will increase rounding for maintaining a clean and safe environment ensuring that the cigarette butts are removed from the ground. Initiated 6/21/21 with frequency of daily inspections. 8) Residents will be visually observed disposing of their smoking material before returning into facility. Staff supervising the resident smoke break will be responsible for the visual observation of residents disposing of their smoking materials in the designated ashtrays placed on the resident smoking patio. Initiated 6/29/21 with frequency of daily inspections.

Based on observation, interview and record review the facility failed to follow the smoking policy by not prohibiting residents from keeping smoking material, properly disposing of smoking material and smoking unsupervised in non-designated areas. This failure affected 8 of 8 (R1, R6, R10, R11, R12, R13, R15, and R17, R15) residents reviewed for unsafe smoking in a sample size of twenty-one. This was identified as Immediate Jeopardy situation that began on 6/14/21 and was removed on 7/1/21. V1 (administrator) was informed of the immediate jeopardy on 6/25/21. While the immediacy was removed on 7/1/21, the facility remains out of compliance at a severity level two until the facility can evaluate the effectiveness of staff training for monitoring residents at risk for unsupervised smoking and disposal of smoking material. Findings include: R6 R6 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief interview for mental status dated 5/31/21 documents: R6 has a score of fifteen which indicates cognitively intact. Smoking Safety Risk assessment dated [DATE] documents: R6 has a minimal problem begging, borrowing, trading items and panhandles for smoking material. R6 requires supervision with smoking and is not able to store smoking material. Initial Reportable dated 6/14/21 documents: Smoke coming from R6's room. Fire noted on R6's bed sheets. Care plan dated 5/21/21 documents R6 is a smoker, instructed about the facility policy on smoking: locations, times and safety concerns. Change in condition dated 6/14/21 documents: R6 set fire to bed. Transfer form dated 6/14/21 documents: Reason for transfer: R6 had fire setting behaviors. Census dated 6/9/21 document: R6 was in room with the fire. On 6/16/21 at 1:23pm and 1:29pm, multiple cigarette butts/buds were observed on the ground on the East/West wing patios during a smoking break. On 6/16/2021 at 2:46pm V3 (Maintenance Director) said, it was a small fire in R6's room that was put out pretty quickly. V3 measured the blackened area on the bed frame and floor, both measured 2cm wide by 8 cm long. V3 said, the bedframe blackened area is from the fire. On 6/17/21 at 3:57pm, R6 who was assessed to be alert and oriented to person, place and time. R6 said, I was smoking a cigarette in my room. I must have dropped some ashes as I walked back from the bathroom. I walked out of my room and heard staff yell fire located in my room. The bed sheets and the tile under the bed sheet were burnt. I saved the cigarette and lighter, I found on the ground during smoking break to smoke later. On 6/16/21 at 4:19pm V4 (Certified Nursing Assistant) said, I put out the fire. The bed sheets were on fire and melting to the floor. The fire [NAME] was on the covers that was partly on the floor. On 6/22/21 at 1:27pm V6 (Nurse) said, there was a fire on the foot portion of R6's bed. A portion of R6's mattress was burnt. The fire department said, the fire was set on purpose based on the location of the fire. Fire Department report dated (6/14/21) documents: Fire alarm activated: facility reported furniture burning in R6's room. The bed mattress burned at the foot end. R6 reported, he was smoking in the room. Smoking Policy dated 11-28-12 documents: To provide a safe and healthy living environment, the facility will designate an area approved for smoking by the resident. The facility prohibits residents from keeping smoking material in his/her possession. Residents are required to turn in all smoking material to the Activity Department. The facility restricts access to smoking products, matches and lighters for person deemed unsafe. R13 R13 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's brief interview for mental status dated 4/12/21 documents a score of ten which indicates moderately impaired. Smoking Safety Risk assessment dated [DATE] documents: R13 has a minimal problem with general awareness and orientation to understand the facility safe smoking policy, potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking material. R13 has a severe problem with following the facility smoking policy, requires supervision and is not able to store smoking material. Nursing note dated 6/15/21 documents: R13 was caught in another room with male peers smoking weed. R13 was redirected not to smoke that kind of thing again. Progress note date 6/15/21 documents: R13 was caught in R12's room passing R12 a lit joint. Care plan initiated on 8/30/18 documents: R13 smoked in an unauthorized area (bedroom) on 1/21/21 and 4/28/21. R13 was caught smoking contraband in another resident's room. Intervention: R13 requires supervision while smoking, smoking supplies stored in the activity room and if behavior occurs address, counsel and remind of facility policy. Inappropriate smoker form dated 6/15/21: Smoking in an unauthorized area: Smoking drugs automatic three-day ban. On 6/16/21 at 1:34pm, R13 who was assessed to be alert and oriented to person, place and time. R13 said, I got caught smoking in R12's room. R13 refused to elaborate on where the smoking paraphernalia came from. R12 R12 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief interview for mental status dated 5/27/21 documents a score of fifteen which indicates they are cognitively intact. Smoking Safety Risk assessment dated [DATE] documents: R12 requires supervision with smoking and is not able to store smoking material. Social service note dated 6/15/21 documents: R12 was caught in the midst of accepting a lit joint of marijuana. Inappropriate smoker form dated 6/15/21: Smoking in an unauthorized area: Smoking drugs automatic three-day ban. Care plan date 6/15/21 documents: R12 was caught smoking marijuana in his room. Intervention: Notify the nurse immediately if R12 is suspected of violating the smoking policy. On 6/22/21 at 4:10pm, V15 (PRSC), said, I smelled what smelled like weed (THC/marijuana/ joint) coming from R12's room. I knew it was weed based on the smell. I walked in the room and caught R13 passing a joint to R12. We took the joint and put it out. R12/R13 would not tell me where they got the weed from. I confiscated the lighter. On 6/23/21 at 12:52pm, R12 who was assessed to be alert and oriented to person, place and time; and refused to elaborate on smoking in the room on 6/15/21 or where the smoking paraphernalia came from. Smoking Policy dated 11-28-12 documents: To provide a safe and healthy living environment the facility will designate an area for approved smoking by residents. The facility prohibits residents from keeping smoking material in his/her possession. Residents are required to turn in all smoking material to the Activity Department. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. R15 R15 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief interview for mental status dated 5/2/21 documents a score of fifteen which indicates cognitively intact. Smoking assessment dated [DATE] documents: R15 has a minimal problem for causing injury to self or others from smoking in unauthorized areas or careless use of smoking material, with hazardous behavior and following the facility smoking policy. R15 requires supervision with smoking and is not able to store smoking material. R15 has a history of smoking unauthorized. Smoking assessment dated [DATE] documents: R15 admitted to smoking unauthorized. Smoking assessment 6/18/21 documents: R15 was caught smoking unauthorized. Social service note dated 6/17/21 documents: R15 and another peer were found in another peer's bathroom filled smoke with an odd odor. Contraband was retrieved from R12's room. R15 reports, taking a puff off some weed. Nursing note dated 6/17/21 documents: R15 was caught smoking in the room with other peers. Social service note dated 6/18/21 documents: R15 was found smoking weed in another peer's room. Contraband was confiscated. R15's care plan dated 6/17/21 documents: I am a smoker. I have a history of suspected inappropriate smoking evidence by smoking in my room. I was caught in a peer's bathroom smoking. I admitted to taking a puff of peer's weed. R15's care plan dated 6/18/21 documents: I was caught allegedly smoking weed. On 6/22/21 at 3:46pm, R15 who was assessed to be alert and oriented to person place and time, refused to elaborate on smoking or where the smoking contraband came from. On 6/22/21 at 4:10pm, V15 (PRSC) said, R1 and R15 were smoking weed in the bathroom of room R12's room. The smoke was fresh and filled the bathroom. R1 and R15 had just finished smoking. We did not find the lighter nor would either resident report where they got the weed. Smoking Policy dated 11-28-12 documents: To provide a safe and healthy living environment the facility will designate an area for approved smoking by residents. The facility prohibits residents from keeping smoking material in his/her possession. Residents are required to turn in all smoking material to the Activity Department. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. R1 R1 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief interview for mental status dated 4/29/21 documents a score of fifteen which indicates cognitively intact. Smoking safety risk assessment dated [DATE] documents: R1 has a minimal problem with begging, borrowing, trades items, panhandles for smoking material, safely following the facility smoking policy, requires supervision with smoking and not able to store smoking material. Social service noted dated 6/17/21 documents: R1 was caught by V15 (PRSC) and V20 (activity director) in a peer's bathroom which was smoke filled with a distinct odor. V7 (PRSD) found additional evidence of unauthorized smoking. R1 admitted smoking weed. Nursing Note dated 6/17/21, R1 was caught smoking weed with another peer. Social service note dated 6/12/21 documents: Staff smelled smoke, asked R1 to leave the bathroom and found a lit cigarette. R1 reported, he just came across the cigarette and denied having any more or a lighter. Care plan dated 6/12/21 documents: R1 was an inappropriate smoker as evidence by possession of smoking materials, smoking in unauthorized area/unauthorized times. R1 was caught smoking in the bathroom. (6/17/21) R1 was caught in peer bathroom filled with smoke of an odd odor. I admitted to smoke weed. Interventions (6/12/21) uphold consequences for inappropriate smoking, (6/17/21) search R1 and immediate area for contraband material if smoking unauthorized is suspected/substantiated. On 6/22/21 at 3:29pm, R1 who was accessed to be alert to person, place and time. R1 said, I smelled the weed, went in the room and was smoking with the other residents. On 6/22/21 at 4:10pm, V15 (PRSC) said, R1 and R15 were smoking weed in the bathroom of room R12's room. The smoke was fresh and filled the bathroom. R1 and R15 had just finished smoking. We did not find the lighter nor would either resident report where they got the weed. Smoking Policy dated 11-28-12 documents: To provide a safe and healthy living environment the facility will designate an area for approved smoking by residents. The facility prohibits residents from keeping smoking material in his/her possession. Residents are required to turn in all smoking material to the Activity Department. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. R10 R10 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Social service's lookback summary dated 3/24/21 documents R10 was observed receiving smoking paraphernalia from others through a window on 1/5/21. I will not smoke without supervision. Brief interview for mental status dated 5/19/21 documents: R10 has a score of thirteen which indicates cognitively intact. Social service note dated 6/17/21 documents: R10 was observed smoking in another resident's room. Smoking Safety Risk assessment dated [DATE] documents: R10 has a minimal problem with general behavior, seeking out/pursues smoking materials, potential for causing injury to self or others from smoking in unauthorized area or careless use of smoking material, following the smoking policy and a moderate problem with trading, borrowing, begging and panhandles for smoking material. R10 requires supervision with smoking and is not able to store smoking material. On 6/17/21 at 10:41am, ashes were noted on the floor and the smell of fresh smoke was noted in R14's room. Two dark brown cigarettes butts, five light beige cigarettes butts with white dots noted on the filter were observed on the floor. On 6/17/21 at 10:53am V17 (Mental Health Tech), said, I saw five to six cigarette butts on the floor. On 6/17/21 at 11:04am V21 (maintenance) said, I smelled smoke in R14's room. R11 was trying to hide in between the closet space and the wall next to the window. I asked, R11 to come out. I notice a pair of jeans behind R11. V22 (maintenance) and myself pulled the pants out and noticed a lite cigarette on the pants. R10 and R11 admitted to smoking in the room. I don't know where they got the lighter or cigarette from. We didn't find the lighter. I only saw the butts and ashes on the floor. On 6/17/21 at 11:15am, a pair of blue jeans with a fresh smell of smoke was noted with a small burned area on the left upper leg near the front pants pocket measuring 5cm. On 6/17/21 at 11:30am, R10 who was assessed to be alert and oriented to person, place and time. R10 said, I was smoking. We got caught smoking. R11 got the cigarette off the ground on the smoke patio. On 6/17/21 at 5:18pm/5:19pm V18 (PRSC)/V19 (PRSC) both said, they did not do a room search for R10/R11. On 6/17/21 at 6:08pm V7 (Social Service Director) said, I didn't directly assign anyone to do a room search. We don't have any residents who are assessed to smoke independently or hold their smoking material. I don't know if staff found the lighter in R14's room. There is no smoking allowed in the building. On 6/17/21 at 6:23pm V1 (Administrator) said, no one is assessed to smoke independently or to have smoking material. During smoking breaks, staff are observing for resident breaking off filter, smoking difficulties with dumping their ashes or holding the cigarette. I wasn't given anything from the room search. On 6/17/21 at 6:37pm V20 (Activity Director), said the mental health techs a monitor the resident for picking up cigarette butts and pocketing them. We provide the cigarettes with the dark brown filter. On 6/17/21 at 7:30pm, observed over 100 cigarette butts outside the window of room BBB, along with an empty package of cigarettes and lighter. Cigarettes butts had both light and dark brown filters. Smoking Policy dated 11-28-12 documents: To provide a safe and healthy living environment the facility will designate an area for approved smoking by residents. The facility prohibits residents from keeping smoking material in his/her possession. Residents are required to turn in all smoking material to the Activity Department. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. R11 R11 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief interview for mental status dated 4/5/21 documents: R11 has a score of fifteen which indicates cognitively intact. Smoking Safety Risk assessment dated [DATE] documents: R11 requires supervision with smoking and is not able to store smoking material. Nursing notes dated 2/19/21 and 6/17/21 documents: R11 was caught leaving out of the room with a peer smoking cigarettes. R11 was assessed to have a change in skin integrity to the left thumb, index and middle finger which was dark in nature. R11's right hand had a change in skin pigmentation. R11 admits to breaking off the tip/filter of his cigarettes to get the full effect. Care plan dated 6/17/21 documents: R11 was smoking in an unauthorized area. Intervention: staff should monitor R11 while smoking to ensure he properly discards cigarettes once done. On 6/17/21 at 11:44am R11 who was assessed to be alert and oriented said, I was smoking. I brought the cigarettes in last night after the 7:30pm smoking break. I didn't smoke all of my cigarette. I put the cigarette out and brought the rest of the cigarette in just in case, I got the urge to smoke later. R11 was noted with light brown burn marks on his right index finger, thumb and left third finger. R11 had thick hard dark brown burn marks on his left index finger and thumb. R11 said, this happened when I smoked on the patio. I break the top of the cigarette off and smoke the cigarette down. I don't throw it away when it gets little. On 6/17/21 at 11:57am V2 (Director of Nursing) said, R11's fingers are signs of unsafe, inappropriate smoking. R11's left hand is old and healing, the right hand is new [CONDITION(S)]. R11's left hand has the most chard skin on the thumb, index and third finger. On 6/22/21 at 2:52pm V14 (Mental Health Tech) said after 3:00pm I am the only person outside to do the 7:30pm smoke break. I have to light the cigarettes then I go out for 5-6 minutes to monitor the residents smoking. Smoking Policy dated 11-28-12 documents: To provide a safe and healthy living environment the facility will designate an area for approved smoking by residents. The facility prohibits residents from keeping smoking material in his/her possession. Residents are required to turn in all smoking material to the Activity Department. The facility restrict access to smoking products, matches and lighters for person deemed unsafe. R17 R17 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's brief interview for mental status dated 5/21/21 documents a score of fifteen which indicates cognitively intact. Smoking assessment dated [DATE] documents: R17 requires supervision with smoking and is not able to store smoking material. Progress notes dated 6/18/2021 documents: R17 was caught trying to light a cigarette in his bathroom. All smoking contraband was confiscated. R17 was verbally warned about the no smoking rule in the building. Daily Communication dated 6/20/21 documents: R17 was smoking in the room and made a lighter out of two batteries/razor blades. Care plan dated 12/04/20 documents: R17 is physical and psychological addicted to [MEDICATION(S)]/smoking and smoking routines. Intervention: Monitor/report any concerns with non-compliance with smoking safety. On 6/23/21 at 4:20pm R17 who was assessed to be alert and oriented time person, place and time. R17 said, I made a lighter from batteries and a razor. I took a razor blade, put it on the positive end of a battery and turned the other battery to the negative side. It will heat up, get hot and light like a lighter. I used it to light my cigarettes to smoke in the bathroom. I saved my cigarette from smoke time. I don't smoke all of it. I'll put the cigarette out and in my pocket for later. I do it all the time. I was smoking in my bathroom yesterday. On 6/23/21 at 4:28pm V7 (PRSD) said, R17 was trying to light a cigarette in his bathroom with an apparatus; a battery and a piece of razor blade from a razor. Fire Department report dated 6/20/21 document: tobacco smoke set off the alarm. Fire Department report dated 6/13/21 documents: smoke detector activated, set off by cigarette smoke. The surveyor confirmed through observation, interview and record review that the following actions were taken to remove the immediacy of the Immediate Jeopardy: 1. Facility wide sweep and room searches for removal of residents smoking material. Initiated 6-14-21, 6-17-21, 6-18-21 and will continue biweekly x 4 weeks. This will be continued monthly thereafter. Room searches are an update to the removal of resident smoking material. 2. Residents who smoke have been re-educated on the smoking policy to include turning in to staff all smoking material. Evaluation of the effectiveness will continue with ongoing interventions. Adjustments/interventions implemented: increase MHT rounding, staff supervising smoke patio will visually observe disposal of smoking material, Reception/MHT will visually inspect packages, and facility increased the frequency of room searches. Initiated 6/14/21 at 10 a.m. and ongoing. 3. Updated/reviewed smoking assessments and care plans. PRSD and/or PRSC are responsible for updating assessments and care plans initiated for residents identified with inappropriate smoking behaviors. These residents had assessment and care plan updates. These updates were completed 06/14/21 and are ongoing. Following the initial updates, assessment/care plans will be updated quarterly and/or PRN as needed. 4. The Facility updated a list of inappropriate smokers based on the updated smoking assessments. Activity Director is responsible for updating the inappropriate smokers list on a daily/weekly basis based on assessment of inappropriate smoking behavior and/or new resident admission. Completed 6/14/21 and ongoing. 5. A list of inappropriate smokers has been placed at the nurse's station, behavior aid desk, activities department, and Social service department. Nursing staff was in serviced regarding monitoring inappropriate smokers during rounds. Administrator and/or designee is responsible for in-servicing staff. Staff on leave will be in serviced upon return. New hires will be in-serviced during the staff orientation process. Rounds will be conducted every hour. Mental Health Technicians will be conducting rounds. Room census will be used as an audit tool. MHT's will note on the room census which rooms that were entered upon their rounding. MHT's are scheduled on a 24-hour basis. Nurse and/or designee will conduct MHT rounding if deemed necessary. PRSD and/or designee will audit MHT rounding. Monitoring for inappropriate smokers in addition to well-being checks on residents was initiated 6/14/21 and updated weekly. Inservice was conducted on 6/21/21, 6/22/21, and ongoing to account for staff on leave of absence, vacation, and new hires. 6. Staff have been in serviced on the smoking policy by the administrator; to include that staff will maintain and distribute smoking material during the supervised smoking times only and will report to administrator or DON if a resident is identified with smoking material in their possession. Administrator and/or designee are responsible for in-servicing staff. Staff on leave will be in serviced upon return. New hires will be in-serviced during the staff orientation process. Initiated 6/14/21 and updated weekly, in services were conducted on 6/21/21, 6/22/21, and ongoing to account for staff on leave of absence, vacation, and new hires. How the facility will monitor system: 1) New residents will be assessed upon admission for any inappropriate smoking behavior and the resident may not be admitted if this behavior is identified. New residents will be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Staff have been in serviced on 6/14/21 to report any resident noted to have smoking materials to management, so the smoking material can be obtained and stored according to policy. Initiated 6/14/21 and updated weekly. Inservice was conducted on 6/21/21, 6/22/21, and ongoing to account for staff on leave of absence, vacation, and new hires. Staff on leave will be in serviced upon return. New hires will be in-serviced during the staff orientation process. 3) Upon admission, staff will perform a search of the resident/belongings for contraband including inappropriate smoking materials. 4) Administrator, DON and/or designee will do random inspections of resident rooms for smoking materials and other devices that would be possible methods for residents to set a fire. This was initiated 6/14/21, then weekly for 4 weeks. This will be continued monthly thereafter. 5) Mental Health Technicians/Receptionist will inspect all resident packages for any contraband items. Inspection will be done by visual observation of the items. All resident packages will be inspected coming into the facility without specific circumstances. This was initiated 6/29/21 with frequency of daily inspections. 6) Maintenance will conduct daily checks on window screens to inspect for tears/repairs needed. This was initiated 6/21/21 with a frequency of daily inspections. The facility will be identifying a more durable screen material to replace the current screen material within the resident windows. Maintenance and MHT staff will monitor areas when screens are being removed for repair by conducting hourly visual observations of resident rooms. This was initiated 7/01/21 and ongoing until completion. 7) Maintenance will increase rounding for maintaining a clean and safe environment ensuring that the cigarette butts are removed from the ground. This was initiated 6/21/21 with a frequency of daily inspections. 8) Residents will be visually observed disposing of their smoking material before returning into facility. Staff supervising the resident's smoke break will be responsible for the visual observation of residents disposing of their smoking materials in the designated ashtrays placed on the resident smoking patio. This was initiated 6/29/21 with frequency of daily inspections.

Based on interview and record review the facility failed to utilize a resident's fall risk assessment to identify fall risk interventions and failed to update the care plan with effective fall interventions after two fall incidents for 1 (R17) of 3 residents reviewed for fall prevention, the facility also failed to follow the fall policy by not updating residents fall plan of care following a fall and failed to provide therapy screen for residents following a fall for 3 of 3 (R9, R11 and R17) residents reviewed for falls. These failures resulted in R17 having a subsequent third fall resulting in a closed injury, and traumatic acute cord [MEDICAL CONDITION] resulting in acute extremity weakness. Findings include: 1) R17 admitted to facility on 4/21/10 with [DIAGNOSES REDACTED]. R17 minimum data set ((MDS) dated [DATE] states under section G functional status documents under bed mobility, transfer and toilet are coded as supervision with set up. Walk in room and walk in corridor are coded as limited assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or non-weight bearing assistance. And one-person physical assist. Under functional limitations in range of motion documents no impairment to upper extremities. Under balance during transitions and walking document not steady only able to stabilize with staff assistance when turning around and facing opposite direction while walking. R17's fall risk assessment dated [DATE] states At risk for falls. Under gait and balance documents balance problem when standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns, and requires use of assistive device R17's progress note dated 2/19/21 states Fall on the smoke patio due to slick floor with no injury noted at this time. R17's progress note dated 3/8/21 states Fall in hallway in front of nurse's station. Resident fell on his buttocks due to misuse of walking device. R17's progress note dated 3/10/21 states Resident reports to nurse of falling last night unwitnessed. Resident further reports hitting his head, but no visible signs of injury. Resident's LOC is unchanged and at baseline. Remains alert and oriented x 3 per baseline. However, resident's mobility is somewhat changed. Unable to sit up per self and requiring staffs' assist x 2. Although unable to render voluntary ROM, with assessment of ROM capability- resident is stiff and resistant to ROM assessment. R17's care plan initiated 12/28/16 with revision date of 2/24/2021 states R17 have potential for minor injury related to fall history I have impaired mobility. I also receives routine [MEDICAL CONDITION] medication in addition I have poor safety awareness. Interventions: Encourage resident to take rest periods during ambulation when feeling weak with date initiated 8/28/19; Remind resident to lock walker. Ensure resident has on proper foot ware when up ambulating. Monitor skin tear s/p fall with date initiated 12/11/18; Staff to clean up spills as soon as it occurs. Encourage resident to be aware of his surroundings with date initiated 6/25/19; Complete routine fall assessment with date initiated 12/28/16; Continue with restorative program with date initiated 12/28/16; Educate on safety with date initiated 11/11/19. Facility's fall policy revised 11/21/17 states The purpose is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive device are utilized as necessary. Under guidelines care plan incorporates identification of fall risk/issue, addresses each fall, interventions are changed with each fall as appropriate and preventative measures. Each resident will be screened by a therapist at time of admission, quarterly, after each fall and with significant change in resident's mental and functional abilities. On 3/24/21 at 11:45 AM, V30 (MDS Nurse) said if resident is coded as limited assistance/one-person assist indicates someone should be present during activity. If activity is coded as supervision/set up staff should be present during the activity to provide assistance as needed. V30 (MDS Nurse) said she is not responsible for fall care plans. On 3/24/21 at 2:39 PM, V20 (MDS Nurse) said she will help with care plans but has not updated any fall care plans for residents. On 3/25/21 at 4:45 PM, V20 said R17 was on restorative but when he returned to facility on 12/8/20 he was not picked up for restorative services. On 3/25/21 at 12:13 PM, V2 (Director of Nursing/DON) said fall care plans should be updated within 24 hours with new interventions. V2 said she is not responsible for care plans and MDS nurses are responsible. V2 said facility does not have a restorative nurse at this time. V2 said she was unable to find therapy screens for R17. On 3/25/21 at 1:41 PM, V34(Medical Director) said R17 's fall was a contributing factor to R17's current [DIAGNOSES REDACTED]. R17's hospital record dated 3/10/21 documents a [DIAGNOSES REDACTED]. R17's CT scan dated 3/10/21 documents a subcutaneous hematoma overlying the left frontal bone. R17's hospital record dated 3/11/21 documents under [DIAGNOSES REDACTED]. Under primary complaint documents patient states, he sustained fall a few days ago and now experiencing weakness. Patient has no movement in upper extremities. Under MRI cervical spine impression documents severe central spinal canal stenosis at C3-C4 due to the [MEDICAL CONDITION] changes resulting in cord compression and mild cord signal abnormality at c4 level which may represent acute cord [MEDICAL CONDITION] or myelomalacia (softening of spinal cord) from chronic compression. According to American Association of Neurological Surgeons, Central cord syndrome (CCS) is an incomplete traumatic injury to the cervical spinal cord - the portion of the spinal cord that runs through the bones of the neck. This injury results in weakness in the arms more so than the legs. The injury is considered incomplete because patients are usually not completely paralyzed. This syndrome more commonly affects patients age 50 and older, who have sustained a neck (cervical) hyperextension injury. R9 was admitted to facility on 8/7/19 with [DIAGNOSES REDACTED]. 2) R9's care plan initiated on 8/7/19 documents (R9) is at risk for falls related to use of [MEDICAL CONDITION] medications and knee pain. Interventions included: Administer medications as ordered with date initated 5/6/20; Ensure resident has on proper footwear with date initiated 8/26/19; Observe for weakness and tiredness and encourage rest periods as needed with date initiated 8/26/19; Observe medications resident is receiving for side effects with date initiated 8/26/19. R9's progress note dated 2/19/21 states Resident reported that she tripped on ice and fell at the smoke patio. R9 's record did not include any therapy screening. On 3/25/21 at 12:13 PM, V2 (DON) said fall care plans should be updated within 24 hours with new interventions. V2 said she not responsible for care plans and MDs nurses are responsible. V2 said she was unable to find therapy screens for R9. 3) R11 was admitted to facility on 12/2/2016 with [DIAGNOSES REDACTED]. R11's progress note dated 2/4/21 states (R11) tripped and fell while trying to open her wardrobe. R11's progress note dated 2/18/21 states (R11) rolled down from her bed with her comforter on the floor no injury noted at this time. R11's care plan dated 4/9/16 states (R11) has potential for injury related to history of fall and use of [MEDICAL CONDITION] medication. Interventions include: Monitor for pain with date initiated 1/22/19; Call light in reach at all times with date initiated 4/9/16; Ensure bed in lowest position with date initiated 4/9/16; Review labs with date initiated 4/9/16. R11's care plan did not document any update after falls on 2/4/21 or 2/18/21. R11's record did not include any therapy screening. On 3/25/21 at 12:13 PM, V2 (DON) said fall care plans should be updated within 24 hours with new interventions. V2 said she not responsible for care plans and MDs nurses are responsible. V2 said she was unable to find therapy screens for R11.

Based on observation, interview, and record review, the facility failed to follow their abuse policy and keep a resident free from physical abuse; failed to create and implement patient specific interventions to prevent abuse from occurring; and failed to substantiate that abuse occurred for two of six residents (R4 and R5) reviewed for abuse. This deficiency resulted in R4 being physically assaulted by R5 and sustaining a laceration to scalp that required staples, multiple bruises and a brain bleed. R4 also sustained psychological harm as evidenced by screaming out and accusing other peers that they are attacking her. Findings include: R4 has [DIAGNOSES REDACTED]. R5 has [DIAGNOSES REDACTED]. Facility initial report sent to state department on 1/17/21 notes at approximately 8:00am, R4 involved in an altercation with roommate (R5) and sustained a wound to her head along with bruises and superficial abrasions to both hands. R4 and R5 were sent to the hospital. V7's Social Service assessment on 1/17/21 at 9:00am (after the incident) notes R4's care plan will be updated. CT of Head on 1/17/21 at 11:10am notes that R4 sustained [MEDICATION NAME] head trauma and has areas of sub-arachnoid hemorrhage (brain bleed). Facility final investigation dated 1/22/21 notes R4 sustained a wound to head Traumatic Subarachnoid Hemorrhage/Bleed, along with bruises and superficial abrasions to both hands. R4's scalp lacerations were treated with staples. R4's mental status is alert and oriented to self only. Upon return from the hospital, R4 stated my roommate .Bam, Bam, Bam. R5 admitted to punching R4 but stated she doesn't know what happened after that. She did not indicate that she used anything other than her hand to strike R4. R5 said she becomes catatonic at times and does not know what she is doing. She woke up with visions of chopped up organs in the room, so she punched the wall. R6 (R4 and R5's roommate) stated that R4 and R5 were arguing, then R5 tackled R4 and she heard a loud noise. R5 indicated she struck R4 due to her delusional thought that R4 had slept with one of her sons. Facility conclusion notes the evidence does not indicate that there was an intent to harm, therefore there was no abuse and abuse cannot be substantiated. Social Service will meet with R4 to maintain a healthy psychosocial well-being and provide her counseling if she verbalized any emotional distress. R4's care plan will be updated. On 1/20/21 at 3:25pm, V6 (Director of Nursing, DON) stated that through interviews with R6, we were able to establish that R4 and R5 first had a verbal altercation, then she heard a boom and R4 asking for help. R5 went to the bathroom to wash her hands. R4, R5 or R6 did not report this but V9 (Environmental Services) found R4 in bed, bleeding from her head about 8:00am when rounding. I encouraged residents to report this next time. R4 or R5 did not say what happened at the time. R4 was sent to the emergency room and received 7 staples to the left side of her head. A CT scan (Head Scan) showed a brain bleed. R4 was readmitted to facility on 1/19/21. R5 was sent to the hospital for evaluation. On 1/20/21 at 3:56pm, V7 (Social Worker) stated that R4's care plan and assessment notes she is at risk for abuse related to her aggressive behavior and mental illness. On 11/22/20, a revision from myself states that she became verbally aggressive with her roommate. I cannot remember who it was or what happened and there is not further note or interventions but there should be more information. R4 also had a history of [REDACTED]. R5's care plan notes she is at risk for abuse related to aggressive behavior, depression and mental illness. The intervention is to report any abuse to administrator immediately. R5 minimized a lot of things and I have seen her agitated at times. I did not know R5 very well. I believed that R4 or R5 would report abuse if it happened. One of the ways we try and prevent abuse is to monitor the resident's for agitated behavior. V7's note on 11/21/20 notes R4 has feelings of depression, trouble sleeping, poor appetite, and had auditory hallucinations on 11/20/20. R4 has verbal and behavioral symptoms directed towards others and is verbally aggressive towards roommate. R4's behavior appears to be worse and refuses medication daily. On 1/25/21 at 10:14am, R4 sat up in bed and pointed to head and stated, bang, bang. V10 (Licensed Practical Nurse, LPN) reached out to touch R4's hair and staples on the left side of her scalp and R4 winced back. R4's left ear is swollen and has crusted, dried blood to the wound. R4 also has bruises to forehead, right elbow, right and left forearms and multiple areas on both hands. Left hand has a healing cut as well. R4 is childlike in responses and difficult to understand at times. On 1/25/21 at 10:15am, V10 (LPN) stated that I had taken care of her when she was on the other wing, before she was injured. Since she came back from the hospital, she has some [MEDICAL CONDITION] (post-traumatic stress disorder) symptoms. She screams out in her room and when the CNA or I go in there, she says that her roommate is trying to get her, but her roommate is asleep in the next bed. She has done this at least once a shift for several days. We talk to her until she calms down. I am not sure who her social worker is. I have told V1 (Administrator) or V6 (Director of Nursing) last week, I think. On 1/25/21 at 11:00am, R4 walked out of room and down the hallway to a male peer standing in his doorway. R4 walked up to his face, pointed and stated loudly, it was you; it was you before staff redirected her back to her room. At 11:14am, R4 screamed in her room, then walked out into the hallway, following several different male peers around. On 1/25/21 at 12:05pm, V6 (DON) stated that we have been watching her more closely since she has been back from the hospital and has a new roommate. She will not pull her call light if she needs anything. The nurses and Certified Nursing Assistant, CNA's are checking in on her and ask her if she is ok? She is not one to readily offer if she needs assistance or anything. I have not had a report that she has had any behaviors since she has returned from the hospital. On 1/25/21 at 12:15pm, V7 (Social Worker) stated that R4's non-verbal status can put her at risk for abuse as well. When residents come back from the hospital, after an abuse situation, social services will check residents, to make sure they feel safe. I checked on her Friday, 1/22 after she returned from the hospital (on 1/19/21) and the nurses are checking on her. I did not get a report from nurses regarding behaviors of screaming or feeling unsafe. The social service assessment on 1/18/21 notes her care plan will be updated but it was not. We constantly monitor residents and address behaviors to prevent abuse. I try to meet with the residents at least twice a month if I can get to them. I met with R5 for well-being checks on 11/1 and 11/24, regarding coping skills. I had not seen her for counseling since. We got understaffed and counseling sessions happened sparsely. Prior to the incident on 1/17/21, I saw R4 for well-being checks and counseling for symptom management last on 12/30/20 and sporadically in between. On 1/25/21 at 2:00pm, V1 (Administrator) stated that upon R4 returning from the hospital, I asked social service to check on R4 for any psychosocial concerns or distress from the incident and to update the care plan. The interventions would depend on what she verbalizes and if she had any other ill effects (from being physically assaulted). I would expect social service to initiate a well-being check 24 to 72 hours after being readmitted to see what she would need or sooner if she needed it. I did get report from V10 (LPN) that R4 was screaming one day last week, but no description was given. Behaviors should be reported in morning meeting so social service is made aware. We are moving R4's roommate to a new room just to be sure that she feels safe, there was an incident just a few minutes ago where R4 was upset. V10's behavior note dated 1/25/21 at 1:30pm notes that R4 keeps saying my roommate is trying to attack me and screaming. This time, R4 attempted to hit roommate. On 1/26/21 at 4:00pm, V1 (Administrator) stated that staff stopped R4, before she struck roommate. R4's care plan notes that, she is at risk for abuse related to aggressive behavior, mental illness. On 11/22/20, I became verbally aggressive with my roommate. Interventions, at this time was to observe resident in care situations and report any verbalization of abuse or neglect to the administrator immediately. R5's care plan, started on 8/24/20 notes that she is at risk for abuse related to aggressive behaviors, depression and mental illness, I hear voices telling me to leave or defend myself against others, have delusions that people are trying to contain or destroy me, so I have to defend myself. The only intervention listed on abuse care plan is to report any verbalization of abuse to administrator immediately. Facility Abuse policy notes that a resident has the right to be free from abuse. Abuse is the willful infliction of injury, resulting in physical harm. Instances of abuse of all resident's, regardless of any mental or physical condition, cause physical harm or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility desires to prevent abuse by establishing a resident secure environment. This will be accomplished by staff identifying residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse.

Based on observation, interview, and record review, the facility failed to provide consistent well-being checks/counseling for two of six resident's (R4 and R5) who are at risk for abuse and behaviors due to mental illness and failed to provide counseling along with updating care plan after abuse occurred. This failure resulted in R4's continued behaviors of screaming out and accusing co-peers of being attacked after returning from the hospital. Findings include: R4 has [DIAGNOSES REDACTED]. R5 has [DIAGNOSES REDACTED]. R4's care plan notes that, she is at risk for abuse related to aggressive behavior and mental illness. On 11/22/20, I became verbally aggressive with my roommate. Interventions, at this time were to observe resident in care situations and report any verbalization of abuse or neglect to the administrator immediately. Further care plans, revised on 11/23/20, also note that I have the potential to be physically aggressive related to [MEDICAL CONDITION], with interventions that include, to analyze triggers and document them; I have been diagnosed with [REDACTED]. The goal is to engage in skills training addressing triggers 2 X per week; I have a history of being verbally aggressive to staff due to ineffective coping skills. Interventions include to encourage resident to attend group and provide her with individual counseling on how to manage her impulse/anger. R5's care plan, started on 8/24/20 notes that she is at risk for abuse related to aggressive behaviors, depression and mental illness. The only intervention listed is to report any verbalization of abuse to administrator immediately. Further care plans note that I hear voices telling me to leave or defend myself against others, have delusions that people are trying to contain or destroy me so I have to defend myself. Interventions include to anticipate care needs and provide them before I becomes overly stressed and provide psychological services as ordered by physician; I have a [DIAGNOSES REDACTED]. Interventions are to discuss benefits of group or individual counseling sessions and encourage R5 to follow mental health treatment plans. Facility initial report on 1/17/21 notes at approximately 8:00am, R4 involved in an altercation with roommate (R5) and sustained a wound to her head along with bruises and superficial abrasions to both hands. R4 and R5 were sent to the hospital. Final investigation notes R4 sustained a wound to head, a brain bleed, along with bruises and superficial abrasions to both hands. R4's scalp lacerations were treated with staples. R4's mental status is alert and oriented to self only. Upon return from the hospital, R4 stated my roommate .Bam, Bam, Bam. R5 admitted to punching R4 but stated she doesn't know what happened after that. She did not indicate that she used anything other than her hand to strike R4. She woke up with visions of chopped up organs in the room, so she punched the wall. R6 (R4 and R5's roommate) stated that R4 and R5 were arguing, then R5 tackled R4 and she heard a loud noise. R5 indicated she struck R4 due to her delusional thought that R4 had slept with one of her sons. Social Service will meet with R4 to maintain a healthy psychosocial well-being and provide her counseling if she verbalized any emotional distress. R4's care plan will be updated. On 1/20/21 at 3:56pm, V7 (Social Worker) stated that R4 is alert but doesn't say a lot. Her care plans note that she is at risk for abuse related to aggressive behavior, mental illness. My revision on 11/22/20 notes that she became verbally aggressive with my roommate. I can't remember, I think they got in an argument. I cannot remember who it was or what happened and there is not further note or interventions but there should be. She had a history of [REDACTED]. R5, minimized a lot of things and I have seen her agitated at times. Her care plan states I am at risk for abuse related to aggressive behavior, depression, mental illness. On 1/4/21, the doctor note states she identifies as man and I did not know that. It states she also wants to be called Augustus. I did not know her very well. On 1/25/21 at 10:15am, V10 (LPN) stated that I had taken care of R4, when she was on the other wing, before she was injured. Since she came back from the hospital, she has some [MEDICAL CONDITION] (post-traumatic stress disorder) symptoms. She screams out in her room and when the Certified Nursing Assistants or I go in there, she says that her roommate is trying to get her, but her roommate is asleep in the next bed. She has done this at least once a shift for several days. We talk to her until she calms down. I am not sure who her social worker is. I have told V1 (Administrator) or V6 (Director of Nursing) last week, I think. On 1/25/21 at 11:00am, R4 walked out of room and down the hallway to a male peer standing in his doorway. R4 walked up to his face, pointed and stated loudly, it was you; it was you before staff redirected her back to her room and she closed the door. At 11:14am, R4 screamed in her room, then walked out into the hallway, following several different male peers around closely before staff asked her to go back to her room and close the door. On 1/25/21 at 12:05pm, V6 (DON) stated that we have been watching her more closely since she has been back from the hospital and has a new roommate. She will not pull her call light or ask for assistance if she needs anything. The nurses and Certified Nursing Assistant, CNA's are checking in on her and ask her if she is ok. I have not had a report that she has had any behaviors since she has returned from the hospital. On 1/25/21 at 12:15pm, V7 (Social Worker) stated that R4's non-verbal status can put her at risk for abuse as well. When residents come back from the hospital, after an abuse situation, social services will check residents, to make sure they feel safe. I checked on her Friday, 1/22/21 after she returned from the hospital (on 1/19/21) and the nurses are checking on her. I did not get a report from nurses regarding behaviors of screaming or feeling unsafe. The social service assessment on 1/18/21 notes her care plan will be updated but it was not. I try to meet with the residents at least twice a month if I can get to them. I met with R5 for well-being checks/counseling on 11/1/20 and 11/24/20, regarding coping skills. I had not seen her for counseling since. We got understaffed and counseling sessions happened sparsely. Prior to the incident on 1/17/21, I saw R4 for well-being checks and counseling for symptom management last on 12/30/20 and sporadically in between. On 1/25/21 at 2:00pm, V1 (Administrator) stated that upon R4 returning from the hospital, I asked social service to check on R4 for any psychosocial concerns or distress from the incident and to update the care plan. The interventions would depend on what she verbalizes and if she had any other ill effects (from being physically assaulted). I would expect social service to initiate a well-being check 24 to 72 hours after being readmitted to see what she would need or sooner if she needed it. I did get report from V10 (LPN) that R4 was screaming one day last week, but no description was given. Behaviors should be reported in morning meeting so social service is made aware. We are moving R4's roommate to a new room just to be sure that she feels safe, there was an incident just a few minutes ago where R4 was upset. V10's behavior note dated 1/25/21 at 1:30pm notes that R4 keeps saying my roommate is trying to attack me and screaming. This time, R4 attempted to hit roommate. Review of V7's social service notes show there were no social service well-being checks/counseling from 11/8/20-11/18/20. V7's note on 11/21/20 notes R4 has feelings of depression, trouble sleeping, poor appetite, and had auditory hallucinations on 11/20/20. R4 has verbal, behavioral symptoms directed towards others and is verbally aggressive towards roommate. R4's behavior appears to be worse and refuses medication daily. There are no well-being checks/counseling notes from 11/22-11/27/20. On 12/3/20, V7's note stated he will continue to provide R4 with counseling and supportive services necessary to benefit her ability to maintain a healthy state of mind, however there were no well-being checks/counseling from 12/3/20 through 12/20/20, or 12/31/20 to 1/17/2, until R5 attacked R4. V7's next note on 1/22/21 at 6:27pm, read, he conducted a well-being check and R4 had no issues or concerns at this time and that staff will continue to monitor and document. V7 did put a late entry note in on 1/25/21 that stated he saw R4 on 1/20/21 (after return from the hospital) despite him stating to surveyor that he did not see her until 1/22/21. Review of social service notes show that R5 had well-being check/counseling sessions on 11/1/20 and 11/24/20 and none from social service since this date. V7's note on 11/24/2020 at 2:14pm states, Plan: This writer along with the social service staff will continue to provide resident with the counseling and supportive services necessary to benefit resident's ability to maintain a healthy mood. R5's physician orders [REDACTED]. R5's Physician order [REDACTED]. R5's Physician order [REDACTED].

Based on interview and record review, the facility failed to prevent an avoidable accident/fall and safely initiate and perform physical crisis prevention intervention during a behavior episode of 1 of 3 residents (R23) reviewed for safe crisis prevention intervention techniques. This failure resulted in R23 being taken to the ground by facility staff and entangling R23 lower extremities causing a fracture to R23's left ankle. Findings include: R23 was admitted to facility on 2/17/16 with [DIAGNOSES REDACTED]. R23's progress notes dated 4/6/20 documents R23 noted with agitation and was CPI by staff. Resident noted with sprain to left ankle. R23 was upset about money missing from his drawer when staff try to redirect him he continued to be upset with staff. R23 escalated to verbally getting aggressive and attempted to swing at behavior aide. CPI was immediately initiated and all 3 went down to floor administrator has launched an abuse investigation. Facility's report to IDPH dated 4/14/20 documents Resident involved with altercation with staff in which resident reports tripping on someone's foot and twisting his ankle Facility preliminary abuse report dated 4/6/20 documents R23 was agitated and attempted ot be physically aggressive with staff. R 23 was place din CPI hold and twisted his ankle Facility's final abuse investigation documents R23 stated he was upset with V32 (ADON) for throwing out his money. R23 said V29 (behavior aide) kept telling him to relax and lower his tone and R23 was tired of him telling him that so he punched V29 in the mouth. R23 stated that when he was in the hold he felt himself trip over someone's foot and his ankle twisted. V32's statement documents R23 became aggressive about money being thrown away. R23 attempted to become physical with V29 and assisted with CPI hold. V32 said during the hold R23 twisted his ankle. V29's statement documents R23 swung at him and V32 assisted with placing R23 in CPI hold. R23 fell to the floor during CPI hold. Under conclusion documents there is no evidence to support V29 and V32 improperly implemented CPI. On 12/15/2020 at 1220 Pm V2 (DON) said R23 upset about money missing and escalated to code yellow with CPI hold. R23 had stepped on R23's foot causing them to fall down. I think it was a bear hug hold. On 12/11/20 at 233pm, V32 (adon) said R23 was upset because I had accidently thrown his money away. R23 was yelling and cursing at me. V29 (behavior aide) intervened and asking him to be more respectful and R23's anger turned toward V29. R23 tried to punch V29 and fell into V29 and they both fell to the ground. V32 denies using any CPI hold on R23. V32 said the fall could have been prevented if R23 was not aggressive. V32 unclear who or when code yellow was called. V32 was given statement from reportable and stated unable to recall events of incident. R23's hospital record dated 4/6/20 document left ankle injury relate to physical altercation at nursing home. R23 stated he tripped over another person. Under clinical impression documents bimalleolar fracture of left ankle. According to the crisis prevention institute, CPI teaches that staff should consider the use of a physical intervention only as an emergency intervention to respond to an individual posing an immediate danger to self or others. CPI also teaches that physical restraint should be used only as a last resort when all other attempts to calm escalating behavior have been tried and have failed. The Nonviolent Crisis Intervention® program focuses not on restraint training, but on ways to avoid the need to restrain. Staff must be aware that serious physical and psychological risks are inherent in any physical intervention. The only truly safe physical restraint is the one that never occurs. Nonviolent Crisis Intervention® training stresses the importance of having a monitor present at every restraint-someone who is not involved in performing the actual physical hold. The person should be assigned the responsibility of monitoring physical signs of distress and obtaining medical assistance. Facility code yellow policy- Behavior crisis policy dated 1-11-18 documents to initiate appropriate measures to control and secure the environment when resident has a behavior crisis. Guidelines include call for help by using intercom to page code yellow, implement measures to provide safety, summon additional staff, defuse crisis through calming communication, assess need for additional intervention as indicated, remove resident from situation, and remove offending stimuli from resident, place resident in safe environment.

Based on observation, interview and record review the facility failed to provide one to one supervision of a resident (R9) with a history of severe mental illness and elopement, and failed to prevent (R9) from using a code to access an exit for employees only. This failure resulted in (R9) exiting the facility unauthorized to engage in sexual activities with a staff member V25 (Housekeeper). This was identified as immediate jeopardy situation that began on 8/1/20 and was removed on 8/27/20. V1 (administrator) was informed of the immediate jeopardy on 8/18/20. While the immediate jeopardy was removed on 8/27/20, the facility remains out of compliance at a severity level two until the facility can evaluate the effectiveness of staff training for monitoring residents at risk for elopement. Based on observation, interview and record review the facility failed to provide supervision and monitoring for residents at risk for elopement or a resident exhibiting negative behaviors, failed to have staff available to monitor a wandering resident and failed to have a resident on their list for residents at high risk for elopement; to prevent and/or immediately alert the facility's staff members when a resident is eloping out of the facility via an exit door. This failure involves 3 residents (R22, R23 and R28) who either eloped or attempted to elope from the facility at the time of the survey. As a result, on 8/18/20 R22 a newly admitted resident with a history of negative behaviors, left out of an exit door without the staff being alerted and later was seen within the local community by an off duty staff member (V37). This was identified as immediate jeopardy situation that began on 8/18/20 and was removed on 8/27/20. V1 (administrator) and V2 (director of nursing/DON) was informed of the immediate jeopardy on 8/20/20. While the immediate jeopardy was removed on 8/27/20, the facility remains out of compliance at a severity level two until the facility can evaluate the effectiveness of staff training for monitoring residents at risk for elopement. Finding Includes: 1. R9 was admitted to facility on 3/21/18 with [DIAGNOSES REDACTED]. R9's minimum data set ((MDS) dated [DATE] documents: R9's brief interview for mental status is a fifteen which indicates cognitively intact. R9's care plan dated 5/11/2020 documents: R9 is an elopement risk. R9 attempted to leave the facility unauthorized. R9's care plan initiated 5/12/2020 documents: R9 wander and display poor boundaries. On 8/4/2020 at 1:42pm, Surveyor observed, R21's bed adjacent to the window. The window showed an unobstructed view of the outside patio. R21's window had a wooden stick screwed into the bottom of the window frame. The window had the ability to open approximately a few inches but the secure stick prevented the window from opening wide enough to allow for any adult to climb through. On 8/6/20 at 12:59 pm, R9 said V25 (Housekeeper) approached R9 in the one to one behavior aide monitoring area. V25 (housekeeping) grabbed R9's hand and said he wanted to talk to me. We went by employee's exit/entry way (door 3). V25 hugged and kissed me. V25 asked, if I wanted to have sex. I said yes. R9 said, we left out the employee exit door (door 3). V25 told me the code, so I could get back in. R9 said, they walked through the back part of the facility. V25 opened all the gates for her. R9 said, she hid behind a van near the east smoking patio in the facility driveway and waited for V25. V25 pulled up in a nice silver car with four doors. I walked to V25's car and got in. We drove a few blocks away. We parked, got out of the front seat and got into the back seat. We had unprotected sex. R9 stated, V25 had a large tattoo on his back with letters and an image of a picture but I didn't want to know what the tattoo was so I wouldn't have to identify V25. V25 drove back to the facility, walked me near the employee smoke door entrance, I put in the code and entered the back into the building through door #3. On 8/6/2020 at 1:42pm, R21 who was alert and oriented said, he heard a noise from the gate outside, looked out of his window and saw R9 outside of the facility with a male that had on a blue shirt. On 8/6/2020 at 3:15pm, R17 who was alert and oriented to person, place and time said, he saw R9 come in through the side patio door but didn't see her leave. There was no behavior aide in the one to one monitoring station when R9 came back in the building. On 8/6/2020 at 3:47pm, R16 who was alert and oriented said, he saw R9 leave with the housekeeper while he was in the one to one monitoring area. On 8/6/2020 at 3:20pm, Surveyor observed R9, entering the code to door number three, exiting the facility, walking out of the first gate, pass the activity office to the second gate then to the final gated area on the east wing smoke patio while demonstrating how she hid behind the facility van to avoid being seen by staff in the front of the building. R9 reported walking to V25's car when he pulled up and riding away with V25 for a few blocks. On 8/7/2020 12:49 pm, V26 (Certified Nursing Assistance/CNA) said, I saw R9 on Saturday (8/1/2020) in the behavior aide monitoring station. R9 ate dinner there. We pass the dinner trays and housekeeping dispose of them. V25 was the only housekeeper working that night. I was looking for R9 for ten to twenty minutes. I would have called a code yellow. I searched the east wing first, then the resident's rooms and I found R9 sitting in the behavior aide one to one monitoring area. R9's pink shirt and hair was wet from what appeared to be rain drops. It was raining outside On 8/7/2020 at 1:00pm, V33 (Activity Aide) said, R9 was observed around 7:30pm in the behavior aide station on one to one monitoring. Around 7:45pm, R9 was no longer in that area. V33 asked, staff where was R9 and if they were going to call a code pink. We checked the exit doors. R9 was observed back in the one to one area. R9 said, she was outside and went through a resident's window. R9's hair and t-shirt was wet. On 8/11/2020 at 9:50am, V5 (Social Service/ Behavior Aide Supervisor) said, residents should not have the code to door number three. On 8/11/2020 at 12:54pm, V2 (Director of Nursing), said, when R9 is challenged her decision making is not a hundred percent. R9 is an elopement risk and should have been on the elopement list. R9 used the facility code to exit out of door #3. I was not aware R9 used the code until being updated by the Surveyor on 8/6/2020. R9 has a history of promiscuity sexual behaviors, this is not the first time. R9 behaviors lead to inappropriate sexual activity with a variety of people. R9 was able to leave the building because there was another incident with another resident. We had two investigations on the same night. It was storming that night. On 8/12/2020 at 4:48pm, R9 said, I tried to elope on August 10, 2020, because I did something bad with an employee and I wanted the support of my family. On 8/13/2020 at 8:00am, V32 (Counselor) said, R9 has poor decision making skills which is based on the community survival skill assessment. R9 is delusional at times. R9 is very sexually promiscuous with men. If you ask R9 to do something, R9 will do it without thinking. R9 might get into a strangers car which is why R9 must be supervised. I have not had any follow-up with R9. Social service is responsible for making sure the resident is safe. I am R9's counselor. On 8/14/2020 at 1:48pm, V25 (Housekeeper), I took R9 out to have a cigarette break. I know, I wasn't suppose too. On 8/19/2020 at 9:02am, R9 said, it's called the Hidden Place because there are no cameras. On 8/20/2020 at 11:17am, V2 (DON) said, we were able to speak to V25. We asked V25 if R9 got into his car. V25 said, no. The only part of V25's story credible is when V25 admitted leaving the building with R9. I don't know about R9 changing her story. When I talked to R9, R9 was very direct. On 8/13/2020, during the interview with V1, R9 did not elaborate on her answers and started to giggle. When R9 giggles, it is a coping mechanism and she is nervous. Listening to R9 talking about the incident with V25, made me feel yucky. R9 only recanted climbing out the window. R9 never recanted her story to me. We did not think to get a vaginal swab. R9's nurse practitioner did not think to do a vaginal swab either. On 8/20/20 at 12:53pm, V22 (Human Resource/ HR) said, that V25 (Housekeeper) will be terminated based on the investigation the facility performed related to R9's allegation. The facility could not determine what happened to R9 when she left the facility with V25. V1 (administrator) and V2 (DON) reported, after viewing the cameras, they observed V25 (housekeeper) leaving with R9 by the east wing smoke patio gates. V22 (HR) said, she thinks they were smoking but was unsure and then reported V25 and R9 slowly inched there way off camera and away from the facility. It was reported that R9 reappeared on camera about thirty minutes later. V22 (HR) said, she recalls staff questioning where they were. V22 (HR) said, she did not see the video but was told information by V1 (administrator) in order to terminate V25 (housekeeper). Elopement/ Unauthorized Leave Risk Review 5/10/2020: R9 is not at risk to elope. Social Service note dated 5/11/2020 documents: R9 attempted to elope from the facility. Staff was able to bring R9 back to the facility. Social Service Look Back Summary dated 7/28/2020 documents: R9 has a history of promiscuous behavior with other residents. Feeling down and depressed or hopeless two to six days, Progress note dated 8/3/2020 documents: R9 reported having sex with male staff on the evening of 8/2/2020. Progress note dated 8/4/2020 documents: R9 politely decline an emergency room visit but requested [MEDICAL CONDITION]. Social Service note dated 8/10/2020 document: R9 attempted to elope from facility. Staff was able to bring R9 back to the facility. R9 was not documented on the elopement list dated 5/2020 R9's elopement/unauthorized leave risk review dated 5/10/20, 7/28/20, 8/12/20 documents not at risk to elope at this time and placement on the elopement risk protocol is not indicated. R9's smoking assessment dated [DATE] documents: R9 does not smoke. Community Survival Skills dated 7/28/2020 documents: R9 does not know how to contact the facility emergency, unable to refrain from self-harm, social inappropriate behavior while in the community, unable to avoid persons who constitute a bad influence and is unable to practice, no knowledge of potentially dangerous situations such as walking alone after dark, straying into an alley or accepting rides from strangers. R9 does not appear to be capable of unsupervised outside pass privileges. Final Abuse Investigation documents: V25 said, he took R9 out on the patio on 8/1/2020. That was the first time, I let anyone out of the building. Human Resources Notice of Corrective Action dated 8/14/2020 documents: V25 was discharge for negligent or willful act of conduct detrimental to customer service or facility operations. Unable to contact employee via phone and email. Code Pink-Missing Resident/ Elopement Policy dated 11/15/17 Revised 11/15/18: Guidelines: All personnel are responsible for reporting cognitively resident attempting to leave the premises or suspected of missing. This included any resident that did not sign out on pass and/or did not notify a staff member of his/her leaving. #4 upon return of the resident the facility, Director of Nursing or Charge Nurse should: complete a new elopement risk assessment and update the plan of care as appropriate. Review and update the elopement risk binder. 2. R22 was admitted on [DATE] with the [DIAGNOSES REDACTED]. interview for mental status which would have determined cognition. Behavior note dated 8/18/2020 at 5:46pm documents: R22 exited the facility without staff supervision on 8/18/2020. Staff was unable to locate R22. R22 was discharge from facility against medical advice (AMA). Nursing Note dated 8/18/2020 at 6:39pm documents: R22 left the building unauthorized through west wing door during smoke break. Staff went to the community in search of R22 but was unsuccessful. Police report made for a missing person. The following interviews were conducted involving R22's elopement from the facility on 8/18/2020: On 8/18/2020 at 4:16pm, V23 (Activity Director) said, I was on the west end patio monitoring the smoking cart and the residents for social distancing. V41 (Behavior Aide) was walking back and forth between the door #6 and the behavior aide desk. Smoke break started at 3:30pm and last for forty-five minutes. R22 had on a red shirt that looked pink, jeans and some gym shoes. R22 has a habit of going around the corner of the west end patio and sitting in a chair against the wall. There was no other staff members outside during smoke break. It was supposed to be a behavior aide monitoring the smoking patio. I was walking back and forth between the smoking cart and the patio. R22 left from the patio, R22 was authorized to be on the patio from smoking break. I never saw R22 come back in or leave the facility. Based on staff description (V37 the Care Plan Coordinator/Restorative Nurse), R22 was seen by staff running down the street. We called a code pink. There is gate that leads to the back of dietary/ laundry and off the facility property. R22 was in the facility for a couple days and I know R22 had some issues about getting some money from the financial service money transfer place. Typically, social service will go get the money but under these circumstances, they had R22 face sheet and identification to get his money. Residents can't go outside during Covid-19. On 8/18/2020 at 4:37pm, V23 (Activity Director) toured the Surveyor through the west end resident smoking patio, the building exterior wall pass door #6 formed an L shape area. An area that cannot be visualized from patio door #6. V23 pointed, to a chair in place in the middle of the lower portion of the L shape facility's exterior wall. V23 said, R22 sits right there when he smokes. There was a camera on the facility wall near the gate facing the smoking patio. On 8/19/2020 at 9:08am, V5 (Social Service), R22's whole concern was to try to get some money from the financial service money transfer place. R22 mentioned the need to get his money on 8/14/2020. I told R22, I won't be able to take him. I didn't want it to look like, I was creating fraud. R22 kept asking if someone could take him so I told V23 (Activity Director). V23 was going to try to take R22 to get his money. On 8/19/2020 at 9:32am, V46 (Social Service) said, R22 use the phone on Saturday 8/15/2020, to call his grandmother to ask for some money and a television. R22 said, his grandmother was going to send R22 some money and a television. When I came to work yesterday, I was informed R22 asked a whole bunch of people to take him to get his money. We can't take residents to get any money. On 8/19/2020 at 1:21pm, V37 (Care Plan Coordinator/Restorative Nurse) said, I was coming back to work from a lunch break. I was in my car. I turned right on the local street. I saw a man running down the street at approximately 4:00pm. It looked like R22. The man had on a pink shirt. I tried to call the facility but no one answered. I came back into the facility. I stopped in my office, checked the census for R22's room number. I remember seeing R22 with a pink shirt on. I checked R22's room and the smoking patio. I told the receptionist, I think I just saw R22 on route 30. The facility didn't answer the phone because they were in an in-service. I told V40 (Behavior Aide), we checked R22 room and patio again. V40 called the code pink. I updated V2 (DON). On 8/19/2020 at 2:21pm, V39 (Nurse) said, R22 was mumbling about a financial service money transfer place and snacks when he was first admitted on [DATE]. R22 never told me he had money and I didn't correlate that R22 had money On 8/19/2020 at 2:24pm, V13 (Certified Nursing Assistant/CNA) said, I was R22's CNA for yesterday. R22 mumbled to staff. R22 was talking about money. R22 requested, I take him to his counselor. I told R22, I would have his counselor come to him. I updated V38 (Counselor). On 8/19/2020 at 2:30pm, V38 (Counselor) said, R22 came to the social service office two or three times the day he eloped. R22 came to the office between 10am or 11am. R22 asked, if someone could take him to financial service money transfer place to get some money. I explained to R22, that we could not do that. R22 asked, if he could go out. I told R22, he could not leave the building. Our protocol is to get the resident's identification and V23 (Activity Director) will go take care of any situation like that. R22 walked out the office without talking. R22 came back to the office around 2:30pm or 3:00pm. R22 asked for his identification. We gave R22 his identification. R22 walked off. R22 appeared to be alert and oriented with some delay. R22 had cognitive issues. R22 affect was flat with a blank stare. R22 didn't process information like other high functioning residents. R22 was fixated on going to the financial service money transfer place to get his money. We were not monitoring R22 for exit seeking behaviors because we know that the residents are in there room due to Covid-19. I was in an in-service around 3:30pm or 4:00pm when the code pink was called. On 8/19/2020 at 4:43pm while with V1 (Administration) the surveyor observed, R22 on the facility's recorded video tape leaving the building unauthorized at 3:24pm through door #6. No staff was observed outside, it was not smoking time. R22 was observed wearing blue jeans and a pink short sleeve shirt walking hurriedly on the inside of the facility's smoking patio to the gate. R22 disappeared out of the video frame for a moment. At 3:25pm, R22 was seen running outside the facility gate adjacent to the pave alley way toward the public sidewalk away from the facility. On 8/19/2020 at 5:06pm, V19 (Behavior Aide) said, I heard someone eloped yesterday. I do not remember hearing the door alarm going off. I did not hear an alarm when R22 left. When I, heard the alarm, I believed they were doing smoke break. On 8/19/2020 at 5:12pm, V40 (Behavior Aide) said, when I got here yesterday door #6 alarm was not active. When the alarm sounded, it was smoke break. I looked on the monitor. I saw V23 (Activity Director) with the smoking cart and the residents lining up for the 3:30pm smoke break. I usually check to make sure the doors are locked when I report to work but yesterday, I was asked to go to an in-service when I got here. I cut off the alarm when I saw V23 on the video monitor and went back into the in-service. I did not hear the alarm when R22 left but I heard the alarm for smoke break. R22 said, I going to get my ID and leave. V38 (Counselor) gave R22 his ID On 8/21/2020 at 9:12am, V46 (Social Service) said, I complete the elopement assessment dated [DATE], based on R22's hospital paperwork, R22 should have been an elopement risk. We were in an in-service when R22 left. I heard the code pink announcement. I did not hear a door alarm. When the alarm goes off, it can be heard on all sides of the building. Staff conducting the in-service was talking in a normal tone. The in-service started at 3:30pm, we were fifteen minutes into the in-service before we stopped, heard the code pink announcement and started looking for R22. On 8/21/2020 at 12:13pm, V1 (Administrator) said, R22 was not given a pass to the community. R22 left unauthorized. R22 eloped. No one talk to R22 about leaving against medical advice (AMA). On 8/27/2020 at 2:55pm, V1 (Administrator) said, I don't know where R22 is at this time. Referral packet dated 8/9/2020 documents: R22 has poor coping skills and lack insight. R22 has the [DIAGNOSES REDACTED]. R22 was admitted with acute [MEDICAL CONDITION]. R22 exhibited guarded demeanor and paranoid ideation. R22 behavior appears impulsive and unpredictable. R22 was aggressive and paranoid. R22 exhibits psychotic disorganized thought process, loose associations and appears to be responding to internal stimuli R22 verbalized wanting to kill himself and anyone in his way. R22 was brought to emergency room by the fire department for bizarre behavior, talking to self and running in front of vehicles. R22 fully alert and oriented time two, memory intact for recent events, insight and judgment impaired. R22' weakness is chronic mental illness and impulsivity. Nursing Facility Placement assessment dated [DATE] documents: R22 was admitted because he had nowhere to go. Medical records states R22 had an increase symptoms in psychotic symptoms. Recommends: twenty-four hour supervision. R22 history of antisocial/maladaptive/risk behavior assessment documents: Behavior type: Antisocial behavior. Elopement/unauthorized leave risk dated 8/13/2020 documents: R22 has a [DIAGNOSES REDACTED]. R22 has the physical ability to leave the building. R22 is not at risk to elope at this time. Personal inventory sheet date 8/13/2020 documents: R22 had on blue jeans, pink short sleeve shirt and gym shoes on admission. Human Recourses Notice of Corrective Action dated 8/19/2020 documents: V23 (Activity Director) was discharged for failure to meet requirements of a performance improvement plan dated 6/15/2020. Security, Supervision and Safety Policy effective 1-11-18: Purpose: To ensure the ongoing security and close supervision of all resident. Due to the nature of the resident population served, the facility employs a number of measure to ensure the ongoing security and close supervision of all residents. The facility maintains a moderate to high level of supervision on an ongoing basis to provide for early detection of and response to any demonstrated behavior changes. 3. According to the face sheet R28 admitted to facility on 7/22/20 with [DIAGNOSES REDACTED]. R28 minimum data set assessment indicated he is alert and oriented with moderately intact cognitive status (brief interview for mental status score of 12/15). R28's progress notes dated 8/24/20 at 19:01 document R28 left the building unauthorized through west wing door, staff went into community in attempt to escort resident back to building but R28 was not found. Missing person report filed. No emergency contact on file. R28's progress notes dated 8/24/20 at 20:51 document police called to inform resident being transferred to local hospital. R28's community survival skills dated 7/29/20 document R28 appears to be capable of outside pass privileges. R28's elopement risk assessment dated [DATE] documents not at risk for elopement. R28's progress notes document on 7/27/20 document resident knocked on the social service door, resident stated he wanted to leave the facility against medical advice. Social service staff advised the resident about safety of leaving against medical advice. Resident became verbally aggressive towards staff and left out of the office. R28's progress notes document on 7/31/20 document R28 called 911 that he did not want to be there anymore and sent to local hospital. On 8/25/20 at 4:42 PM, V40 (behavior aide) said he was working with one other behavior aide on 8/24/20. R28 was delusional and not acting himself. R28 said he did not get his medications and said there were people in his room and R28 was trying to fight with them. V40 said he informed nurse. V40 said he escorted R28 back to his room and showed him no one was in his room. V40 said about 10 minutes later the alarms on exit door near R28's room went off and R28 left through the doors. V40 said he was unable to locate R28. On 8/25/20 at 4:06PM, V1(administrator) said R28 was observed standing by Door 6 looking outside then just pushed the doors opened and left the facility. Alarms sounded and code pink initiated. R28 left before dinner. Police called and informed facility R28 called 911 and transferred to local hospital. R28's local hospital records dated 8/24/20 document 911 call received at 17:39 (5:39pm). R28 reported medications were not working. R28 admitting to seeing and hearing things that were not there. R28 transferred to local hospital for evaluation. R28's ER records document R28 had complaints of hearing voices. Patient states he is being stalked and someone is trying to get him. Under Clinical recommendations: Patient appears to be psychotic, patient appears with auditory and visual hallucinations, disorganized speech and thought processes. Patient denies suicidal and homicidal ideation. On 8/25/20, V24 (PRSD) confirmed that there were only 2 behavior aides working on unit at time of R28's elopement. The behavior aide schedule dated 8/24/20 documents 2 behavior aides scheduled for 300pm to 1100pm. 4. On 8/21/10 at 2:46pm, the surveyor observed staff responding to code pink called at door. At 2:50pm, R23 was observed walking with V40 (behavior aide) to central nursing station. On 8/21/20 at 3:39pm, V40 (behavior aide) stated R23 is usually redirect able but some days has behaviors where he will not listen/comply to redirection. He will pace the hallways but does not try to leave. R23 walked to smoke patio and was sitting on bench per V40 behavior aide. Unsure what R23 was doing prior to opening the door. R23 has [DIAGNOSES REDACTED]. R23's minimum (MDS) data set [DATE] documents Brief Interview for Mental Status score of 00/15. Score of 00 indicate cognitively impaired. R 23's progress notes document dated 11/29/19 document resident had an authorized departure from the facility. Staff members intervened in a timely manner and he was redirected back into the facility. Resident was monitored at this time. R23's Elopement risk review dated 12/4/19 documents R23 is at risk to elope and should be placed on the elopement risk protocol. A care plan for elopement is indicated. R23's medical record documents elope risk review performed on 7/16/2018, 11/29/2019, 12/4/2019 and 8/21/2020. Facility's Elopement risk list 8/21/20 did not document R23. On 8/21/20 at 4:06pm, V1 (administrator) said R23 was looking for his wife and pushed opened Door 1. Door alarm went off. Code pink called and staff were able to redirect Resident back to the building. V1 was unclear where or what resident was doing prior to elopement. V1 said hopefully in his room. V1 said she started in February and unsure why R23 was not on current elopement risk list. On 8/27/2020 the surveyor confirmed through observation, interview and record review that the following actions to remove both the immediacies: 1. 8/18/2020 facility initiated staff were in-serviced/trained on procedures of supervising and monitoring residents and protecting the door code. All staff will be re-educated prior to next scheduled shift. V2 (director of nursing/DON) verbally conducted in-service which was completed on 8/20/2020. Any staff not attending will receive in-service upon the return to duty. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. 2. 8/07/2020 at 4:00pm, the facility immediately changed the door code upon being informed of the potential that an unauthorized person may have knowledge by the Maintenance Assistant 3. 8/18/2020 at 6:00pm, the facility initiated the reassessment of all elopement risk residents to ensure that they are included on the elopement list and care plan interventions will be updated as needed. Completed on 8/21/2020 by Assistant Psychiatric Rehabilitative Service Director (APRSD) 4. 8/18/2020 R9's care plans were updated to include psychosocial interventions to address the resident's psychosocial needs. Intervention implemented: psychiatrist ordered a discharge to the hospital for a psychiatric evaluation. Completed by: Psychiatric Rehabilitative Service Director (PRSD) 5. 8/18/2020 R9's decision making capability will be assessed and her psychosocial wellbeing will be monitored upon her return from her psychiatric hospitalization . PRSD 6. 8/18/2020 at 5:00pm, R9's psychiatrist was notified of reported anxiety, depression, and suicidal ideation. R9 was placed on one to one supervision. R9's psychiatrist responded on 08/18/20 with an order for [REDACTED]. 7. 8/18/2020 at 7:00pm facility immediately initiated a code pink to take action to locate the resident. Facility staff followed code pink protocol by conducting a resident head count, searched internally and surrounding area, and notified local police department after duty staff members were alerted of R22's absence from the facility. 8. 8/18/2020 at 7:00pm, the facility did immediately determine that R22 exited through door 6. Staff did not determine the accurate cause of the audible alarm sounding. Facility determined that all door alarms were functioning properly. Plan has been developed to prevent residents from eloping from the facility. Plan: Every time the alarm sounds staff will announce a code pink indicating the location and initiating code pink protocol; Initiated 08/21/20 at 10:00am Maintenance will check the door alarms daily for proper functioning and Behavior aides will check door alarms every shift to ensure the alarms are engaged; Initiated 08/21/20 at 11:00am Behavior aides will sign off on a check sheet confirming that the alarms are re-engaged at the end of the smoking break and/or any time the door needs to be disarmed/rearmed 9. On 8/21/2020 Observation of door being propped open by EVS (environmental services) 8/18/2020 at 11am, an immediate in-service with EVS staff, centralized trash removal from facility, EVS will inform behavior aides to disarm and rearm door alarms, EVS will utilize a staff buddy system to monitor the area when needing to remove trash, Staff were notified that a door should never be propped open; Copy of in-service provided to surveyor on 08/21/20; All EVS staff will be educated prior to next scheduled shift. 10. On 08/23/2020 all resident charts were reviewed for being an elopement risk. Elopement risk assessments and care plans were updated if needed. Resident elopement list was updated to include residents that were found to be at risk. Completed 8/23/2020 at 12:30pm 11. Starting on 8/27/2020 Non-Mechanical staff supervision and monitoring: C.N.A (certified nurse aide) and behavior aide staff to conduct regular rounds of resident rooms and common areas to provide resident supervision. Behavior aide staff are in designated areas of the building to provide resident supervision. C.N.A will conduct rounding a minimum of every 2 hours and behavior aides will conduct rounding a minimum of every 30 minutes to include checking the doors. Behavior aides will use a check off sheet to be completed every shift. Behavior aide supervisor will check the sheet daily. Maintenance will check door functionality on a daily basis. C.N.A's will utilize the in-house census to confirm completion of rounding. Census will be turned into the nurse to be signed off by the nurse and C.N.A per shift. There are 3 behavior aides scheduled on 7a-3p and 3p-11p shift and 2 behavior aides scheduled on 11p-7a. On 7a-3p and 3p-11p shifts, behavior aides are assigned a unit (East, Central or West). On 11p-7a shift, behavior aides are assigned on East and West and divide evenly.

Based on observation, interview and record review the facility failed to follow their abuse policy and prevent an incident of sexual abuse and sexual exploitation of 1 of 2 (R9) residents reviewed for sexual abuse. This failure resulted in R9 being coerced out of the facility for a sexual encounter with a male staff member (V25). The failure involving R9 was identified as an immediate jeopardy situation that began on 8/1/20 and was removed on 8/27/20. V1 (administrator) was informed of the immediate jeopardy on 8/18/20. While the immediacy was removed on 8/24/20, the facility remains out of compliance at a severity level two until the facility can evaluate the effectiveness of staff training for monitoring residents at risk for elopement. Next, based on interview and record review the facility failed to follow their abuse policy and prevent incidents of physical abuse and physical assault of 2 of 11 residents (R3 and R10) reviewed for physical abuse by peers (R10, R15 and R19). This failure resulted in R3 being struck in the face of by a peer (R4) and sustaining a left orbital fracture and R10 being urinated on by a peer (R15). Findings Include: 1. R9 has [DIAGNOSES REDACTED]. R9's minimum (MDS) data set [DATE] document R9's with brief interview for mental status was scored a 13. A score of 13 indicates cognitive intact. On 8/6/20 at 1259Pm, R9 said V25(housekeeping) approached R9 in the one to one area. V25(housekeeping) grabbed R9's hand and said he wanted to talk to me. We went by (door 3) entranceway and V25(housekeeping) hugged and kissed me. V25 (housekeeping) asked me if I wanted to have sex and I said yes. R9 said she went to get her shoes from her room, and we left out the door (door 3). R9 said they walked through the back part of the facility and V25 (housekeeping) opened all the gates for her. R9 said she hide behind a van near the east smoking patio and waited for V25 (housekeeping) to pick her up in his car. R9 said he had a nice silver car with 4 doors. R9 said they drove a few blocks and they both got out of the car and went into the back seat. R9 said they had unprotected sex. R9 stated V25 (housekeeping) had a large tattoo on his back with letters and an image. V25 (housekeeping) drove back to the facility and he gave me the code to get back into the building through door 3. On 8/6/2020 at 3:20pm, Surveyor observed R9, entering the code to door number three, exiting the facility, walking out of the first gate, pass the activity office to the second gate then to the final gated area on the east wing smoke patio while demonstrating how she hid behind the facility van to avoid being seen by staff and reporting walking to V25's car when he pulled up. On 8/14/2020 at 1:48pm, V25 (Housekeeping) said he took R9 out to have a cigarette break. V25 said he knew he was not supposed to take R9 out of the building but nothing else happened. Facility final abuse reportable undated documents V25( housekeeping) stated that on Saturday he took a resident out to the patio. V25 stated that it was a Latino girl. V 25 stated that this was the first time he has let anyone out of the building. V25 stated that R9 asked him if she go out on the employee smoke patio to smoke. V25 stated that R9 asked for a cigarette and he gave her one. V25 stated that de did not let anyone know he was taking R9 out. V25 stated that he needed to check his phone messages due to personal issues and was walking away from R9. V25 stated that R9 asked if she could go with him. V25 stated they walked to his car and R9 stood by his car and R9 stood outside his car while he checked his messages, V25 stated R9 did not get into his car. V25 stated that R9 then walked back into the building the same way she came out. He stated that he went through the front doors, let her back into the building the same way she came out. Then V25 stated that he went with her the same way they went out, let her in and then doubled back to make sure the gates were secure and then walked through the front. On 8/20/20 11:18 pm, V2 (DON) said V25 (housekeeping) came in for interview unsure of date, his story did not seem credible. V25 said he went to take R9 to smoke but R9 doesn't smoke. V25 (housekeeping) said they stood at his car and he walked R9 back to the door (3). V25(housekeeping) said he gave her the code to get into building (DOOR 3) and he double backed to go in front door and another time he said he opened the door to let R9 back in the building and then went back to ensure gates were locked and reentered through front door. The whole situation felt yucky. V25(housekeeping) denied R9 getting in his car but V2 stated she did not directly ask V25(housekeeping) if he had sexual contact with R9. V2 asked V25 (housekeeping) to write down his statement what he wrote was vague and did not match what he verbalized. R9's smoking safety risk dated 7/28/20 documents resident is nonsmoker. Police report 20- 90 dated 8/3/20 documents R9 said she was approached by facility staff member who requested if R9 wanted to engage in sexual intercourse with him. R9 agreed and left the area with staff member to unknown location. R9 advised she engaged in sexual intercourse with the staff member in his car. R9 advised she did not know staff members name and staff not at facility at time of report. R9 advised the staff had tattoo on his upper back. On 8/19/20 at 10:59 am, V2 (DON) V2 said they called police to follow up and police reported it was an internal facility investigation and unless nurse/administrator wanted to pursue further there was no ongoing police investigation. On 8/6/20 at 315pm, R17 who was alert and oriented said he was in one to one area and he saw R9 come back in the building through the side patio door but didn't see her leave. R17 said there was no behavior aide and activities aid at one to one area. On 8/6/20 at 347pm, R16 who was alert and oriented said he was in one to one area and saw R9 leave with housekeeper. On 8/6/20 142pm, R21 who was alert and oriented was in his room when he stated he heard a noise from the gate and looked at his window and saw R9 with a male that had on a blue shirt outside the facility. On 8/7/2020 1249 pm, V 26 (CNA) said on Saturday (8/1/20) another resident gave me R9's cell phone to give back to her after dinner. V26 went to R9's room and she was not in the room. V26 started looking in other resident's rooms and then found R9 at one to one monitoring area. R9 appeared to have raindrops on her clothes but denied being outside. On 8/7/20 at 1:00pm, V33 (activities aide) said she was monitoring smoking break at 730pm and observed R9 was on one to one monitoring. Around 745pm, R9 was no longer at one to one area. V33 was asking staff where R9 was and they were going to call code pink. Staff were checking exit doors. R9 was observed back in the one to one area. R9 said she was outside and went through a resident's window. R9's hair was wet, and t-shirt was wet. On 8/6/20 at 1159 am, V2 (DON) said R9 was consistent with her encounter with V25 (housekeeping). R9 reported she likes V25 (housekeeping) and he likes me. On 8/20/20 at 12:53Pm, V22 (HR) said that V25 will be terminated based on the investigation the facility performed related to R9's allegation. The facility could not determine what happened to R9 when she left the facility with V25 (housekeeping). V1 (administrator) and V2 (DON) reported that after viewing the cameras, they observed V25 (housekeeping) leaving with R9 by the east wing smoke patio gates. V22 (HR) said she thinks they were smoking but unsure and then reported V25 and R9 slowly inched their way off camera and away from the facility. It was reported the resident reappeared on camera about 30 minutes later. V22 (HR) said she recalled staff questioning where they were. V22(HR) said she did not see the video but was told information by V1 (administrator) in order to terminate V25 (housekeeping). Facility reportable dated 8/3/20 documents on 8/1/20 late evening outside facility R9 reports to having consensual sex with V 25 (staff). V25 was immediately suspended. R9's progress note dated 8/3/2020 at 11:10 documents that R9 reports to staff that she is alleging having sex with male staff evening of 8-2-20. A complete body assessment was rendered and no physical signs of injury. Resident is reporting no pain and discomfort at time of this assessment. Administration and DON are aware. The abuse protocol has been launched and ongoing. Call placed to CHPD to file a report and pending their arrival. R9's progress note dated 8/4/2020 at 08:35 documents that R9 was approached and informed the need for an ER visit and evaluation connected to her reported allegation. R9 is aware of the need, but politely declined. R9 continues to verbalize no concerns regarding this report and continues to be pain free. Resident is requesting [MEDICAL CONDITION]. MD made aware and lab. On 8/20/20 at 11:18 pm, V2 (DON) said they requested R9 to go to hospital on Tuesday but R9 declined. R9 [MEDICAL CONDITION] and the Nurse practitioner ordered additional sexual transmitted disease testing. R9 did not have any vaginal swab or rape kit. On 8/12/2020 at 4:48pm, R9 said she felt scared and thought she was doing something wrong in regard to having sex with V25. R9 said if she says no to sex, then the men will just try to convince her, so she just said yes so, she would not have to go through the convincing stage. R9 said she tried to elope (On 8/10) because she felt she did something bad. R9 expressed feelings of guilt and remorse. I felt like nothing. R9 said she had thoughts of suicide running through my mind but no plan. R9 said she does not have an appetite and feels depressed. R9 said she cares for V25 (Housekeeping). R9's petition for involuntary admitted d 8/18/20 documents: Resident is verbalizing wanting to harm self if not supervised by staff. Once you leave me alone, I don't know what I'll end up doing In addition resident exhibiting depressed mood and verbalizing anxiety. R9's progress note dated 8/18/20 at 17:15 documents Resident had verbalized feelings of anxiety, depressed mood, and potentially harming herself. In her words, Once you leave me alone, I don't know what I'll end up doing. Resident is currently sitting on 1:1 with nurse for supervision and maintenance of safety. MD was placed on page and awaiting her return call. R9's progress notes dated 8/18/20 at 1730 documents MD responded and made aware of resident's current state. MD has given me the order to transfer resident to local hospital with petition. Order noted and carried out. Resident remains on 1:1 with nurse. On 8/11/20 at 12:54, V2 (DON) said, R9 has history of promiscuous and sexual behavior. R9's behaviors can lead to inappropriate sexual activity with a variety of people. R9 is cognitive and coherent for everyday thinking but if R9 is challenged, her decision making is not 100 percent. On 8/11/20 at 11:05 PM, V5 (social service) stated R9 is unable to make her decisions. R9 is inconsistent with decision making. On 8/13/20 at 8:00 AM, V 32 (social service) stated R9 is unable to make her own decision and has poor decision making skills. If you ask R9 to do something she will do it without thinking. R9 would get into a stranger car or go inside a stranger's home. R9's community survival skills dated 7/28/20 documents the resident does not appear to be capable of unsupervised outside pass privileges at this time. Under the statement, The resident has knowledge of potentially dangerous situations, such as walking alone after dark, straying into an alley, accepting rides from strangers, carrying valuable items where they are easily seen. The response was marked no. Under the statement The resident appears able to refrain from self-harmful and/or socially inappropriate behavior while in the community (including abstaining from alcohol and illicit drugs, avoiding persons who constitute a bad influence and is able to practice harm reduction strategies. The response is marked no. R9's Strength, deficit and priority need assessment dated [DATE] documents under strengths/deficits symptom or behavior: for coping skills- minimal, self-image- negative, logical thinking-illogical, loose associations. R9's assessment dated [DATE] under section B documents resident has history of promiscuous behavior with other residents. R9's progress notes dated 2/3/2020 documents, upon charting at nurses station, resident informed writer that the new male peer entered her room and sexually penetrated her with his penis. Resident states that she shoved male peer away and told him no, however he did not. Writer then called administrator to report this allegation. Resident was then taken into bathroom for body assessment, no apparent injuries were noted at this time, however, writer made preparation for resident to be sent to nearest hospital post interview with police. Resident was calm and cooperative and giggly at this time and was advised of the serious nature of this accusation. Vital signs within normal limits and resident asked to remain in her room until police arrived. On 8/25/20 at 3:40 pm, V24 (PRSD) said R9 has only one capacity for sexual consent assessment within last year. The assessment is not completed because there was not a confirmed relationship between the resident and another resident. R9's capacity for sexual consent dated 8/18/20 documents Resident is not in a known relationship with any peers. R9's care plan revised 7/28/20 documents resident is able to exercise the right to engage in a sexual relationship. I have received counseling as appropriate regarding sexual practice and behavior boundaries, respect for roommate's healthy relationships and only engaging in this type of relationship with counseling party. 2/3/20 male co-peer allegedly physically approached resident without resident consent. Interventions revised on 7/28/20 documented demonstrate how to maintain personal safety in the bedroom and encourage resident to alert staff when she needs assistance; provide individual counseling regarding safe sexual [MEDICATION NAME] including education regarding transmission of [MEDICAL CONDITION], contraceptives, privacy issues, respect for ones roommates and respect for one's partner; intervention initiated on 2/13/20 documents, Received counseling as appropriate regarding sexual practice and behavior, boundaries, respect for roommates and healthy relationships and only engaging in this type of relationship with a counseling party. 2/3/2020 resident counseled. R9's care plan does not document any effective interventions following incident on 2/3/20. R9's care plan revised 5/12/20 documents R9 wanders and displays poor boundaries. Interventions documented include counsel R9 individually on what the risks are when she displays poor boundaries; redirect R9 to display healthy boundaries. R9's care plan revised 7/28/20 document R9 exhibits sexually inappropriate behavioral symptoms related to strong need for attention. These behavioral symptoms are manifested by physically touching, grabbing and displaying sexual behavior in the hallway. Interventions include encourage R9 to drink lots of fluids and rest when needed; Intervene and redirect when any inappropriate behavior is observed. Communicate assertively that resident must exercise control over impulses and behavior. R9's abuse and neglect screening dated 2/4/20 signed 2/13/20 documents a yes under history of abuse and neglect; psychiatric history and/or present mental health [DIAGNOSES REDACTED]. There is no other abuse screening noted in the progress. Facility abuse policy revised 1-22-19 documents the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Sexual abuse is nonconsensual sexual contact of any kind with a resident. Sexual abuse includes but not limited to unwanted initiate touching of any kind, all types of sexual assault or battery such as rape, sodomy and coerced nudity. Generally sexual contact is nonconsensual if the resident either appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur. During the course of the investigation of an allegation of resident sexual abuse the facility shall assess and make the determination of whether the sexual activity was consensual on the part of the resident. A resident apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion or fear whether it is expressed by the resident or suspected staff. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a preexisting or current sexual relationship is considered to be sexual abuse. On 8/6/20 at 1159 pm, V2 (DON) said V25 attempted to be contacted but unable to reach him since allegation. We sent text message to inform him that he was suspended, pending the investigation. On 8/20/20 11:18 pm, V2 (DON) said facility was able to contact V25 to come in for interview. After V25 gave his statement we have not been able to get back in touch with him to give termination papers. V25 employee file documented an office of the inspector general (OIG) search on 5/22/20 with no results found. No other background checks or fingerprints were completed for V25 prior to employment or documented in V25's employee file. V25's employee file did not contain any photo identification or birth certificate or social security card. On 8/27/2020 the surveyor confirmed through observation, interview and record review that the following actions to remove the immediacy after V25 termination on 8/20/2020: 1. On 8/18/2020 at 3:30pm, staff in-serviced/trained was initiated on how to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to residents. All staff will be re-educated prior to next scheduled shift. V2 (DON) verbally conducted in-service. Staff acknowledge information via signature. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. Completed 8/20/2020. Any staff not attending the training will receive training upon returning to duty. 2. On 8/18/2020 at 6:00pm, All staff members have been screened to determine potential criminal background history related to abusive behavior by the Human Resource Director. 3. On 8/18/2020 at 6:00pm the facility initiated, the review of all resident's charts for being at risk for sexual abuse and/or any abuse. Care plans and assessments were updated as needed. PRSD (Psychiatric Rehabilitative Service Director) and Administrator. Completed on 8/24/2020 4. On 8/18/2020 at 5:00pm, the facility has not identified any other residents that have had any inappropriate sexual contact with V25. All residents were questioned regarding any contact with V25. PRSD 5. On 8/18/2020 at 5:00pm, R9's care plans have been updated to include psychosocial interventions to address the resident's psychosocial needs Intervention implemented: psychiatrist ordered a discharge to the hospital for a psychiatric evaluation. PRSD 6. On 8/18/2020 at 5:00pm, R9's decision making capability will be assessed and her psychosocial wellbeing will be monitored upon her return from her psychiatric hospitalization . PRSD R9's psychiatrist was notified of reported anxiety, depression and suicidal ideation. R9 was placed on one to one supervision. R9's psychiatrist responded with an order for [REDACTED]. 2. R3 has [DIAGNOSES REDACTED]. A score of 0 indicates severe impairment. R3's minimum (MDS) data set [DATE] document R3 is one person assist with transfers, walking in room/corridor and on/off unit. R4 has [DIAGNOSES REDACTED]. R4's minimum (MDS) data set [DATE] document brief interview for mental status was scored a 15. A score of 13-15 indicates cognitively intact. On 8/5/20 at 1:50 pm, R4 said he remember R3 an old man in bed one that would urinate on the floor and would put plates of food in the drawers. R4 stated he asked R3 to remove plates/dirty dishes and R3 refused. R4 stated R3 pushed him because he was removing the plates and he pushed R3 back. R4 stated he made second contact with R3 and hit him in the cheek or eye. R4 was taken out of room and does not recall anything else. On 8/5/20 1235 pm V7 (nurse) said R4 hit R3 because R3 was disturbing him. V7 unable to recall what R3 was doing but stated R4 admitted to hitting R3. R3 sustained an injury to his eye and was sent out to the hospital. R4's progress note dated 3/1/20 document R4 stated, he was going through my closet and stealing my belongings, so I got physically aggressive. Police reported dated 3/1/20 documents R4 punched R3 in the face causing a laceration under left eye. Spoke to R4 who stated R3 was going through R4's clothing and spit inside a lotion bottle at which time R4 struck R3 in the face with a closed fist. Facility preliminary abuse investigation dated 3/1/20 documents R3 stated R4 was physically aggressive towards him in the room. Facility final report dated 3/6/20 documents abuse could not be substantiated. It is unclear why the incident started, but it is clear that R4 was physically aggressive towards R3. Local hospital records dated 3/1/20 document patient (R3) got in a physical altercation with one of the other residents in the group home. Patient was punched several times in the face. CT of facial bones on 3/1/20 document a left orbital fracture. 3. R10 has a [DIAGNOSES REDACTED]. R10's brief interview for mental status on 7/15/20 was 14. At time of interview R10 was alert and oriented x1. R15 has a [DIAGNOSES REDACTED]. R15 is alert and oriented x3. On 8/11/20 R10 was alert and oriented x1 (Self). R10 stated R15 hit him and tried to make him drink urine on Christmas day. R10 was unable to provide any further details related to incident. On 8/11/20 at 9 42 am and on 8/12/20 at 3:15 pm, R15 was alert and oriented x 3 during these interviews. R15 said when he was roommates with R10, he admitted to hitting R10 in the face because he was snoring. On another occasion he admitted to pouring a bottle of urine on the resident while he was sleeping because it was funny. R15 also admitted to urinating on R10 while R10 was sitting on the toilet in their common bathroom, because R15 had to go to the bathroom and R10 was not moving fast enough to get off the toilet. Facility preliminary abuse reportable dated 6/1/20 documents R10 reported being hit by R15 a few days ago. Bruise noted around R10's right eye. Facility abuse reportable dated 6/5/20 documents R10 stated he has had issue with 2 roommate R15 and R19. R15 tried to have him drink pee and has choked and slapped him. R19 gave him birthday licks. R15 stated that a week ago R10 was coming out of the bathroom and he accidently hit him with his elbow and then R10 hit the door. R19 stated that R15 told him that he punched R10 in the eye and poured urine on him. R10's care plan dated 6/16/20 documents that R10 is at risk for abuse related to mental illness. R15's care plan dated 6/1/20 documents R15 became physically aggressive/abusive towards his roommate. The facility abuse policy revised 1-22-19 documents the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting 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 the individual must have intended to inflict injury or harm.

Based on interview and record review the facility failed to follow its behavior management program by not proving therapeutic programing to address the psychosocial needs for a [DIAGNOSES REDACTED]. This failure resulted in R9 becoming depressed, and having thoughts of helplessness and suicidal and was petitioned to the hospital for a psychiatric evaluation and treatment. Findings include: R9 was admitted to facility on 3/21/18 with [DIAGNOSES REDACTED]. R9's minimum data set ((MDS) dated [DATE] documents: R9's brief interview for mental status as a fifteen which indicates cognitively intact. On 8/13/2020 at 8:00am, V32 (Counselor) said, I am R9's counselor. I have not had any follow-up with R9. On 8/19/2020 at 9:00am V5 (Behavior Aide Supervisor/ Assistant PRSC) said, we don't have any groups. On 8/19/2020 at 9:50am, V24 (Social Service Director), said, I am not aware of any group being ran, the groups can be completed on a one to one basis. On 8/19/2020 at 10:17am, V35 (Group Coordinator), we are not running groups due to Covid-19. On 08/12/2020 at 4:48pm, R9 said, I feel like I'm in a deep depression. When I was going to groups I felt a lot better. Now that I'm not going to groups, I feel bad. Maybe, if I was going groups, I wouldn't have sex with the staff member. I would have thought about losing out on going to the program. I would have behaved better. On 8/19/2020 at 12:10pm and 1:51pm, V1 (Administrator) said, groups are still on hold. We are meeting the resident's psychosocial needs with activities, walks, coffee, snacks and hallway games while they remain in their room for social distancing. The residents can't be in a group setting. We do family care cards, phone calls and window visits. I was informed by V35 (Group Coordinator), that the groups could not be ran until everyone has their own tablet. We have one tablet. On 8/19/2020 at 1:53pm, V10 ([MEDICAL CONDITION] Nurse) said, R9 is not participating in any psychoactive groups or therapy via telehealth, due to Covid-19, the residents are not attending groups. Social service note dated 3/4/2020 and 3/13/2020: R9 attended a social service groups for thirty minutes in Boundaries discussing personal boundaries. R9 is motivated by being in the boundaries groups. R9's physician progress notes [REDACTED]. R9's attendance sheet for Boundaries documents: R9's last date for attending group was 3/9/2020. On 8/12/2020 at 4:48pm, R9 said she felt scared and thought she was doing something wrong in regard to having sex with V25. R9 said if she says no to sex, then the men will just try to convince her, so she just said yes so she would not have to go through the convincing stage. R9 said she tried to elope (On 8/10) because she felt she did something bad. R9 expressed feelings of guilt and remorse. I felt like nothing. R9 said she had thoughts of suicide running through my mind but no plan. R9 said she does not have an appetite and feels depressed. R9 said she cares for V25 (Housekeeping). A review of R9's petition for involuntary admitted d 8/18/20 documents: Resident is verbalizing wanting to harm self if not supervised by staff. Once you leave me alone, I don't know what Ill end up doing In addition, resident exhibiting depressed mood and verbalizing anxiety. R9's progress note dated 8/18/20 at 5:15 documents Resident had verbalized feelings of anxiety, depressed mood, and potentially harming herself. In her words, Once you leave me alone, I don't know what I'll end up doing. Resident is currently sitting on 1:1 with nurse for supervision and maintenance of safety. MD was placed on page and awaiting her return call. R9's progress notes dated 8/18/20 at 5:30pm documents MD responded and made aware of resident's current state. MD has given me the order to transfer resident to local hospital with petition. Order noted and carried out. Resident remains on 1:1 with nurse. Behavior Management Program Policy effective 11/28/12 revised 1/15/20: Purpose: To establish a system for identifying behaviors and implementing appropriate intervention consistent with the individualized plan of care to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being.

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview and record review, the facility failed to ensure that: residents' movements were limited in the facility; group activities and communal dining had been canceled; social distancing for residents was monitored and maintained; residents performed hand hygiene appropriately; and, dining tables were disinfected between uses by different residents. This had the potential to affect all 195 residents in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ began on 3/13/20, at the time of release of the revised QSO-20-14 by CMS which directed all Nursing Homes nationwide to cancel communal dining and all group activities and directed all facilities to remind residents to practice social distancing and perform frequent hand hygiene to prevent direct and indirect transmission of COVID-19. The facility is located in a county with many active cases of COVID-19 and several deaths have occurred. The facility continued to provide communal dining and group Activities. The Administrator was notified of the Immediate Jeopardy 3/26/20 at 3:30pm. Findings Include: At the time of the entrance to the facility on [DATE] at approximately 9:30am, the Administrator informed the surveyors that this was a psychiatric care facility. The residents were ambulatory and independent in activities of daily living. Observations on 3/26/20 at 9:30am, revealed the following: Approximately sixty residents were ambulating aimlessly up and down the hallways and going in and out of resident rooms on the East and West Wings of the facility. Although various licensed and non-licensed staff were seated at the front entrance to the Dining Room, or were ambulating in the hallways, staff failed to stop and re-direct residents to maintain the recommended social distancing space of six feet. Observation on 3/26/20 at 10:25am, in the Main Dining Room, revealed two residents were seated directly across from one another at a two foot wide table playing cards. These residents were R10 and an unknown female resident. Observation on 3/26/20 at 10:30am, revealed five residents congregating in the hallway outside of the Activity Room door. The Activity Director then unlocked the door and seven residents entered the Activity Room in a line without social distancing being maintained. No staff directed residents to space themselves following social distancing rules. In addition, observation revealed that residents failed to perform hand hygiene prior to entering the room from the hallways and went directly to their activities of interest. The size of the Activity Room was approximately 40 by 30 feet. During this observation, two residents (R2 and R7) began playing pool and two additional residents (R10 and an unidentified female resident) were seated at a table sitting directly across from each other approximately two feet apart, playing cards. Additional residents entered the small room and at one point 15 residents were in the room and were not [MEDICATION NAME] the recommended six feet of social distancing. At 10:36 am, the Activity Director opened a door from the Activity Room to an outside basketball court. Five residents (R1, R3, R5, R6 and R9) exited onto the basketball court and were observed playing basketball, which included physical contact and residents to be in close proximity to one another, while four additional residents (R4, R8 and two unidentified residents) were observed congregating on the sides of the basketball court. Observation revealed that at approximately 10:45am, the Activity Director went outdoors onto the basketball court and while outdoors, lowered his facial mask below his chin while being with the residents. During this same observation, the Activity Director rubbed his face and failed to perform hand hygiene. Following this observation, the Activity Director was questioned about the observations and verified that he forgot to wash his hands and stated, Safety always, we are to keep our nose covered at all times, while inside and outside, I shouldn't have removed the mask. When questioned about the basketball game and maintaining social distancing, the Activity Director stated, The basketball was a communal game and social distancing not less than six feet had not been maintained. When asked if residents were to perform hand hygiene prior to entering the Activity Room, the Activity Director stated Yes, before they come into the room and when they leave the room. When asked who monitored hand hygiene, the Activity Director stated E1 (employee's name) who was seated at a table at the front of the Activity Room, who watched as residents came in and out of the Activity Room, was to monitor tht the residents had cleaned their hands. Observation on 3/26/20 at 11:52am, revealed 24 residents were lined up in the hallway outside of the Main Dining Room. All residents in the line were observed to be standing one to one-and-a-half feet from one another and some residents were positioned touching back to front of another resident. At 11:57am, when the residents entered the Main Dining Room, observation revealed that residents were not being stopped by staff and reminded to perform hand hygiene nor did staff cue any residents to maintain social distancing. Although E2 was stationed at the outer entrance to the Dining Room, to ensure that residents' maintained social distancing and performed hand hygiene, observation revealed that hand hygiene was not performed appropriately and/or not performed at all. Observation at the time, revealed that approximately twenty residents just swiped their hands at the wall hand sanitizer unit and other residents just walked by the hand sanitizer without using the hand sanitizer. During an interview with E2 on 3/26/20 at approximately 12:15pm, E2 was asked about his responsibilities. E2 stated to make sure the residents in line for dining were standing apart from each other and that residents sanitized their hands going into the Dining Room and coming out. During this same observation, R11 who was standing to the side of E2 was observed to sneeze directly into his hand, wipe his face with his hand and then entered a multi resident room without being instructed to perform hand hygiene. Review of the facility's Infection Control policy dated 3/5/20 related to the Interim policy addressing healthcare crisis related to Human [MEDICAL CONDITION] related to Hand Hygiene indicated HCP (Health Care Professionals) should perform hand hygiene before and after all patient contact, contact with potentially infectious material . perform hand hygiene by using an Alcohol Based Hand Rub (ABHR) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. Continued review of the section related to Hand Hygiene revealed the policy did not address resident hand hygiene despite the fact that the facility had indicated that the residents were all independent with personal hygiene. Observation on 3/26/20 at 12:10pm, revealed that 43 residents were seated at the dining tables eating lunch. Forty-one of the forty-three residents were not [MEDICATION NAME] the recommended six feet of social distancing. Continued observations at this time, during the delivery of the luncheon meals to residents seated in the Dining Room, revealed that staff were not appropriately wearing face masks. Observation revealed that E3 (a dietary staff member) who was dishing out the meal onto the plates wore a face mask that was positioned below her nostrils and above her chin. Following the observation, E3 was asked about the position of the face mask, E3 stated I know, it is hot. E3 then pulled the face mask up to cover her nose, but did not perform hand hygiene following the repositioning of the face mask. Continued observation during this time of the pouring and distribution of drinks to residents during the luncheon meal, revealed that E4 was wearing a face mask below her nostrils and above her chin. When E4 was asked the how the face mask should be worn, E4 stated I know it should be over my nose. Review of the facility's Infection Control policy dated 3/5/20, titled Interim policy addressing healthcare crisis related to Human [MEDICAL CONDITION] indicated under section Identification and Prevention Steps number 3 All HCP (health care personnel) that provide direct care such as licensed nurses Certified Nurse Assistants (CNA), Qualified Medication Assistants (QMA) will be required to wear a surgical mask during their shift .HCP must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene. Review of the policy revealed it failed to include instructions for dietary staff and failed to address the use of masks by these staff members. Following the completion of the luncheon meal, residents carried their dining trays and dishes to a soiled cart where the residents either scraped their uneaten items into a garbage can and/or gave their soiled dishes to a Dietary Aide. Following completion of this task, the residents exited the dining area without performing hand hygiene and ambulated back into the populated hallways and/or multi resident rooms. Although E2 was still positioned at the outer entrance of the Dining Room, observation revealed that resident hand hygiene was not encouraged or enforced. During an interview on 3/26/20 at approximately 12:20pm, with the Assistant Director of Nursing (ADON) who was monitoring the dining activities at the time of luncheon meal, revealed that residents were expected to perform hand hygiene prior to entering the Dining Room and again when leaving the Dining Room. When asked how this was monitored, the ADON stated that E2 would observe hand hygiene when residents entered the Dining Room and again when residents left the Dining Room. When asked about maintaining social distancing, the ADON stated This is a challenging population and can't always get them to do what is needed. Observation following the completion of the dining for group one on 3/26/20 at approximately 12:30pm, revealed that E5 (an environmental aide) walked into the Dining Room carrying a plastic bag. Observation revealed E5 removed a wet cloth from the bag and dropped a cloth on each of six tables. Following the placement of the individual cloths on the tables, E5 returned to table one and used the cloth to partially wiped the center surface of the table. Observation revealed that the entire surface and sides of the table had not been wiped clean with the cloth. E5 then proceeded to clean the additional tables in the same manner. Following the completion of this task, E5 was asked about the cleaning product that was being used on the tables. E5 stated Just water, I just wet the cloths and wipe the tables down. During an interview with the Environmental Supervisor on 3/26/20 at approximately 1pm, revealed that water should not have been used to clean the tables. She stated that Fuzion (a select Environmental Protection Agency (EPA) product identified as a Cleaner Disinfectant) should have been used to clean the tables. Review of the Technical Information Clorox Healthcare Fuzion product safety form indicated that Fuzion was identified as a registered disinfectant that had micro bacterial activity against pathogens most likely to contaminate the resident care environment. Review of the label on the Fuzion bottle revealed it was effective against the human coronavirus. Review of the undated policy and procedure titled Environmental Services A Key Role in Infection Prevention revealed that Clorox Fuzion are {sic) approved disinfecting products that are approved for COVID. The spray and wipe technique does not adequately kill .[MEDICAL CONDITION] contact time for Clorox Fuzion is 3 minutes .Correct use of disinfectants are a priority. Observation on 3/26/20 at 2pm, at the Central Nurses Station in the presence of the Director of Nursing (DON) revealed that E6 was observed in the hallway without a face mask. When questioned about wearing a face mask, E6 stated that she was outdoors and had just returned to work. E6 stated I forgot about the mask. Observation and validation from the DON revealed that E6 was required to wear a face mask and had walked pass the Screener at the front door and E2 (the desingated Screener) should have informed E6 of the requirements to wear a face mask when going onto the resident care unit. During an interview with the Administrator on 3/27/20 at 1:20pm, when asked to describe the facility's process for dining and activities, the Administrator stated, We thought we put together an appropriate COVID-19 dining program by placing the residents 6 feet apart and minimizing the individuals in the dining room. It was once they got into the dining room, but the concern was while the residents were waiting to get in the Dining Room. They were used to lining up so it was difficult for staff to redirect. During the same interview, when asked if the dining process followed the 3/13/20 CMS recommendations for prevention of COVID-19 in long term care, the Administrator stated, We thought it was. During the same interview, when asked if the facility's activity program followed the 3/13/20 CMS Recommendations for prevention of COVID-19 in long term care, the Administrator stated All group activities were supposed to be canceled. Review of CDC's undated guidance titled, Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-10 in Nursing Homes, revealed the following directive for implementation by nursing homes for prevention and containment of the [MEDICAL CONDITION]: Cancel communal dining and all group activities, such as internal and external activities. Remind residents to practice social distancing and perform frequent hand hygiene. The above document further directed the following in the section titled Resident Monitoring and Restrictions: Encourage residents to remain in their room. If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes. If they leave their room, residents should wear a facemask, perform hand hygiene, limit their movement in the facility and practice social distancing (stay at least 6 feet apart from others,) implement protocols for cohorting ill residents with dedicated HCP. Review of the memo QSO-20-14-NH with a revised date of 3/13/20 revealed the following under the section headed Guidance for Limiting the Transmission of COVID-19 for Nursing Homes: Additional Guidance: 1. Cancel communcal dining and all group activities, such as internal and external group activities .3. Remind residents to practice social distancing and perform frequent hand hygiene. The Administrator was notified that the Immediacy was removed on 3/27/20 at 2:20pm, after the surveyors' verified implementation of an acceptable removal plan that included: 1. Observations and interview with the Administrator on 3/27/20 at 10am, revealed that all residents had been assessed for supervision during dining. A list of residents had been developed and residents were assigned to eat in designated areas due to medical and/or behavioral concerns. Other residents would receive meals in their rooms. Observation during the luncheon meal on 3/26/20 at 12pm, revealed that dining furniture was rearranged and one resident was assigned per table in the Dining Room and in the Activity Room in order to ensure proper social distancing. This dining plan was monitored by the Administrator who begun auditing meals, social distancing and hand hygiene. 2. All other residents assessed as for not requiring supervision in dining ate in their rooms. 3. Observation on 3/27/20 11am, and interview with the Activity Director revealed that all group activities had been canceled. Bingo and word games were being called over the intercom while residents participated in their individual rooms. 4. During the same observations, staff and residents performed hand hygiene prior to and following dining. 5. Review of In-Service/Ongoing Education records dated 3/26/20 provided to all staff related to: hand hygiene, social distancing, including during smoking, and monitoring for compliance had been initiated. 6. Interviews were conducted to assess staff's knowledge related to hand hygiene, wearing of facilal mask, social distancing and new dining requirements. 7. The Abatement Plan was reviewed for monitoring and to ensure accountability of all corrective actions that included oversight by Administrative staff. After removal of the Immediacy, the noncompliance remained at the level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy until sustained compliance is verified.

Based on interview and record review, the facility failed to follow their abuse policy for protecting a resident (R1)from being sexually assaulted by another resident (R2). This applies to two of four residents (R1, R2) reviewed for abuse in a sample of four. This failure resulted in R1 being sent to the emergency room and diagnosed with [REDACTED]. Findings include: On 4/4/17 at 10am, E4 ([MEDICAL CONDITION] Nurse) stated that on 4/1/17 at approximately 8am, R1 came up to her at the nursing station and said she needed to talk to her. R1 told her that her vagina hurt and that R2 climbed in her bed this morning, pulled her pants down and forced sexual intercourse. R1 told her that R2 climbed on top of me and raped me. R1 told her that she did not scream because R2 threatened her and said he (R2) would just keep doing it again if she said anything or told anyone. E4 stated that R1 told her that when R2 was done, he looked at his watch and said he was done for now but would be back. R1 then indicated that this happened to her multiple times. E4 stated that E5 (PRSC - Psychiatric Rehabilitation Services Coordinator) stayed with R1 and that she (E4) called the police and E1 (Administrator). R1 was sent to hospital emergency room and returned back to the facility with a [DIAGNOSES REDACTED]. On 4/4/17 at 10:30am, R1 stated that she did not want to talk about it because she is afraid of him (R2) and she does not feel safe in the facility. R1 was quiet and did not have eye contact with surveyor. R1's BIMS (Brief Interview Mental Status) score dated 3/13/17 read 15 out of 15. On 4/5/17 at 11am, R3 (R1's roommate) stated that R2 would come into the room looking for R1. R3 stated that she would hear R1 say No, no, no and R2 would say Yes, yes, yes. R3 stated that R2 was not someone you could say no to. R3 stated I heard R2 is in the hospital. That is good. Everyone is afraid of him. R2 is scary. I feel like our room is targeted. I did not hear anything on 4/1/17. R3's BIMS score dated 2/10/17 was 15 out of 15. The EMS (emergency medical service) form dated 4/1/17 at 9:35am reads R1 Complaint - rape. In summary, crew called to the scene for a subject (R1) who was sexually assaulted last night. R1 transported to hospital. emergency room notes dated 4/1/17 at 10:43am read This is a [AGE] year old female (R1) who presents herself from the nursing home complaining of sexual assault. R1 states she was sleeping in her room when she heard someone walk in to the room. R1 stated R2 came toward her, grabbed her wrist, took her watch, and then climbed on top of her. R1 states R2 who attacked her is another resident in the facility. R1 stated that he raped her, penetrating only vaginally, not anally. Stated that she was so scared that she did not try to fight him off. States that when he left, he said he would come back 5 minutes later, but he never did. Physical exam - R1 is oriented to person, place and time R1 is very tearful and upset that this happened. Clinical impression - Sexual assault of adult, initial encounter. R1 will be discharged back to nursing home as the accused man R2 has been removed from the facility. R1 returned to the facility with an anti infective medicine prescription [MEDICATION NAME] 500 mg twice a day for 7 days. The facility's abuse prevention program policy dated 91/2016 reads This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This will be done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of treatment.

Based on interview and record review, the facility failed to supervise and implement effective interventions to address a resident aggressive behavior to prevent the resident from harming other residents. This applies to one out of four residents(R2) reviewed for behavior symptoms in a sample of four. As a result R2's continued to have multiple episodes of physical aggression since admission to the nursing home and one incident on 4/1/17 R2 sexually assaulted a female peer R1. Findings include: R2 was admitted to the facility on [DATE]. R2's face sheet lists the following Diagnoses: [REDACTED]. R2's social service notes dated 7/1/16 read that R2 was admitted to the nursing home from the hospital where R2 was treated for [REDACTED]. R2's psychiatric evaluation/assessment dated [DATE] reads Agitated/impulsive, delusional, argumentative, no insight. R2's behavior charting dated 7/11/16 at 12:46 reads R2 was involved in a verbal altercation with his roommate. R2 intimidated his roommate (cornering him, yelling obscenities). R2 difficult to redirect, moved to another room. R2 agrees that he was aggressive. R2's psychiatric progress notes dated 7/28/16 read Easily agitated, delusional, poor insight. R2's clinical notes dated 8/1/16 read R2 was walking in hallway when another resident approached him from behind. R2 turned around and hit peer with a open hand in his face. R2 was brought to the nurses station attempted to redirect and calm down with no success, PRN (as needed medication) given. R2 transferred to hospital for psych evaluation due to aggression, verbal threats to staff/peers and admitted with Schizoaffective disorder. R2's psychiatric notes dated 8/30/16 read R2 starting to cause problems with roommates, insight poor. R2's clinical notes dated 9/10/16 at 11:40 read R2 involved in physical altercation with female peer. R2 angry and agitated, received PRN (as needed medication) for agitation. R2's behavior charting dated 11/2/16 reads R2 was physically aggressive with female peer. R2 was accused of hitting female peer in the eye. R2 sent to hospital and admitted with aggressive behavior. R2's behavior charting dated 12/13/16 at 12:15 reads R2 was involved in a physical altercation with a male peer. R2's nurses notes dated 1/10/17 at 20:29 reads R2 had a verbal and physical altercation with peer. R2's notes dated 1/26/17 at 07:35 reads R2 verbally and aggressive to residents in search of a phone. R2 wanted to fight everyone due to the misplacement of phone. R2's clinical note dated 2/8/17 at 17:42 reads R2 involved in physical altercation with male peer. R2 is verbally aggressive with staff. R2 sent to hospital for aggressive behavior and admitted to hospital. R2 returned to facility on 2/13/17 R2's clinical notes dated 2/21/17 reads R2 got into a physical altercation with another peer. R2's notes dated 4/1/17 at 08:20 read R2 accused of engaging in unwanted sexual act with R1. On 4/4/17 at 10am, E4 (Psychotropic Nurse) stated that on 4/1/17 at approximately 8am, R1 came up to her at the nursing station and told E4 that she needed to talk to her. E4 stated that R1 told her that her vagina hurt. E4 stated that R1 told her that R2 climbed in her bed this morning, pulled her pants down and forced sexual intercourse. E4 stated that R1 told her that R2 climbed on top of me and raped me. E4 stated that R1 told her that she did not scream because R2 threatened R1 and told R1 that he would just keep doing it again if she said anything or told anyone. E4 stated that R1 told her that when R2 was done, he looked at his watch and said he was done for now but would be back. E4 stated that R1 indicated that this happened multiple times. E4 stated that E5 (PRSC) stayed with R1 and E4 stated that she called the police and E1 (Administrator). R1 was sent to hospital emergency room and returned back to the facility with a [DIAGNOSES REDACTED]. On 4/4/17 at 10:30am, R1 stated that she did not want to talk about it because she is afraid of him (R2) and she does not feel safe in the facility. R1 was quiet and did not have eye contact with surveyor. On 4/5/17 at 11am, R3 (R1's roommate) stated that R2 would come into the room looking for R1. R3 stated that she would hear R1 say No, no, no and R2 would say Yes, yes, yes. R3 stated that R2 was not someone you could say no to. R3 stated I heard R2 is in the hospital. That is good. Everyone is afraid of him. R2 is scary. I feel like our room is targeted. I did not hear anything on 4/1/17. R3's BIMS score dated 2/10/17 was 15 out of 15. On 4/5/17 at 9:50am, E3 (PRSC- Psychiatric rehabilitation services coordinator) stated R2 was always agitated. E3 stated R2 was very aggressive. R2 gets angry and unleashes. The victim does not have to do anything. R2 would hit anyone who got in his way. R2 would go to hospital and it would help for a few days. R2 refused to go to groups. My approach was to try to talk to him. E3 stated that after an episode out R2's aggression, a staff member would stay with him until he calmed down or given a PRN (as needed) medicine. E3 stated that R2 was always agitated and aggressive. E3 stated that R2 was the only problem resident the facility had. E3 stated that R2 would lash out and go on a rampage. The facility did not have any plan in place to supervise and implement effective interventions for R2's multiple episodes of aggression. R2's care plan dated 7/22/16 reads R2 has a history of the following symptoms due to a [DIAGNOSES REDACTED]. Goal: R2 will learn anger management. Interventions include: Develop a level of trust with R2, provide support and empathy to encourage R2 to feel safe. Explore source of R2's feelings of vulnerability and Psych eval as ordered.

Based on observations, record reviews and interviews, the facility failed to implement appropriate treatments and services to address assess problems for 1 of 27 (R 25 ) sampled residents, who displayed mental and psychosocial adjustment difficulties (such as: using drugs, soliciting peers for sex, being verbally abusive toward staff and peer, physically attacking another residents (R3) while he was sleeping in his bed). This failure resulted in one resident (R3), who was physically assaulted by R25, being sent to the hospital for medical treatment. Also, this failure has the potential to effect all the residents in the facility, who are dependent upon staff to intervene and ensure resident's mental and psychosocial adjustment difficulty are appropriately addressed, to prevent possible harm to themselves and peers. Findings Include: On 1/20/11, R3 was observed walking around the facility socializing with other residents. R3 told surveyor that R25 came into his room about 10 PM (on 12 17/10), and hit him in the face and chest. R3 stated that he had done nothing to this person (R25). R3 said, "He (R25) just came and start hitting me while I was sitting on my bed in my room." R3 states that no one came to help him. After receiving a physical beating, R3 said he went to the nursing station. R3 told surveyor that he was bleeding from his nose, hurting, holding his chest, when he went to the nurses asking for help. . Review of the facility incident report dated 12-17-10 notes the following: "At approximately 10:00 PM, R3 alleged that he was punched in the face by his roommate "R25" ... R3 noted with blood and bruising on his face." The known facts during the investigation notes: R3 approached the nurses station about 10:30 PM with blood on his face. He indicated his roommate "R25" hit him in his face. Interview with another roommate indicated that R25 struck R3 in his face. R3 physician notified, x-rays were order and results were negation for fractures. R25 was placed on one to ones supervision and psychiatrist was notified. Orders were given to discharge R25 to hospital for psychiatric evaluation. Review of R25's admission records documents that R25 is a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Social Service Notes dated 10-22-10 documents that R25 is socially inappropriate. E 15 ( activity aide) stated on 1-21-11 that shortly after R25 was admitted to the facility he began soliciting for sex while in his room. R25's Social Service Notes dated 11-16-10 documents: R25 has an aggression towards peers and staff. Social Service Notes dated 11-20-10 details that R25 has a documented history of verbally and physically aggressive behavior toward staff and peers, which required the usage of restraints. R25 also has a history of destruction's of property which indicates impaired judgement. E14 and E15 (activity aides) stated on 1-21-11 that R25 lived down the hall from R3. E14 and E15 told surveyor that when R25 initially came to the facility, he was quiet and followed directions. But after a while, R25 began to harsher the other residents and not follow staff's instructions. E14 and E15 also stated R25 beat up a resident who is very fragile and does not brother anyone. E14 and E15 stated that after the beating, R3 had 2 black eyes and complained of pain. E14 and E15 told surveyor that R25 had a lot of girls going in and out of his room, soliciting sex and would not follow the rules smoking rules. They (E14 and E15) reported that R25 would leave the facility without permission and had several verbal confirmation with the staff. E17 ( social service) per interview, on 1-25-11 at 2:15 PM, confirmed R25's behavior of paying for sex in the facility, being verbal and physical aggression toward staff and peers. E17 also reported that R25 did not adhered to the rules of the facility. E17 stated after the initial physical alternation with R3, R25 was transferred out to another facility and once return way put on one to one supervision. E17 state after each inappropriate behavior, she would not allow R25 a community pass. According to Social Services Notes dated 12-21-10 notes R25 was exhibiting aggressive behavior, verbally and physically toward staff and peers. such as threatening remarks, screen homicidal ideation. Social Services Notes dated 12-23-10 notes R25 displays physically/verbally aggressive alone with socially inappropriate behavior. According to the nursing notes R25 was discharge to the hospital on 12-23-10, 6 days after an physical attack on R3. Z2 (R25's psychiatric physician) stated on 1-25-11 that the facility did not notify him of any of R25's abnormal behaviors. Z2 said, "If the facility would have notify me I could have given something to handle him, not just allow him to continue to have abusive behavior. The facility did not call me until the physical alternation and R25 was transfer out of the facility." Z2 stated as he remembers, R25 came back to the facility the same day and the facility was very concern that he would hurt another resident. So, R25's physician interviews provides additional evidence that no treatment or services were given to address R25's abnormal behaviors. After R25's assault on R3, the facility began calling the doctor, and placement to another facility was made a few days later.