Every finding on record at Arc at El Paso

Based on interview and record review, the facility failed to follow its abuse prevention policy for three of four residents (R2, R3, and R4) with abuse-related concerns. Findings include:1. R2 had an allegation that R2 had been called a racial slur. The facility knew about the allegation and moved R2 to a different room after administration was made aware. The facility did not provide documentation showing the allegation was reported to the State Agency, investigated, concluded, or followed up on. On [DATE] at 12:12 PM, V3/LPN stated concerns regarding R2's previous roommate (now deceased ) calling R2 a racial slur were brought to management's attention by V3. V3 stated, I advocated to have R2 moved to a different room because he was being called racial slurs by his roommate. I notified V1, Administrator, of the incident and that's why they moved R2 to a different room. I never heard anything else about it. Management does not follow up on concerns at the facility. This is an ongoing issue with the administration at the facility.R1's electronic health record contained no documentation of the room move at the time of the incident other than in the Census line and no documentation the facility reported the allegation involving R2 being called a racial slur to the State Agency. Review of facility documentation did not show the facility completed an abuse investigation related to R2's allegation. The facility did not provide documentation showing it protected R2 from further possible abuse, interviewed R2, interviewed the alleged resident, interviewed witnesses, reviewed records, checked how the incident affected R2, documented findings, reached a final decision, or took action to prevent it from happening again.On [DATE] at 12:40 PM, V1, Administrator, and V2, Director of Nursing, confirmed they were aware of the allegation that R2 was called a racial slur and that R2 was moved to a different room. V1 initially stated he was not aware of the allegation; however, after V2 confirmed awareness of the concern and that it had been discussed with Administration, V1 confirmed the facility was aware of the situation. V1 and V2 confirmed the facility did not complete an abuse investigation and did not report the allegation to the State Agency.On [DATE] at 12:43 PM, V11, Regional Director of Operations, stated the allegation involving R2 being called a racial slur should have been reported. V11 stated the facility should have done something to prevent the abuse from happening again. V11 stated, This is very concerning for me, and stated she needed to decide what to do about the situation.V1, Administrator's initial statement that he was not aware of the allegation was inconsistent with the later confirmation by V1 and V2 that the facility knew about the allegation and moved R2. The facility's documentation did not support that the facility followed its abuse prevention policy after learning of the allegation. The facility did not provide documentation showing the allegation was reported, investigated, concluded, or followed up on.The facility failed to follow its abuse prevention policy for R2 when it failed to treat the racial slur allegation as possible verbal abuse or mistreatment, failed to report the allegation to the State Agency, failed to complete and document an investigation, failed to document protection measures, failed to document follow-up with R2, failed to document a final decision, and failed to document what was done to prevent it from happening again.2. R3 had concerns related to staff treatment, refusal or delay of help, dignity, and possible mistreatment. R3 reported staff conduct/mistreatment to V1, Administrator, that should have been reviewed by the facility as possible mistreatment, neglect, retaliation, or degrading treatment. On [DATE] at 11:45 AM, V7, CNA, stated she reported allegations of mistreatment/abuse to V1, Administrator, related to R3 and V10, CNA, multiple times. V7 stated, He just sweeps everything under the rug. V7 stated R3 told V7 that V10 told R3 she was lazy because she wanted a lid taken off of her cup. On [DATE] at 1:03 PM, R3 stated V10, CNA, was intimidating, demanding, and argued with R3. R3 stated R3 told V1, Administrator, and nothing was done. R3 stated V10 pulled a chair up to R3's bed after arguing, waited, and did not come in when R3 needed help. R3 stated V10, called R3 lazy and V10 was not a nice person to her on multiple occasions. R3 stated V10 made her feel bad about herself and did not like to help her even though she needed assistance. On [DATE] at 1:10 PM, V1, Administrator, stated there was no investigation related to R3's concern, but V1 was aware of the situation and spoke with V10, CNA, about the incident.On [DATE] at 1:44 PM, V10, CNA, stated R3 asked her to remove a lid and V10 refused to do so. V10 stated, I told her she could do it herself. We (R3 and V10) always had issues and would get into arguments when bathing R3 too. V10 stated she told R3, Your hands or arms aren't broke, and stated R3 got upset. Administration talked to (V10) about the situation. V10 stated she did not want to do anything for R3 because she felt like it's a race thing and stated R3 had a problem with her no matter what V10 did.Review of the facility's abuse and reportable documentation did not show the facility reviewed R3's concern as possible mistreatment, neglect, dignity concern, retaliation, or abuse-related concern. The facility did not provide documentation showing it determined whether the concern had to be reported, protected R3 from further possible mistreatment, interviewed R3 when the concern was reported, interviewed V10 when the concern was reported, interviewed witnesses, reviewed records, followed up with R3 about how the concern affected R3, documented findings, or reached a final decision.The facility failed to follow its abuse prevention policy for R3 when it treated the concern as a general staff and resident conflict or task-assistance issue. The facility failed to review R3's report of arguing, refusal or delay of help, and feeling bad about herself as possible mistreatment or degrading treatment. The facility failed to determine whether the concern required reporting, failed to process the concern through the abuse prevention policy, failed to investigate the concern, and failed to document a decision or follow-up action.3. R4 had an allegation involving degrading staff conduct during wound care. The allegation involved staff conduct that made R4 feel embarrassed, fearful, and degraded during care.On [DATE] at 10:00 AM, V8, Registered Nurse, stated R4 reported a concern regarding V14/LPN to V8. V8 stated recently within the last couple weeks, staff came and got V8 because R4's bandages were wet and R4 was upset when V8 entered the room. V8 stated the concern involved V14/LPN saying the bandages were gross and she did not want to catch anything from R4's draining wounds. V8 stated this was a dignity concern and it was reported to V1, Administrator, and as neglectful and abusive. V8 stated V8 also reported the concern to V2/Director of Nursing. V8 stated R4 wanted to discharge and did not want the staff member to care for him anymore. On [DATE] at 12:35 PM, R4 stated V14/LPN came into R4's room to complete wound care. R4 stated V14 had a disgusted look on her face, sighed, and asked if R4's wounds were contagious. R4 stated the interaction made R4 feel angry, degraded, and awful about himself. R4 stated R4 was fearful and wondered what the nurse said to other residents who couldn't speak for themselves or stand up for themselves.On [DATE] at 2:40 PM, V1, Administrator, stated he did not have an abuse investigation related to the incident between R4 and V14/LPN. Review of facility abuse and reportable documentation did not show the facility completed an investigation related to R4's allegation. The facility did not provide documentation showing the allegation was reported to the State Agency, reviewed as possible abuse, neglect, or mistreatment, or reviewed for R4's dignity, emotional impact, protection, or follow-up.The facility had knowledge of the concern before the surveyor interview with R4 because V8 stated V8 reported the concern to V1, Administrator, and another facility manager. The facility did not provide documentation showing it followed its abuse prevention policy after receiving the report. The facility did not provide documentation showing it determined whether the allegation had to be reported, protected R4 from further possible mistreatment, interviewed R4, interviewed the alleged staff member, interviewed R4's wife as a witness, reviewed wound-care documentation, followed up with R4 about how the concern affected R4, documented findings, reached a final decision, or took corrective action.The facility failed to follow its abuse prevention policy for R4 when it failed to recognize and process the allegation of degrading treatment during wound care as possible abuse, neglect, mistreatment, or dignity-related harm. The facility also failed to act on V8's report that the concern was neglectful and abusive, failed to determine whether the concern required reporting to the State Agency, failed to complete an investigation, failed to document findings or a decision, and failed to complete resident follow-up or action to prevent the same concern from happening again.On [DATE] at 1:10 PM, V1, Administrator, stated all abuse allegations were expected to be investigated fully, documented, and reported accordingly. V1 stated R2, R3, and R4's allegations of abuse were not investigation, documented, or reported and should have been.On [DATE] at 12:43 PM, V11, Regional Director of Operations, stated all abuse/neglect allegations should be investigated and reported. V11 stated the concerns about multiple allegations of abuse not being investigated, reported, or followed up on are very concerning. V11 stated she needed to decide how to handle the situation after being made aware due to the seriousness of the concerns. The facility policy titled, Abuse Prevention and Reporting - Illinois, revised 03/2026, documented the facility prohibited abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. The policy documented any suspected abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property was to be immediately reported to the Administrator/designee. The policy documented residents were to be protected from further possible abuse. The policy documented the facility was to complete a prompt and thorough investigation, including review of the allegation, identification of the alleged staff member, resident interviews, witness interviews, record review, documentation of findings, and a final decision. The policy documented investigation records were to be maintained and abuse-related concerns were to be reviewed for patterns, follow-up, and corrective action.

Based on observation, interview and record review the facility failed to serve hot foods in a sturdy bowl, this failure caused R8 to spill hot chili on her chest causing a burn with blistering that required treatment for one resident (R8) reviewed for a burn injury in a total sample of thirty eight. Findings include:R8's Medical Record documents she was admitted to the facility on Hospice services on 12/10/2024 with diagnosis to include but not limited to Congestive Heart Failure, Atrial Fibrillation and Dementia. R8's Medical Record documents she is cognitively impaired and has short term memory problems. Throughout the survey R8 did not recall the incident on 3/24/26 with chili. The facility's Incident dated 3/24/26 documents V19 (Registered Nurse) was called to R8's room by V15 (Certified Nurse Aide) during lunch time because R8 had yelled out and was found with chili down the front of her chest.R8's Skin-Other Skin Condition assessment dated [DATE] documents R8 had a new skin concern: burn. The Skin-Other Skin Condition assessment documents area to right upper chest 15 cm (centimeters) by 9 cm red warm redness with mild skin sloughing to top layer. R8's Physician Order Sheet Dated March 2026 documents a new order from V10 (R8's doctor) for Silvadene cream to burn twice daily.On 5/27/26 V20 (R8's Family Member) stated R8 prefers to eat in bed, but V20 thinks she needs more supervision while eating. R8 stated, If someone had been in the room helping her with her lunch or making sure she could reach everything she would not have gotten burned. On 5/27/26 V15 (Certified Nurse Aide), V21 (Certified Nurse Aide) and V22 (Certified Nurse Aide) all confirmed they were the staff members who passed the room trays to residents on 3/24/26. All three V15 (CAN), V21 (CNA) and V22 (CNA) stated they do not remember who took R8's tray to her on that day. All denied any concerns with lunch that day prior to R8 receiving a burn from the chili. On 5/27/26 V15 (CNA) stated she heard R8 yell, Mom, I hurt! and then V15 could hear R8's roommate yelling that R8 had spilled something. V15 (CNA) stated she immediately put a cool cloth on R8's chest because it was red, hot and very painful to R8. V15 (CNA) stated V19 (Registered Nurse) applied Silvadene cream to R8's chest. V15 stated, The area was pretty big, long and wide. R8's IDT (Interdisciplinary Team) Meeting note dated 3/25/26 documents, It was determined the incident (burn) was caused by her chili being served in a Styrofoam bowl. R8's IDT note does not include why a Styrofoam bowl was used instead of normal dinner ware. R8's Nurse's Note dated 3/24/26 at 12:15 PM documents, This writer went to kitchen to have the temperature of the chili redone. The temp of the chili at this time was 180 degrees. The Facility's Food Temperature Logs dated 3/24/26 documents Protein Final Cooked Temperature 190 degrees Fahrenheit. Protein Holding Temperature 187 degrees Fahrenheit.The Facility's Food Temperature Logs dated 3/24/26 document a key at the bottom Final Cooking Temperature Reference Casserole/Soup 165 degrees Fahrenheit. On 5/28/26 V8 (Cook) stated she did not know if 180 degrees Fahrenheit would be considered a safe temperature to serve a soup/casserole at per the facility's own printed key at the bottom of the Food Temperature Logs. V8 (Cook) could not provide temperature checks of meal trays that were sent to resident rooms at any point. V8 (Cook) did not know why R8 was served hot chili in Styrofoam instead of regular dinnerware. On 5/27/26 V1 (Administrator) confirmed the IDT notes, We think that she attempted to pick up the bowl full of hot chili and the bowl failed and the hot chili hit her upper right chest. The new intervention is to always serve hot food in regular dinnerware. R8's Medical Record does not contain any information regarding education of R8 and/or V20 (R8's Health Care Power of Attorney) regarding any risks of eating unsupervised in her room. R8's Medical Record did not contain any safety risk assessment to determine what risks R8 would have to eat unsupervised. The Facility's Monitoring Food Temperatures for Meal Services policy dated 5/2026 documents If the serving/holding temperature of a hot food item is not at 135 degrees Fahrenheit or higher when checked prior to meal service the item will be reheated to at least 165 degrees Fahrenheit for a minimum of 15 seconds. Meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident.

Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions by not cleaning a debris/grime covered exhaust vent located above kitchen food preparation area. This failure has the potential to effect all 55 residents residing in the facility.Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 5/26/26, signed by V1/Administrator, document 55 residents reside in the facility. On 5/27/26, at 11:30 a.m., the exhaust vent, located above the kitchen's food preparation area, was covered with debris/grime. On 5/27/26, at 11:30 a.m., V7/Regional Dietary Manager confirmed the exhaust vent, above the food preparation area, should be cleaned. Facility Policy, entitled, On Tray Dietary Policies and Procedures Ceiling, Vents, document: Purpose: To ensure food safety. 1. Schedule with maintenance to complete the following. Remove all the parts of the vents that are removable (keep all the parts together) and wash, rinse, and sanitize in a proper location. 2. Wipe all the surfaces using a detergent solution and rinse. You may use degreaser to loosen the dirt. 3. Sanitize and allow to air dry. You may use degreaser to loosen the dirt. 4. Replace the removable parts of the vents. Wash and sanitize cleaning equipment and return to the proper storage area.

Based on observation, interview, and record review, the facility failed to ensure the lids of trash dumpsters, located outside, are closed/secure to prohibit pests/animals from gaining access to discarded food/trash. This failure has the potential to effect all 55 residents residing in the facility. Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 5/26/26, signed by V1/Administrator, document 55 residents reside in the facility. On 5/26/26, at 9:30 a.m., during the Initial kitchen tour, the two outside trash dumpsters were not secured as lids, on both were open. On 5/26/26, at 9:30 a.m., V8/Cook confirmed the trash dumpsters should have the lids closed.The facility's Pest Control Policy, effective 1/2026, document: Put garbage in sealed plastic bags before placing them in a covered, rodent-proof dumpster.

Based on observations, interviews, and record review, the facility failed to implement an infection prevention and control system to identify, report, and manage infections and symptoms associated with communicable illnesses among residents; and failed to ensure proper disinfectant monitoring practices, including the use of testing protocols to verify acceptable disinfectant ranges and documentation of testing results for Legionella. These failures have the potential to affect all 55 residents who reside in the facility.Findings Include:On 5/27/2026 at 12:10 PM, V2 (Director of Nursing) confirmed she has no log that track infections or symptoms residents exhibit daily to track communicable infections and diseases.On 5/27/2026 at 12:30 PM, V13 (Maintenance Director) stated the Water Management Program Committee Protocol items listed to be completed are not completed. V13 stated there is no chlorine test that the facility or water department performs on a weekly or monthly basis to test the disinfectant in the water. The shower heads and aerators are not disinfected every six months and the ice machine is handled by the company that owns the machine and he does not have access to their cleaning schedule.The facility's Infection Prevention and Control Program policy dated 12/2025 documents, Purpose: to comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Guidelines: 6. The program proves for the recording for each suspected infection and surveillance activities as they relate to the individual resident infections. A log is maintained of suspected and actual infections on a day-to-day basis. McGeer's Criteria is used to determine if criteria for an infection is met.The facility's Water Management Program for Prevention of Legionella Growth dated 02/2026 documents, Purpose: to reduce Legionella in the facility water systems to prevent cases and outbreaks of Legionellosis. Development of a Water Management Program: Implementing a water management program to reduce the buildings risk for growing and spreading Legionella. The elements of the Water Management Program should be reviewed annually. Date shows control measures are persistently outside of control limits. Components of a Water Management Program: Control limits for each control measure at each control location determine control limits, including the maximum value, minimum value or range of values of a chemical or physical parameter that shall be monitored and maintained in order to reduce hazardous conditions. Monitoring, establish a system for monitoring the parameters associated with the control limits. Examples of chemical and physical control measures and limits to reduce the risk of Legionella growth: measuring water quality throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring. Maintaining water heaters at appropriate temperatures. Maintaining and regularly monitoring disinfectant and other chemical levels in cooling towers and hot tubs. Surfaces with any visible biofilm (i.e. (example) slime) should be cleaned.The facility's Water Management Program Committee Protocol-SNF (Skilled Nursing Facility) policy, not dated, documents, A water management program is in place to reduce the risk for Legionaries disease and other potential diseases that may be associated with the building of water systems and devices. This program identifies areas or devices where bacteria, such as Legionella might grow or spread to people. The water management program committee will review all the above as well as the control measures used to maintain a safe water provision for residents, staff, families, and visitors. The committee consists of but is not limited to the following people: Administrator, Director of Nursing, Infection Preventionist, Maintenance Supervisor. Items reviewed are: all points flushed every month for 2 minutes, aerators, shower wants disinfected every six months, ice machine cleaned monthly, chlorine test completed by local water department, Infection Preventionist and control log reviewed for upper respiratory infections and outcomes, and employee infection record reviewed monthly.

Based on observation, interview and record review the facility failed to include a resident's wish to eat in their room for 15 residents (R2, R4, R8, R11, R20, R21, R28, R32, R38, R39, R41, R47, R50, R53, R58) of twenty residents who have indicated that they wish to eat in their room instead of the main dining room for meals in a total sample of thirty eight. Findings include: The Facility's Comprehensive Care Plan policy dated 08/26/2025 documents 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. Throughout the survey the following residents were observed eating meals in their rooms during meal times: (R2, R4, R8, R11, R20, R21, R28, R32, R38, R39, R41, R47, R50, R53, R58) On 5/27/2026 V8 (Cook) provided a handwritten list of residents that usually eat their meals in their rooms instead of the main dining room. The list included: (R2, R4, R8, R11, R20, R21, R28, R32, R38, R39, R41, R47, R50, R53, R58) R2, R4, R8, R11, R20, R21, R28, R32, R38, R39, R41, R47, R50, R53, R58 care plan do not include any mention that these residents prefer to eat in their rooms during meal times. On 5/28/2026 V1 (Administrator) confirmed that the listed residents' care plans do not include their wish to eat in their rooms. V1 stated that should be on there (care plan).

Based on interview and record review, the facility failed to inspect and regularly check the mattress and bed rails for areas of possible entrapment for 3 (R2, R6, and R8) of 3 residents reviewed for bedrails in a sample of 38. 1. R2's Medical Record documents she was admitted on [DATE] with diagnosis to include but not limited to Morbid Obesity, Type II Diabetes Mellitus and Chronic Respiratory Failure with Hypoxia. R2's Medical Record documents she cognitively intact and makes her own decisions. Throughout the survey R2's upper half side rails on both sides were up while she was in bed. On 5/27/2026 R2 stated she used the side rails for turning in bed. R2's Side Rail assessment dated [DATE] documents the side rails do not restrict mobility or prevent independent functioning. R2's Side Rail Assessment documents the side rails are used for increased mobility in bed. R2's Medical Record did not document any Entrapment Risk assessment for R2's side rails. 2. R6's Medical Record documents she was admitted on [DATE] with diagnosis to include but not limited to Osteoarthritis, Atrial Fibrillation and Dementia. R6's Medical Record documents that she is cognitively impaired and does not have good short term memory. Throughout the survey R6's upper half side rails on both sides were up while they were in bed. On 5/28/2026 during cares R6 used the side rails to assist in turning herself from side to side in bed. R6's Side Rail assessment dated [DATE] documents the side rails do not restrict mobility or prevent independent functioning. R6's Side Rail Assessment documents the side rails are used for increased mobility in bed. R6's Medical Record did not document any Entrapment Risk Assessment for R6's side rails. 3. R8's Medical Record documents she was admitted on [DATE] with diagnosis to include but not limited to Bipolar, Post Traumatic Stress Disorder and Encephalopathy. R8's Medical Record documents she is cognitively intact and makes her own decisions. Throughout the survey R8's upper half side rails were up when she was in bed. On 5/28/26 R8 reported she uses the half rails to help turn herself in bed. R8's Medical Record does not contain any Entrapment Risk Assessment for R8's side rails.

Based on interview and record review the facility failed to ensure prompt communication between Hospice Services and the facility for one resident (R6) of three residents reviewed for Hospice Services in a total sample of thirty eight. The Facility's Hospice Services Agreement signed and dated 8/1/2023 documents Hospice personnel shall provide all necessary oversight of services provided to Residents in accordance with the Hospice Plan of Care. Hospice shall review documentation of such services and shall communicate weekly Facility personnel to ensure that the needs of Residents are met in a comprehensive, coordinated fashion twenty-four hours a day. Such communication shall be documented pursuant to Hospice Policy. R6's Medical Record documents she was admitted to the facility on Hospice Services on 12/10/2024. R6's diagnosis include but are not limited to Congestive Heart Failure, Atrial Fibrillation, and history of Myocardial Infarction. R6's Medical Record documents she cognitively impaired and has short term memory problems. On 5/27/2026 V17 (Certified Nurse Aide) stated Hospice staff usually give R6 her bed bath/shower. It is a holiday week though, so I am not sure when they are coming or if they have already been here. On 5/28/26 V16 (Hospice Registered Nurse) stated she does not document in the facility's Electronic Medical Record at all. V16 (RN) reported that her office faxes her notes to the facility. V16 did not know where the Hospice CNAs would document where showers or any other cares given would be documented for communication to facility staff. On 5/28/2026 V6 (Registered Nurse) stated, Hospice faxes us lots of stuff, we put it right there (a box marked medical records by the fax/copy machine) and someone eventually scans it into the medical record. R6's Medical Record did not contain any information scanned from hospice to indicate what cares Hospice has provided when they were in the facility.

Based on interview and record review, the facility failed to accurately reflect a resident's injection and insulin status related to the Minimum Data Set assessment for 1 (R21) of 24 residents in a sample of 38. Findings include:R21's admission Record indicates R21's diagnoses. Diabetes Mellitus is not listed as a diagnosis.R21's Quarterly MDS (Minimum Data Set) assessment dated [DATE] documents in section N0300. Injections R21 received 7 injections in a week. Section N0350. Insulin documents R21 received 7 insulin injections in a week. R21's Order Summary Report does not document a physician order for insulin injections. On 5/28/2026 at 9:30 AM, V2 (Director of Nursing) stated V2 could not find documentation in R21's electronic health record confirming R21 has received insulin injections since admission to the facility or has any current or past orders for insulin injections.

Based on interview and record review the facility failed to monitor a resident's condition after return from the hospital for one resident (R2) of four residents reviewed for hospitalizations in a total sample of thirty eight. R2's Medical Record documents she was admitted to the facility on [DATE] with diagnosis to include acute and Chronic Respiratory failure with Hypoxia, Type II Diabetes Mellitus, Congestive Heart Failure and Hypertension. R2's Progress Notes dated 11/25/2025 document 2 was being sent to the emergency room for abnormal Hemoglobin. R2's admission assessment dated [DATE] documents she returned from the hospital after hospitalization for low Hemoglobin that was treated with blood transfusions. R2's Medical Record does not contain any other follow up or mention of R2's condition after hospitalization. On 5/28/2026 V2 (Registered Nurse/Director of Nursing) confirmed there was no ongoing monitoring of R2 by nurses after her hospitalization. V2 stated, (R2) should have had assessments for three days after she got back, if everything is stable then we would not continue. I don't know why (R2) has no documentation of ongoing assessment.

Based on observation, interview and record review the facility failed to put a splint on as ordered for one resident (R6) of one resident reviewed for positioning/mobility in a total sample of thirty eight.R6's Medical Record documents she was admitted on [DATE] with diagnosis to include but not limited to Bipolar, Post Traumatic Stress Disorder and Encephalopathy. R6's Physical Therapy Discharge summary dated [DATE] documents, (R6) exhibits good improvements in right ankle range of motion. Correspondence with primary caregivers (facility staff) to facilitate development and follow-through of patient's plan and discussed equipment needs in preparation for next level of care. The facility's Training Acknowledgement training sign in sheet documents the topic as correct donning right AFO (Ankle Foot Orthosis). Put on Right AFO in the morning and remove before bed. for (R6). Throughout the survey R6 did not have a splint on her ankle. On 5/28/2026 R6 stated she wasn't sure if she was supposed to have a splint on any part of her legs or feet. R6 stated, I did for a while but I'm not sure anymore. I cannot remember when I last had it. On 5/28/2026 V15 (Certified Nurse Aide) confirmed she was the staff member responsible for R6's cares on this day. V15 (CNA) stated she did not know if R6 should have a splint on or not. V15 did confirm that R6 did not have any sort of splint on today 5/28/2026 or yesterday 05/27/2026.

Based on observation, interview and record review, the facility failed to prevent resident to resident abuse from occurring for one of two residents (R10), reviewed for abuse, in a sample of 38. R10's facility admission Record documents R10 was admitted to the facility on [DATE] with the following diagnoses Dementia, Anxiety and Depression. R10's current Care Plan, dated 3/23/26 documents R10 has the following Focus Areas: Behavior Problems due to anxiety, wandering, yelling at staff; Wandering/poor safety awareness and Impaired Communication. The facility report, Final Abuse Investigation Report, dated Initial Report: 4/14/26 and Final Report: 4/20/26. At 6:25 P.M. on 4/14/26, (V1) was notified of an alleged physical altercation between (R10 and (R18) in the hallway near the nurse's station. Both residents were immediately separated. Facility leadership reviewed the medical record of the residents. Employees and residents that were knowledgeable of the allegation were interviewed by the Abuse Coordinator. (R18) was interviewed and stated, (R10) was trying to push me in my wheelchair. I told her no; I can do it myself. It was at that time I reached back and hit (R10) and then (R10) pulled my hair. No staff witnessed the alleged allegation. V4/Certified Nursing Assistant stated I walked out of the dining room and noticed (R10) was trying to push (R18) in her wheelchair. (R18) got mad and told her to stop and swung her arm back to try to hit (R10). I was walking towards them to separate both residents and that is when (R10) pulled R18's hair. It was at this time I was able to separate both residents. On 5/26/26 at 10:15 A.M., R18 was up in a wheelchair, in the facility front room. R18 was able to propel her wheelchair using her feet. R18 was alert, and able to answer questions appropriately. R18 stated she does recall the incident that occurred a few months ago when R10 (able to recall R10's name without prompting) and she were sitting at the nurse's station and R10 started pushing her wheelchair, without being asked. R18 stated she told R10 repeatedly to stop, R10 continued pushing her chair. R18 reached behind her to grab R10, missed R10 and then R10 pulled her hair. R18 stated it hurt when R10 pulled her hair. R18 stated at that time, facility staff intervened and took R10 to her room. R18 stated she has had no other occurrences with R10. On 5/26/28 at 1:03 P.M., V4/Certified Nursing Assistant stated she witnessed (R10) pull (18)'s hair one evening after supper. It was in April of this year, and as she was coming out of the dining room, she heard yelling and witnessed (R18) reaching behind her towards (R10) who was pushing her wheelchair. V4 stated she witnessed (R10) pulling (R18)'s hair. V4 stated she was able to reach the two residents, separate them and she reported the incident to the nurse. The facility policy, Abuse Prevention and Reporting, dated (revised) 3/2026 directs staff that the facility affirms the right of our residents to be free from abuse. This same policy also documents that abuse is the willful infliction of physical harm, pain or mental anguish.

Based on observation, interview and record review the facility failed to implement new interventions after falls and failed to complete a thorough post fall assessment for three of three residents (R2, R4 and R5.) reviewed for falls in a sample of 15. Findings include: 1. R2's medical record documents that R2 was admitted on [DATE] with diagnosis to include but not limited to unspecified dementia, moderate without behavioral disturbance, cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's documentation Un-witnessed fall dated 8/13/25 filled out by V2 (Director of Nursing) documents resident self-transferred from toilet resulting fall. Resident lying on left side of shower room floor. R2's documentation Un-witnessed fall dated 8/13/25 filled out by V2 (DON) documents under Mental status that resident was disoriented, but wnl (within normal limits) for this resident, oriented to person and oriented to situation were marked. The areas of resident did call for help, resident was able to call for help and call light was within reach were not marked.R2's documentation ~Un-witnessed fall dated 8/13/25 filled out by V2 (DON) has a documentation area marked Predisposing Physiological Factors that had Weakness/Fainted, Forgets to use call light and fragile skin marked. The same area had resident was standing, resident was lying, resident was sitting areas available and none were marked. R2's Unwitnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation area also had antihistamine use as an area available and it was not marked. R2's Physician Order Sheet dated August 2025 documents R2 receives Hydroxyzine (antihistamine) 10 mg (milligrams) every 8 hours as needed. The facility could not provide Medication Administration Record for August to include any use of this antihistamine for review. R2's Unwitnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had Anti-hypertensive use as an area available and it was not marked. R2's Physician Order Sheet dated August 2025 documents that R2 receives Metoprolol (anti-hypertensive) Tartrate 50 mg twice daily.R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had an Anti-depressant use are available to be marked. R2's Physician Order Sheet dated August 2025 documents R2 receives Sertraline (anti-depressant) 25 mg daily. Throughout the survey R2 was wearing glasses and did not answer questions appropriately. R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had areas for impaired vision, wears glasses, was wearing glasses. None of these areas were marked. R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) Predisposing Physiological Factors documentation had an area for restorative programs that was not marked. R2's current Care plan dated 3/24/25 documents R2 is on a restorative ambulation program, restorative dressing and grooming program dated 7/20/25, and Restorative AROM (Active Range of Motion) program dated 7/20/25.R2's Un-witnessed fall dated 8/13/25 filled out by V2 (DON) had Predisposing Situation Factors as listed Increased agitation, other, recent room change, side rails up, using cane, using wheeled walker, none, change in sleep patterns, recently sleeping less than usual, combative, restless, wandering, recent LOA (leave of absence ) with family, other recent fall, padded rails, Geri sleeves, other (describe), large groups, reaching, restrained, staff approach, using walker, wanderer, resistive to care, recent over sleeping, agitated at the time of fall, hallucinations at time of fall, sundowns, recent blood draw, combative with care and previous skin tears or bruises. None of these areas were marked. R2's Nurse's Notes dated 8/14/25 at 4:00 PM document that the IDT (Interdisciplinary Team) met to discuss R2's fall and the new intervention to implement was Anticipate resident's toileting needs. Offer assistance to toilet before and after each meal. R2's current care plan implemented 08/01/2025 and last updated 8/14/25 documents R2 is at risk for falls related to confusion, gait/balance problems, self-ambulating to restroom, fracture of right hip and acute pain right hip. Interventions for R2's fall risk document anticipate and meet the resident's needs dated 8/1/25 and anticipate and offer assistance with needs with toileting throughout the night. On 9/5/25 at 12:45 PM V6 (Care Plan Coordinator) confirmed R2 already had an intervention in place on her fall plan to anticipate her needs and to anticipate her toileting needs. V6 stated, That isn't very different. 2. R4's Medical Record documents that she was admitted on [DATE] with diagnosis to include but not limited to unspecified dementia, anxiety and fracture in thoracic spine. R4's Un-witnessed fall dated 6/14/25 filled out by V18 (LPN) documents on 6/14/25 at 5:00 AM R4 was found on the floor at the foot of opposite bed. R4's Un-witnessed fall dated 6/14/25 filled out by V18 has a Mental Status section had area marked that documented disoriented, but wnl (within normal limits) for this resident. The Mental Status section also had sections for resident was able to call for help, resident did call for help and call light was within reach that were not marked.R4's Un-witnessed fall dated 6/14/25 filled out by V18 had Predisposing Physiological Factors that only had wears glasses marked. The form did not have Osteoporosis marked. R4's Physician Order Sheet dated June 2025 documents a diagnosis of age related osteoporosis. The form did not have Discomfort/Pain marked. R4's Physician Order Sheet dated June 2025 documents Gabapentin 1000 mg (milligrams) twice daily (an anticonvulsant medication used to treat seizures and nerve pain) for spinal stenosis and Hydrocodone-Acetaminophen (narcotic) 5-325 mg every 4 hours as needed for pain. The form did not have Anti-hypertensive use marked. R4's Physician Order Sheet for June 2025 documents Metoprolol Tartrate (Anti-hypertensive) 25 mg twice daily for hypertension.R4's Un-witnessed fall dated 6/14/25 filled out by V18 had Predisposing Situation Factors listed as active exit seeker, ambulating with assist, behavior symptoms, during transfer, increased agitation, other, admitted within last 72 hours, ambulating without assist, dislikes roommate, improper footwear, large groups and reaching. None of these areas were marked. R4's Un-witnessed all dated 6/14/25 filled out by V18 had Predisposing Situations Factors listed as recent room changes, side rails up, using cane, using wheeled walker, none, change in sleep patterns, recently sleeping less than usual, combative, restless, wandering, recent LOA (leave of absence) with family, other recent fall, padded rails, geri sleeves, other (describe), restrained, staff approach, using walker, wanderer, resistive to care, recent over sleeping, agitated at the time of the fall, hallucinations at the time of the fall, sundown, recent IV use, recent blood draw, long fingernails, combative with care and previous skin tears or bruises. None of the predisposing situations factors were assessed/marked. R4's current Care Plan initiated 8/7/25 last updated on 8/11/25 documents, Floor bed (42 inch) with floor mats of equal height obtained. Ensure bed in lowest position to floor and bed mat at bedside while in bed to establish a larger safe space for resident while in bed. On 8/3/25 at 10:30 AM V6 stated that the bed listed on the care plan is a floor bed that sits directly on the floor. V6 confirmed that R4 had a regular bed with a floor mat that was slid underneath the bed. The resident was not in the bed during the observation. V6 stated, I don't know why that isn't a floor bed in her room. R4's Nurse's Notes dated 6/17/25 at 10:24 AM document that the IDT (Interdisciplinary Team) determined the root cause of R4's fall on 6/14/25 was that R4 attempted to self-transfer with no assistance. The new intervention to be put in place was to encourage resident to participate in activities when restless. R4's current Care Plan initiated 8/7/25 last updated 8/11/25 documents that R4 is at risk for falls related to impaired gait and stability, unaware of safety needs, poor judgement, daily use of pain and psychotropic medications and attempts to self-transfer from bed. R4's intervention dated 8/7/25 documents, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. On 8/3/25 at 10:30 AM V6 (Care Plan Coordinator) stated, encouraging people who fall to do activities is pretty standard, they need to build up strength and they are less likely to try to self-transfer if they are out amongst a group of people. V6 stated she didn't know where the intervention of encouraging R4 to participate in activities came from, a fall or a high risk for falling. 3. R5's Medical Record documents that she was admitted on [DATE] with diagnosis to include but not limited to Alzheimer's Disease, abnormalities of gait and mobility and osteoporosis. R5's Un-witnessed fall dated 5/16/25 filled out by V18 (LPN) documents that R5 was found on the floor sitting on her bottom next to her bed. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had an area labeled mental status that oriented to person was marked. The areas available for resident did call for help, resident was able to call for help, and call light was within reach were not assessed/marked. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had a section Predisposing Environmental Factors with the following areas listed ; clutter, fall alarm, noise, other (describe), poor lighting, uneven floor, none, bedspread or blanket, cords, resident to resident contact, crowding, furniture, other, pets, rugs/carpeting, wet floor, slick floor, clothing or shoes, other personal items, and there was already a safety intervention in place. None of these areas were assessed/marked.R5's Un-witnessed fall dated 5/16/25 filled out by V18 had a section Predisposing physiological factors with the following areas listed: confused, drowsy, gait imbalance, impaired memory, new/signs of infection, recent change in cognition, recent illness, current UTI (Urinary Tract Infection), functional loss, hypotensive, incontinent, other, recent change in medications/new medications and sedated. None of these area were assessed/marked. R5's Un-witnessed fall dated 5/16/25 filled out by V18 (RN) had a section Predisposing Physiological Factors with Forgets to use call light marked. Restorative Programs was not marked. R4's current care plan dated 1/31/25 documents that R4 is on a restorative dressing/grooming program and also a restorative walking program. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had a section Predisposing Situation Factors with areas listed as: active exit seeker, ambulating with assist, behavior symptoms, during transfer, increased agitation, admitted within last 72 hours, ambulating without assist, dislike roommate, improper footwear and large groups. No areas were assessed/marked. R5's Un-witnessed fall dated 5/16/25 filled out by V18 had Predisposing Situation Factors with areas listed as: other, recent room change, side rails up, using cane, using wheeled walker, none, change in sleep patterns, recently sleeping less than usual, combative, restless, wandering, recent LOA (Leave of absence) with family, other recent fall, padded rails, geri sleeves, other (describe) reaching, restrained, staff approach, using walker, wanderer, resistive to care, recent over sleeping, agitated at time of fall, hallucination at time of fall, sundown, recent IV use, recent blood draw, long fingernails, combative with care, previous skin tears or bruises. None of these areas were assessed/marked. On 9/5/25 at 9:30 AM V2 (Director of Nursing) stated, All of these blank areas area addressed with a different assessment (72 hour monitoring). V2 was unable to provide a 72 hour monitoring form or any assessment that documented the predisposing physiological and environmental factors for R2, R4 or R5 throughout the survey. The Facility's Fall Prevention Program policy dated 5/2022 documents the purpose of the policy is to assure the safety of all residents in the facility, when possible. the program will include measure 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. Quality Assurance Program will monitor the program to assure ongoing effectiveness. The fall Prevention Program includes the following components: methods to identify risk factors, methods to identify residents at risk immediate change in interventions that were successful documentation requirements Care plan incorporates identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures.The Facility's Fall Prevention Program documents a fall risk assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. A fall risk assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident.

Based on interview and record review the facility failed obtain physician ordered weekly weights for one resident of three residents (R1) reviewed for weights in a sample of 15. Findings Include:The facility's Significant Weight Gain or Loss Policy dated 02/2025 documents, All residents will be weighed monthly unless physician order indicates differently.R1's physician's orders, dated 9/5/25, document weekly weights were ordered to begin for R1 on 6/23/25. R1 also has orders to receive the following medications for the diagnosis of congestive heart failure: Torsemide 20mg (milligrams) by mouth daily, Diltiazem 300mg by mouth daily, Metoprolol Succinate ER 50mg by mouth daily, and Aldactone 12.5mg by mouth.On 9/3/25 at 11:17 AM, R1 stated she has not been getting weighed because the machine used to weigh her has been broken.R1's Weight and Vitals Summary dated 9/3/25 documents from 6/23/25 to 8/17/25 weights were only obtained on the following dates: 6/23/25 (419.8 pounds), 7/1/25 (416 pounds), and 7/7/25 (415 pounds).On 9/3/25 at 9:38 AM, V1 (Administrator) verified the facility has three mechanical lifts, and the mechanical lift with the scale attached has not been functioning since 7/10/25.On 9/3/25 at 11:15 AM, V2 (Director of Nursing) confirmed R1 had not been weighed from 7/8/25 through 9/3/25.

Based on observation, interview, and record review the facility failed to maintain resident rooms in a clean and safe manner for four residents (R6, R8, R12, and R13) of four reviewed for safe, clean and homelike environment in a sample of 15.Findings Include:Facility's Maintenance Director Job Description dated 3/2024 documents: The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner.On 9/3/25 at 1:30 PM V1 stated he is unable to locate a policy for cleaning the air conditioner units in resident rooms.On 9/3/25 at 9:35 AM The AC (Air Conditioner) units in R6 and R13's room is located in the wall under the window. There are foam tubes around AC unit with a quarter sized hole where daylight can be seen. The vent slats of AC unit have multiple pinpoint black spots on them. V3 (Maintenance Director) stated probably mildew. Units are cleaned two times per season to prevent mildew build up, but he is unsure if there is a policy. On 9/3/25 at 10:21AM R6 and R13's AC unit has multiple black pinpoint spots on vent slats.

Based on interview and record review, the facility failed to prevent staff to resident verbal abuse for two of three residents (R2 and R3) reviewed for abuse in a sample of three. Findings include:The facility's 24-hour Abuse Investigation Report, dated 7/16/25, documents V1, Administrator, was informed V4 (Certified Nursing Assistant), alleged cussing and yelling at a resident (R3) during care. V4 was suspended immediately pending investigation.V10's, Certified Nursing Assistant, signed statement, dated 7/17/25, documents R3 put on her call light. V4 said, Why did you have me pull you the F K up in the bed? This form also documents V4 is rough towards residents.On 8/19/25 at 3:00pm, V10, Certified Nursing Assistant, stated V4 answered R3's call light and wanted to be pulled up. V10 stated he heard V4 say Why the F k do you want me to pull you up, when all you do is slide right back down? V4 stated he used several other curse words while he was in the room. V10 stated he told the nurse right away. On 8/19/25 at 12:30pm, V1, Administrator verified he did not consider V4 cussing at R3 verbal abuse. V1 also stated the second allegation was not founded because V4 quit before the investigation could be completed. V1 stated corporate makes the final decisions concerning the allegations of abuse. V11's Certified Nursing Assistant, signed statement dated 7/17/25, documents V4 can be kind of rude to residents and use curse words and yell at them.R2's statement, undated, documents the CNA said, I need to get up. I told him I did not want to get up. It seemed to make him mad. He pushed down on my hands and said we got to go, hurry up.On 8/18/25 at 10:00am, R2 stated V4, Certified Nursing Assistant, was attempting to get her out of bed one morning. R2 stated she did not want to get up, so she told him no. R2 stated V4 came in and held her arms down to make her get dressed. R2 stated she continued to refuse. R2 verified V4 was rough while attempting to get her dressed. R2 stated she told the next shift what happened.On 8/19/25 at 11:00am, V4 stated he was suspended twice for allegations of abuse. V4 stated the first time was because of an allegation of him cussing at a resident. V4 stated instead of a three-day suspension, it was nine days, because he had to retake the abuse, customer service training. V4 stated the second time was because of being rough with a resident. V4 stated he stayed over to help the day shift and was told everyone had to get up for breakfast. V4 stated R2 kept refusing, so then he began to persuade her to get up. V4 stated he was just tired of all the allegations and quit.The facility's Final Abuse Investigation, dated 7/30/25, documents R2 stated, The tall male CNA, (V4) with tattoos, was rough with her while trying to get her out of bed for the day. R2 stated, I kept telling him I don't want to get out of bed, and it seemed to make him mad. This form documents V4 was suspended immediately pending an investigation, but V4 voluntarily terminated his position effective 7/26/25.The facility's Abuse Prevention and Reporting policy, revised 9/2024, documents the facility 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. This form documents verbal abuse may be considered to be a type of 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.

Based on interview and record review the facility failed to ensure a resident's haircut was done safely for 1 of 5 residents (R1) reviewed for safety in the sample of 5. The findings include: On 7/8/25 at 9:17 AM, R1 was seated in a wheelchair in his room. R1 had a full beard and partially bald head. R1 stated he received a hair and beard cut a couple of weeks ago and was all cut up during the process. R1 said a female staff member (name unknown) wheeled him into the beauty shop and just started in on me with hair clippers. R1 said the staff member took the guard piece off the clippers during the process and cut him under his chin. R1 said he hollered and yelled quit!. R1 said the staff member 'kept right on with what she was doing', and he felt like she didn't care. R1 said she moved to the back of his head with the clippers, and it was hurting him there too. On 7/8/25 at 9:39 AM, V1 (Administrator) stated R1 was given a haircut a few weeks ago by a CNA. V1 said when the facility beautician was out on medical leave, the aides cut R1's hair and beard. V1 said V9 (CNA) took it upon herself to wheel R1 into the beauty shop and use electric clippers to trim his beard and hair. V1 said V9 is not a trained beautician, and she should not have been giving haircuts to any resident. V1 said as far as he knew, none of the CNAs are licensed beauticians. On 7/8/25 at 10:09 AM, V10 (R1's daughter) stated R1 was complaining to her about a haircut he had received from a staff member (V9). V10 said the facility knows she does not want V9 caring for R1. V10 said she feels like V9 rushes R1 during cares and does not like him. V10 said R1 is very sensitive to who can cut his hair. V10 said several other aides told her R1 was cut up during the haircut by V9. V10 said only beauticians are allowed to cut his hair, but it was so bad this time another aide (V4) had to go back over it and fix it. V10 said she is okay with the aides cutting R1's hair if it is not V9. On 7/8/25 at 10:50 AM, V4 (CNA) stated she heard R1 yelling stop it from the beauty shop a few weeks ago. V4 said she did not go and see what was happening but could tell that R1 was upset and agitated. V4 said she spoke with R1 about 30 minutes later and was told V9 just cut his hair and beard. V4 said it was horrible and uneven. R1 had a large red area on the back of his neck that looked like razor rash. The skin was all red and patchy behind his ear and under his neck. R1 had razor nicks under his neck. V4 said the family has allowed her to cut R1's hair in the past so she did her best to recut his hair that same day. On 7/8/25 at 10:24 AM, V3 (CNA) said V9 was accused of cutting R1 during a haircut and 'yes that is exactly what happened'. V3 said she spoke with R1 the day after it happened, and R1 was grumpy. V3 stated R1 was asked what happened and R1 replied, She cut my g*# d*#m hair! R1 said (V9) just started in ripping off my skin. I was yelling for her to stop but she kept right on going. V3 said she took R1 down to the administration office and showed V1 his neck and head. V3 said R1 had red lines under his beard and his skin was cut behind his ear. R1 said the marks were from the clipper V9 used on him. V3 said the family only wants someone to cut R1's hair that is capable. V3 said the family does allow V4 to cut him because she knows what she is doing. On 7/8/25 at 11:16 AM, V5 (CNA) said she saw R1 the day V9 cut his hair. R1's neck was nicked up and he had a red rash going up the back of his neck, into his hair line. V5 said she asked what happened and R1 said V9 took the guard off the hair clippers and that is when he got cut. On 7/8/25 at 11:40 AM, V6 (CNA) said she was walking past the beauty shop and saw V9 giving R1 a hair and beard cut. V6 said everything looked normal at that time. V6 said she saw R1 later in the same day and he was in a down mood. R1 told her V9 cut him during the haircut. V6 said she saw a rash behind his ears and a razor nick on his neck. On 7/8/25 at 1:26 PM, V9 (CNA) stated she was talking with R1 after lunch a few weeks ago and something came up about his hair. V9 said R1 was fine if I cut it for him. V9 wheeled R1 into the beauty shop and got a set of clippers out. V9 said she asked R1 what size blade he wanted (R1 is cognitively impaired) and R1 asked for a big one. V9 said R1 picked the cover he wanted as well. V9 said she cut his beard and hair. V9 said she saw a rash on the back of his head after his hair had been cut off, so she left that area alone. V9 said she did not notice the rash until after she cut his hair. V9 said she did nick R1's neck while cutting under there and he said ouch. V9 denied R1 ever yelling out to stop. R1's face sheet printed on 7/8/25 showed diagnoses including but not limited to cerebral infarction, vascular dementia, aphasia (difficulty speaking), and cognitive communication deficit. R1's facility assessment dated [DATE] showed moderate cognitive impairment. The facility was unable to prove any policy related to hair or beard cuts provided to residents. The facility did provide a staff in-service sign in sheet dated 7/1/25 related to: No one is allowed to provide a resident with a haircut. Only licensed barber or hairstylists are allowed to do this. The facility's Resident Rights policy states under the safety section: Your rights to safety .Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Based on observation, interview and record review, the facility failed to ensure prepared refrigerated foods were labeled and dated with an expiration date, opened foods were stored in covered containers to prevent contamination, the kitchen floor/dry storage room floor were kept clean and free of debris, and kitchen surfaces were kept free from dust and debris. These failures have the potential to affect all 49 residents in the facility. Findings include: The facility's Food and Supplies: Storage Policy, dated 1/2024, documents, Policy: Food and supply storage areas shall be maintained in a clean, safe and sanitary manner. Procedures: 1. Food services will maintain clean food storage areas. 4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. 6. All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product. The facility's Dry Storage Policy, dated 3/2025, documents, Dry storage areas will be kept neat, orderly, and in a condition which protects foods in a safe and sanitary manner. Procedure: 6. Floors will be swept daily and mopped at least weekly. The facility's Kitchen Sanitation Manual Policy, dated 9/2023, documents, Policy: The kitchen will be maintained in a clean and sanitary condition. The state and/or federal food code will be maintained on file within the food service department and will be the basis of all sanitation and food safety practices. 13. Sanitation is the entire departments responsibility. The facility's Cleaning and Sanitizing in Place Policy, undated, documents, Fixed equipment, utensils, and equipment too large to be cleaned in sink compartments will be washed manually or cleaned with a pressure spray method, rinsed, and then sanitized by spraying or swabbing with chemical sanitizer. Procedure: 1. Food service workers who use the equipment will be responsible for washing, rinsing, and preparation, food service areas, storage areas, and dish room. On 3/23/25 at 9:24 AM the kitchen was entered and toured with V6/Cook. In the walk in cooler there was a clear three liter container of green beans with a lid , pre made ham salad (according to V6) in a large metal container with a lid 1/2 full , two large cake pans of fruit crisp uncovered, a large metal pan 1/2 full of cooked cabbage with a lid, peeled potatoes in a square metal pan with a lid and a large metal pan 1/2 full of green gelatin with a lid. None of these items were labeled with an expiration date. V6 verified none of the prepared refrigerated items had a label with an expiration date and should have. V6 also verified the pans of fruit crisp were uncovered and anything prepared and stored in the refrigerator should be covered. In the dry storage room, the floor was covered in dirt and debris along with six cigarette butts scattered in the middle of the dry storage room floor. V6 verified the floors were covered with dirt and debris and cigarette butts were lying on the floor. V6 stated, I don't know why the floor is dirty like this, it should have been swept and mopped yesterday. The cigarette butts must be from a chair we take in and out from smoking. I didn't even notice them on the floor. The kitchen floor was observed to have dirt, debris, old food, and crumbs underneath the preparation tables. The four-burner stove had thick grease splatter built up on the stove and the inside of the left oven beneath the stove had black thick crusted matter built up inside of the stove. A shelf located above the kitchen stove was covered in dust and debris. The shelf underneath the steam table located in the kitchen had built up dust and debris where the pans were being stored. V6 verified the kitchen stove, the oven, the floors underneath the preparation table, the shelf above the stove, and the shelf underneath the steam table all needed cleaned. The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 3/23/25 and signed by V1 (Administrator), documents 49 residents currently reside within the facility.

Based on interview and record review, the facility failed to offer Covid-19 vaccinations and vaccination education to all employees. This failure has the potential to affect all 49 residents residing in the facility. Findings include: The facility's Interim Covid-19 Vaccination Guidelines - Residents and Employees policy, dated 10/2024, documents, To minimize the risk of residents acquiring, transmitting, or experiencing complications from Covid-19. The facility maintains documentation related to staff Covid-19 vaccination that includes at minimum the following: That staff were provided education regarding the benefits and potential risks associated with Covid-19 vaccine; Staff were offered the Covid-19 vaccine or information on obtaining the Covid-19 vaccine. On 3/26/25 at 10:40 AM V13 (Licensed Practical Nurse/ Infection Control Preventionist) stated she doesn't have documentation to show Covid-19 vaccinations are offered to all employees or to show they are given education related to the Covid-19 vaccination. V13 stated, Staff are told to go to the local pharmacy to get the Covid-19 vaccination if they want it. If we have extra Covid-19 vaccine after giving to the residents, we will offer those to staff but otherwise staff are not offered the Covid-19 vaccination in the facility. We don't ensure that staff get the Covid-19 vaccine offered here, they are expected to pay for it at the pharmacy if they choose to get it. The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 3/23/25 and signed by V1 (Administrator), documents 49 residents currently reside within the facility.

Based on interview and record review, the facility failed to provide eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 49 residents residing in the facility. Findings include: The facility's Facility Assessment Tool, dated 7/1/2024, documents the facility will provide a Registered Nurse (RN) as required with CMS (Centers for Medicare and Medicaid Services) minimum staffing requirements (eight consecutive hours per day). The facility's nursing staff schedule for March 2025, documents on 3/23/25 the facility did not have eight hours of an RN staffed in the facility. The facility's daily staff posting documents on 3/23/25, the facility was staffed with Licensed Practical Nurses (LPN) and documents no Registered Nurses provided resident care throughout 24 hours. On 3/25/25 at 1:45 PM, V1 (Administrator) confirmed the daily staff postings provided for March 2025 are accurate. On 3/26/25 at 11:16 AM, V13 (LPN/ Infection Control Preventionist) confirmed that she has been doing some nursing assistant schedules and Director of Nursing duties for an interim time period. V13 confirmed the facility did not have RN coverage on Sunday, 3/23/25. V13 stated, If the daily staff sheet documents no RN was working, that is accurate. We have been short an RN every other weekend on several occasions. The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 3/23/25 and signed by V1 (Administrator), documents 49 residents currently reside within the facility.

Based on interview and record review, the facility failed to provide supervision to a resident identified as an elopement risk, who had been exhibiting an increase in verbalizations of exit seeking behavior. On the morning of 05/18/24, R1 removed his (elopement alert bracelet) and exited the facility unnoticed. R1 was later found propelling his wheelchair approaching a road containing a high volume of traffic. R1 was one of three residents reviewed for wandering/elopement in the sample of three. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 07/10/2024, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their In-service training and Quality Assessment oversight. Findings include: The facility's 'Code Pink- Missing Resident/Elopement' policy (revised 04/2023) documents, The facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of admission. Elopement is the ability of a cognitively impaired resident who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. This same policy documents, Risk Reductions Measures: Interventions that may be used for residents identified as high risk for elopement include: Frequent monitoring of the resident's whereabouts to assure he or she remains in the facility; room placement close to common areas such as the nurse's station and away from exits; promoting activities that are in full view of staff members; Alternative activities to maintain the interest level of the wanderer; Implementation of wander bracelet or other electronic alert systems, transfer to a more suitable or more secured unit/facility, if needed. This policy also documents, Verification of control systems: If an electronic surveillance system is in place, door alarms are tested weekly for proper functioning and the testing is documented; Door alarm codes are changed routinely; Resident electronic monitoring sensors are checked every shift for placement and daily for proper functioning and documented in the Resident Record, Treatment Administration Record, Medication Administration Record, or a specifically designed log. R1's Medical Record documents R1 was admitted to the facility on [DATE] with the following diagnoses: Urinary Tract Infection, Major Depressive Disorder, Vascular Dementia, and Delusional Disorder. R1's Elopement Risk Assessment (dated 05/13/24) documents a score of 8, indicating R1 is, at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. R1's Elopement Risk/Wanderer care plan (dated 05/13/24) documents R1 is at risk for elopement and documents the following interventions: 1:1 monitoring. IDT (interdisciplinary team) to discuss and re-evaluate; Assess for fall risk; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; Identify pattern of wandering- Is wandering purposeful? Does it indicate the need for more exercise? Intervene as appropriate; Provide 1:1 supervision with staff; Provide structured activities- toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. R1's Physician Order (dated 05/21/24) documents the following order: Ensure (elopement alert bracelet) is attached to right ankle every shift and night shift to test function. R1's Treatment Administration Record (dated May 2024) documents R1's elopement alert bracelet was not checked on the day shift of 05/18/24 and was last checked at some point during night shift on 05/17/24. R1's Progress Note (dated 05/13/24) documents: (R1) was assessed for elopement/unauthorized leave. The resident does not have a history of wandering/elopement and does not verbalize a strong desire to leave. The resident has a diagnosis of dementia and/or severe mental illness. Resident has reported or documented episodes of elopement and/or attempts to elope. The resident's representative (i.e., Health Care Power of Attorney, close family member, guardian) has requested that the resident be monitored on the Elopement Protocol. Behavioral Observations include: Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan. Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. Has the physical ability to leave the building. Becomes agitated, confused and/or disoriented or displays consistently poor judgement (would not be able to safely care for him/herself outside of the facility). Resident is at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated. On 07/03/24 at 10:30 AM, V11 (Social Service Director) stated R1's cognition would fluctuate from day to day, He could always answer the questions from the BIMS (brief interview for mental status) assessment correctly and would score 15 (indicating cognitively intact), but there were several instances when he could not recall a conversation I had with him the previous day. I had multiple conversations with him about why he had a court-appointed guardian. He would then ask me the same thing the following day and could not recall the same conversation we'd had about it from the day before. R1's Progress Note (dated 05/18/24), written by V1 (Administrator), documents, Resident (R1) noted to have exited facility, no alarm sounded. Staff approached resident and attempted to redirect back to the facility; these attempts were unsuccessful. 911 called and (R1) resisted and was aggressive towards emergency personnel before being sent to (local hospital) for evaluation. No injury noted. Guardian and physician notified. On 07/02/24 at 01:35 PM, V3 (Certified Nursing Assistant) stated the following regarding R1's 05/18/24 elopement, I know it was on a weekend sometime in May. I was told he made it a couple of blocks. He was close to Route 24, which is a pretty busy road. He would say that he was going to leave daily. I heard he cut his (elopement alert bracelet) off and then left. I don't think the alarm sounded since he wasn't wearing his (elopement alert bracelet). He was pretty well in his right mind most of the time. The code to exit the building used to be posted next to the keypad in the breezeway near the front door, so he probably just entered the code to get out. I know they had to change codes to some of the other doors because he knew the code to unlock and open them. When (R1) got out of the building, he was in his wheelchair, and I believe someone in a car spotted him and notified the facility. I believe (V4, Certified Nursing Assistant) and (V5, Registered Nurse) left the building to find him. On 07/02/24 at 02:00 PM, V6 (Certified Nursing Assistant) stated, (R1) got out of the building on 05/18/24. He kept saying to that he was going to leave. I know he told (V7, Certified Nursing Assistant) that he was leaving on that same morning before he eloped. From what I have been told, (R1) got out alone and nearly made it to Route 24, and that is a very busy road. I am not sure how he was found. On 07/02/24 at 02:10 PM, V4 (Certified Nursing Assistant) stated she was working on 05/18/24 when R1 eloped from the facility. V4 stated, We were getting ready to serve breakfast, and I got a message from (V8, Certified Nursing Assistant) on our work communication messaging app. The message said, '(V5, Registered Nurse) and I (V8) are on (Route) 24 with (R1).' I tried calling (V5 and V8) and got no answer from either one of them. A few minutes later, I told the other staff in the building I was going to go find them. I got in my van and headed toward (Route) 24. I didn't see them, so I sent a text to (V8) for their location, and she responded that they were up by (Route) 24 on the side road towards (nearby town). When I found them, (R1) was very agitated, and shortly after I got there, the police showed up followed by an ambulance. V4 then stated, (R1) must have gotten out the front door. He was in his wheelchair and made it down to the corner, turned left and headed toward Route 24. I believe some lady driving saw him and notified the facility. On 07/02/24 at 02:30 PM, V8 (Certified Nursing Assistant) stated she was one of two staff members that were first to locate R1 on 05/18/24 after he had eloped from the facility. V8 stated, It was about 08:00 AM and we were serving breakfast. I was up front in the lobby. (R1) likes to sit up front near the entrance to the building in the living room. I was talking to (V5, Registered Nurse), and a lady came in the front door. She told us she was driving and saw a man in a wheelchair on the road. She said that she had stopped to check on the man and he told her he was going home, so she decided to drive here and come inside to alert someone. (V5) and I got in her car and found (R1) propelling his wheelchair a couple blocks away. He had almost made it up to Route 24. He was actually very close, and that road is very busy with traffic. He was in his wheelchair, and he was very agitated because we had found him. We called (V1, Administrator) and (V2, Director of Nursing), and they talked to (R1) and basically explained his options. He remained agitated, so (V5) called 911. Two police officers showed up and then an ambulance. (R1) was sent to the emergency room and they (medics) had to sedate him to get him into the ambulance. (R1) somehow got his (Elopement alert bracelet) off. I heard he cut it off, and then he entered the code to exit the building since it used to be posted on the wall next to the keypad by the front door. It has since been changed. (R1) is alert enough to know how to enter the code to unlock the door. At some point, I had messaged (V4, Certified Nursing Assistant) to let her know where (V5) and I were because we had been out of the building for at least 30 minutes, and I knew people were going to start wondering where (V5) and I were at. (V4) came to where we were in the road in her van, and we loaded (R1's) wheelchair in her van when (R1) was taken to the hospital. V8 stated she was never asked to give a witness statement about the incident, No one ever talked to me about it, and I thought that was a little weird. On 07/03/24 at 09:35 AM, V5 (Registered Nurse/Former Manager on Duty) stated she is one of the staff members that responded after R1 eloped from the facility on 05/18/24. V5 stated, I remember I was on the phone with a resident's family member about lab results. A lady from the community came in the building and told (V8, Certified Nursing Assistant) that there was a man in a wheelchair going down the road. (V8) and I got in my car and located (R1). He was agitated that we had found him, and he was dead set that he was going home. I called (V1, Administrator) and (V2, Director of Nursing). Both tried talking to (R1) and he still refused to return, so 911 was called. The police arrived and then the medics. (R1) was combative with them and had to be sedated before they transported him to the hospital. While we were standing in the road, I noticed he did not have his (elopement alert bracelet) on his wheelchair. I asked him where it was, and he would not tell me. When he returned from the hospital a couple days later, he told me he had found a pair of scissors in the receptionist's desk drawer, cut the bracelet off, and threw it in a drawer with the scissors. I went and checked the drawers in the front living room, and there sat a pair of scissors and a cut (elopement alert) bracelet. (R1) had made it very close to Route 24. If that lady wouldn't have come when she did, it could have turned really ugly. I believe (R1) would have attempted to cross that road, and it's a road that is very, very busy with traffic. V5 stated she was never asked to give a witness statement or provide any details of the incident after it had occurred. V5 stated R1 was alert and oriented most of the time, but did exhibit some confusion about going home, He did not understand why he had a court-appointed guardian, and this had been explained to him often. At times, (R1) would get into a state of mind where he was not making safe, rational decisions. Before he got out of the building, he kept talking about leaving. He knew the code to exit the dining room door that led to the courtyard, and since he was not allowed outside by himself after the incident, the code to exit the dining room door was changed. The code to the front door used to be posted right next to the keypad where you enter the code to unlock it. I am sure this is how (R1) got out, the code was posted so all he had to do was type it in on the keypad. That code had to be changed after all of this occurred. On 07/03/24 at 10:55 AM, V7 (Certified Nursing Assistant) stated she was working on 05/18/24 when R1 eloped. V7 stated, I talked to him early that morning when he was in his room. I asked him how he was doing, and he said 'OK.' He told me not to worry about his stuff because it's all packed up, and I saw that all of his personal items were packed in a black garbage bag. He then told me that he was going to leave that day. He said, 'right after breakfast I'm going to head out those doors.' I told (V12, local agency Licensed Practical Nurse), who was working in the East Hall that day. I never saw (V12) go and start checking on (R1) frequently after I had reported all of this to her. She really didn't do anything after I told her. On 07/03/24 at 03:00 PM, V12 (local agency Licensed Practical Nurse) stated she recalls the day when R1 eloped from the facility, I had never worked with that resident (R1) before. I was told he had been saying he was going to leave and go home. One of the CNAs (V7) told me that he told her he was leaving after breakfast and that he had all of his bags packed in a garbage bag. I saw him when he was heading to the dining room. I went ahead and gave him his medications, and that was the last time that I saw him. The manager on duty (V5, Registered Nurse) was aware of what he was saying and told me she had spoken with (R1), so I continued on with my medication pass. V12 stated, I haven't worked at that facility much, but I do remember the code to unlock the door is posted right by the keypad in the entryway. On 07/03/24 at 08:15 AM, V1 (Administrator) confirmed R1 eloped from the facility on 05/18/24 and stated, It happened on the weekend. The alarm didn't give warning and (R1) went through the door. I believe he was about half a block away. When staff found him, he was very noncompliant and wasn't rationalizing with anyone. 911 was called and (R1) was sent to the hospital for a psychiatric evaluation. He was placed on 1:1 supervision when he returned to the facility. I believe someone from the community alerted staff in the building that a man was propelling his wheelchair down the road. V1 stated an incident investigation was not completed after R1's elopement, and therefore, he cannot provide an investigation for review. On 07/03/24 at 12:55 PM, V2 (Director of Nursing) stated that R1 eloped on a day during the weekend, and she was not at the facility when it occurred. V2 stated, I got a call from (V5, Registered Nurse) and she told me that she was outside of the building with (R1). I could hear (R1) in the background saying he wanted to go home. He lived in (nearby town), which is at least a 30-minute drive from the facility. I asked him to return to the facility with (V5) and told him that if he was not willing to return, EMS (emergency medical services) would be contacted to handle the situation. 911 was then called and R1 was taken to the hospital. I did find out later that he told (V5) that he cut his (elopement alert bracelet). V2 stated there was no type of investigation completed on R1's 05/18/24 elopement incident because, he wasn't harmed from what I understand from the regulations. V2 stated, (R1) has some periods of confusion. He couldn't understand why he couldn't just leave the building and wheel himself back to his hometown. There were multiple conversations that had to be repeated because he couldn't recall the same conversation that occurred the day before. He lacked safety awareness. On 07/08/24 at 08:50 AM, V2 (Director of Nursing) stated an intervention should have been implemented on 05/18/24 when R1 was making statements of leaving the building. V2 stated, If he had his bags packs and he was verbalizing a plan, I would expect staff to put him on 1:1 supervision. On 07/08/24 at 09:00 AM, V5 (Registered Nurse/Former Manager on Duty) stated, I was the Manager on Duty when (R1) eloped. I remember seeing (R1) in the dining room. I believe one of the CNAs (V7) reported to the nurse (V12) who then came to speak with me. I do recall speaking with (V12) about (R1). He was out in a common area, so he was never put on 1:1 supervision. The Immediate Jeopardy was identified on 07/09/24 at 10:20 AM to have begun on 05/18/24 when R1 verbalized he was going to leave the facility and no additional supervision was provided. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 07/09/24 at 10:28 AM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 07/10/24, V1 (Administrator) and V2 (Director of Nursing) were interviewed and spoke in detail about the facility's abatement plan. On 07/10/24, R1's most current medical record was reviewed and documents the following was completed upon R1's return from (local hospital) on 05/21/24: R1 was assessed by nursing and no pain or skin issues were identified; R1 was reassessed for risk of elopement and community survival skills; R1 was placed on 1:1 supervision that later decreased to 15 minute checks which was documented on 24 Hour/15 Minute Monitoring logs. This documentation was reviewed weekly by V2 (Director on Nursing) until R1 was discharged from the facility. On 07/03/21, V1 (Administrator) stated that an individual from maintenance came to the facility on [DATE] to check the door alarm's functional status and the front door alarm code was changed at that time. V1 stated that the keypad code posting was taken down and would no longer be posted in the front breezeway near the keypad that unlocks the front door. V1 then provided copies of forms titled 'Daily Maintenance Tasks' (dated 05/13/24 - 07/07/24), which indicate that maintenance staff have checked the functionality of the exit door and elopement alert bracelet alarm system daily during this time frame. On 07/10/24, V1 provided documentation indicating that V11 (Social Service Director) reviewed all facility resident's most current Elopement Risk Assessments for accuracy, and on 07/09/24, V11 completed a new Elopement Risk Assessment on every resident in the facility. V1 also stated that all residents will be evaluated for elopement risk at admission, readmission, quarterly, annually, with a significant change, and incidentally if risk behaviors are identified. V1 stated V11 is responsible for conducting these assessments, and a six-week audit is being conducted by V1. V1 provided copies of the Weekly Audit forms (dated 05/24/23 - 07/05/23) that have been completed. On 07/10/23, V1 provided copies of Elopement Drill/Post-Elopement Checklist logs that were completed on 05/18/24 and 07/03/24. On 07/10/23 at 10:00 AM, V1 stated that nursing staff check residents with elopement alert bracelets each shift to ensure the bracelet is in place. V1 stated elopement alert bracelets are also checked for functionality daily by nursing and maintenance, and facility staff as well as agency staff have binders to access at the nurse's station. On 07/10/24 at 12:40 PM, a binder labeled Agency Staff Orientation was accessible at the nurse's station and contained the facility's Elopement Device policy (dated 09/2019), and Code Pink-Missing Resident/Elopement policy (dated 04/2023). At this same time, a binder labeled, Exit Seeking Residents, contained an Exit Seeking Profile, A current Face Sheet, and a large color photograph of all residents who have been identified as elopement risks. R2 and R3's medical records were reviewed and indicate staff have been checking their elopement alert bracelets for placement and functionality as indicated. On 07/10/23, V1 provided copies of Attendance Sign-In Sheets for the following in-services: Elopement Policy & Procedure, Identifying Risks of Elopement, Wandering/Exit Seeking Behavior, and When to Provide/Implement Increased Supervision (Initiated on 05/18/24); Elopement and (Elopement Alert Bracelets), (initiated on 05/18/24); 1:1 Supervision (specific to nursing staff who provide 1:1 supervision, initiated on 05/24/24); Supervision of Elopement Risk Residents Outdoors (initiated on 06/06/24). These forms contained facility staff member's signatures confirming attendance, and these forms also document 30 staff members were called on 07/09/24 and given the in-service per telephone conversation. On 07/10/24, the following staff members were interviewed and indicated receiving the above noted in-servicing in May 2024: V15 (Licensed Practical Nurse); V18 (Registered Nurse); and V3, V21, and V24 (Certified Nursing Assistants). On 07/10/24 at 10:50 AM, V16 (Certified Nursing Assistant) stated he was called by someone at the facility on 07/09/24 and was given in-servicing and education over the phone at that time. On 07/10/24 at 10:52 AM, V17 (Activity Aide) stated she received instructional training, I was told (R1) was placed on 1:1 supervision, so I know he had a sitter. I only work twice a week, so I did not attend any education in-services back in May when (R1) left the building. On 07/10/24 at 11:15 AM, V19 (Receptionist/Hairdresser) stated, I am going to be honest with you. I just received training about elopement this morning (07/10/24). My phone was not available last night, but I did see that someone tried to call me. I knew that (R1) left the building and I knew the door code had been changed. This morning is the first time that I have received education from anyone about the incident. The elopement policy and protocol, who to contact, how to handle a situation with someone trying to leave the building, the chain of command to report to, and resident behaviors were the topics discussed with me this morning. On 07/10/24 at 11:35 AM, V20 (Housekeeping) stated he just received training regarding elopement on 07/09/24, They called me yesterday and told me everything over the phone and then someone talked to me when I arrived at work this morning. On 07/10/24 at 12:05 PM, V22 (Dietary Cook) stated she was called yesterday and given training pertaining to elopement and supervision over the phone. On 07/10/24 at 01:35 PM, V23 (Certified Nursing Assistant) stated she knew about the elopement that occurred on 05/18/24 and was aware R1 was on 1:1 supervision for a period of time after he eloped from the building. When asked if she had received education after R1's elopement V23 stated, I was called yesterday (07/09/24) and given education over the phone. That is the first time I have received education about the elopement. On 07/10/24, V1 provided a copy of the facility's Quality Assurance form titled 'Ad Hoc Quality Assurance (Plan of Correction)' which was completed on 05/21/24 regarding the facility's elopement policy and procedure, and indicated responses for each of the following questions: The problem?, How the problem is to be corrected and when will it be corrected?; and What is going to happen to ensure the problem will not happen again? How will this be monitored, by whom and how often? V1 then stated the facility's next Quality Assurance Meeting is scheduled for 07/25/24, and elopement/supervision will be discussed at this meeting and will continue to be reviewed during the next four quarterly meetings.

Based on observation, interview and record review, the facility failed to prevent three incidents of abuse, and failed to ensure residents felt safe in their home for five (R1-R4 and R6) of five residents reviewed for abuse in a sample of six. These failures resulted in R3 sustaining a skin tear from an incident involving R1; and R3, R4 and R6 verbalizing psychosocial feelings including intimidation and fear of R1. Findings include: Facility Resident Rights for People in Long-Term Care Facilities, revised 3/2017, documents You have the right to safety and good care where your facility must provide services to keep your physical and mental health, and sense of satisfaction. You must not be abused by anyone. Facility Abuse and Neglect policy, revised 3/15/18, documents All residents have the right to be free from verbal, sexual, physical, and mental abuse. Abuse is the willful infliction of injury, intimidation, or punishment with physical harm, pain, or mental anguish. R1's incident report dated 2/22/23 at 11:50am was reported to state agency and documents the following: Incident where (R1) hit (R6) in the dining room. Neither resident able to give further details. Both R1 and R6 not cognitively intact. R1's incident report dated 3/5/23 at 9:10am was reported to state agency and documents the following: (R1) and (R2) were standing in a room with arms around their upper body/head area and both residents came into contact with one another using their other arms. R1 and R2 not cognitively intact. R1's incident report dated 3/17/23 at 7:05am was reported to state agency and documents the following: (R1) and (R3) were in the dining room where (R1) was shaking (R3's) walker and making contact with (R3's) arm causing a skin tear. R1 not cognitively intact. R1's care plan with a start date of 7/25/22 documents R1 has the Potential to demonstrate physical behaviors related to poor impulse control. R1's medical record documents R1 was admitted on [DATE] and is not cognitively intact. R1's nurses notes document several incidents. On 2/8/23 R1 hit staff. On 2/22/23 there were two incidents documented where R1 hit a resident (R6) and the second incident was where R1 had aggression towards a CNA. Increased agitation and assaulted his nurse (V13) where R1 was sent to the emergency room for a psych evaluation. On 3/5/23 R1 had physical contact with another resident (R2) where they had arms wrapped around one another with closed fists making contact. On 3/8/23 R1 was physically aggressive to CNAs with contact; and on 3/17/23 R1 had physical contact with another resident (R3) where R1 was hitting R3 and R3 got a skin tear. On 3/28/23 R1 was unable to be interviewed due to aphasic (unable to speak) due to a stroke. On 3/28/23 at 3:12pm, R1 was sitting by the nurses desk on a chair and grabbing at staff as they walked by. R1 got up from the chair when he saw staff gathered around the nurses desk. R1 walked up to a female CNA and was in her personal space (very close to her face and facing her). The female CNA backed up and walked away. A male CNA was able to redirect R1. On 3/28/23 R2 was confused and unable to answer questions regarding the incident dated 3/5/23. R2's medical record documents he is not cognitively intact. On 3/28/23 at 10:30am, R3 was alert and oriented and stated, He (R1) does stuff all the time, it doesn't matter where I am I feel like he finds me. I try to stay out of his sight. I told (V1/Administrator) that I am going to call the police if he hits me again. I don't make any advances towards him at all. This has been going on for about five to six months where he goes after people or me. They walk with me to the dining room so I don't fall. Staff sometimes sits with (R1) but not all the time. I watch out for him because I know he will find me if I am alone so staff doesn't let me walk alone. I don't need help walking but I know he will come after me if I am alone. I don't need this at my age. R3's medical record documents R3 is cognitively intact. On 3/28/23 at 10:50am, R4 was alert and oriented. R4 stated, (R1) has been harassing us (R3 and R4) for the past six to eight months and (V1/Administrator) is aware of it. He will clench his fists and make faces and flip us off. He tried to trip me in the hallway. If he sees someone (staff) with me he is not as bad but if I am alone, he is agitated and angry. He can't speak, all he does it stare, and the help has tried to keep us apart. We used to eat in the same dining room but we eat in separate dining rooms. He has shoved his walker at us, sometimes he uses his walker and sometimes he doesn't when walking. I am going to take a garbage can and hit him with it if he comes after me. I pay my rent so I shouldn't have to put up with this. R4's medical record documents R4 is cognitively intact. On 3/28/23 at 3:20pm, R6 was alert and oriented and stated, I stay away from (R1). I don't like to be around him. He stares at people and then wants to fight them. It makes me feel afraid so I just avoid him, he can be scary. On 3/28/23 at 12pm, V6 CNA stated, I was working on 3/17/23 when (R1) hit (R3). I wasn't there to witness the incident but I heard about it. Sometimes (R1) can be aggressive and does flip people off. (R1) sits in the hallway and uses his walker to walk and then sits his walker down by the person as a form of aggression. On 3/28/23 at 12:15pm V4 CNA stated, I was working on 3/5/23 and 3/17/23. On 3/5/23 (R1) and (R2) were hitting one another and in headlocks with each other. It did not happen in their room and it happened right after breakfast. I told (R1) to stop hitting (R2) and he stopped. I found out about it happening because I answered the call light that was on. On 3/28/23 at 1:30pm V5 CNA stated, I was working on 3/17/23 when (R1) and (R3) had an incident but I did not see it happen. (R1) stares people down as a start to his aggression. (R1) stares (R3) down. (R3) looks around the corner watching for someone and it appears he may be fearful. When I push (R6) in to the dining room she says, Oh good, (R1) isn't in here. On 3/28/23 at 3:35pm V14 Environmental Services stated, I was working on 3/17/23 when (R1) was shaking (R3's) walker. (R1) was reaching towards (R3) and (R1) took a swing towards (R3). (R1) hit (R3) three to four times on his arm. I removed/separated them and put myself in between (R1) and (R3). (R1) was trying to reach over me and punch (R3). I got (R1) to walk away but he continued to make faces towards (R3). This was during set up for breakfast time, breakfast gets served at 7:30am. On 3/28/23 at 3:34pm, R1 Administrator stated, I have a couple reportables on (R1) to the state agency where he was in altercations with residents. On 3/29/23 at 2:45pm, V13 LPN/Licensed Practical Nurse was reached by telephone and stated, On 2/22/23 (R1) went after a CNA three times where I intervened. When I intervened (R1) punched me. The CNA went down the hallway and (R1) ran after the female CNA but he fell when he was running. I went and assessed (R1) and sent him into the hospital to be evaluated and get a psychological evaluation for his behaviors. He (R1) has behaviors daily to where they are gestures or physical.

Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse for one resident (R1) of three residents reviewed for abuse in the sample of three. This failure resulted in R1 being sexually abused on 5/16/21 by V3 (Certified Nursing Assistant). This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 5/21/21, the facility remains out of compliance at Severity Level 2 while the facility continues employee education and training on abuse specifically related to the following: The need to report suspicious activity to the Abuse Coordinator (V1); the need to report instances of potential sexual abuse and that all residents have the right to be free from sexual abuse; and the definition of sexual abuse. The facility also continues to review the Resident Care Policy and Procedure regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media with all staff members. Findings include: The facility's Abuse Prohibition policy, revised 3/15/18, states, 1. All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. 2. All residents have their right to personal privacy of not only their own physical body; but also of their personal space, including personal care, and living accommodations. Definitions: 14. Sexual Abuse is non-consensual sexual contact of any type which includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual coercion shall include any intentional or knowingly touching or fondling a non-consenting resident's sex organs, anus, or breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused. Sexual assault means sexual penetration. R1's Quarterly Minimum Data Set (MDS) dated [DATE], documents R1 to be cognitively intact without any memory impairments. On 5/25/21 at 10:38 A.M., R1 stated, In the morning of Sunday, 5/16/21, I was in the bathroom, when (V3/Certified Nursing Assistant) came in and asked me if I had any lotion. I said I might have some in the top drawer of my dresser. (V3) went out and came back and walked back into the bathroom, closed the door and applied lotion directly on my penis. (V3) started rubbing me (on my penis). I looked down and noticed his mouth on me (R1's penis). (V3) was really working on it. I didn't say anything because it felt so good, but I knew it wasn't right. R1 verified it was just V3 and R1 in the bathroom. R1 stated, (V3) then asked me if I'd like to go back to bed and I said I would. Before that, (V3) helped get me dressed in the bathroom. (V3) put a blue (incontinence brief) on me. (V3) also put blue jeans and a T-shirt on me. We walked from the bathroom to the bed, (V3) then pulled the covers back and let me lay down. (V3) pulled my jeans down to here (pointing to the middle of R1's thigh), (V3) opened my diaper and then (V3) started working on me. (V3) was rubbing my penis with (V3's) hand, (V3) was standing on the floor on the left side of my bed. (V3) was using (V3's) mouth and hand on my penis, but mostly the mouth. I ejaculated into his mouth. R1 denied that V3 said anything after the incident. R1 stated V3 helped R1 get dressed and that R1 stayed in the bed afterwards. R1 stated R2 (R1's roommate) was in the room during the incident but denied that R2 was able to see or hear anything. R1 denied asking for V3 to perform any sexual acts on R1. R1 stated, (V3) just walked into the bathroom and started touching me, I have never seen (V3) before this day. R1 described V3 as a tall, slender, black male with facial hair. R1 also stated, (V3) was wearing dark scrubs and a pair of gray tennis shoes with a woven pattern to it and a pink check mark on the sides. R1 stated V3 had a days worth of (facial hair) growth on the side of (V3's) face. He was otherwise very clean cut. On 5/25/21 at 10:33 A.M. R2 (R1's roommate) verified last Sunday, May 16 in the morning, V3 (Certified Nursing Assistant) was with R1 near R1's bed with the curtain pulled. On 5/25/21 at 12:18 P.M., V8 (Registered Nurse) verified that on 5/16/21, V8 was passing morning medications in R1's hallway. V8 verified seeing V3 (CNA) enter R1's room on 5/16/21 around 8:00 A.M. On 5/25/21 at 1:00 P.M., V11 (CNA) stated, (On 5/16/21), I had a split room assignment with (V3). (V3) had (R2) and I had (R1). I went to (R1's) room to get him dressed for the day and (V3) was already in there with (R1). The door was open but the curtain was pulled. I didn't see anything, but (V3) had said from the other side of the curtain, that (R2) didn't want to get up, so (V3) was helping (R1) instead. At the time I didn't think anything of it, but this happened in the morning the same day and around the same time (R1) said the incident occurred. On 5/25/21 at 11:40 A.M., V7 (CNA) stated, I was working on 5/17/21. I was getting (R1) ready in the morning and (R1) said (R1) had something to tell me, but (R1) wasn't sure if (R1) should tell me or not. I assured (R1) it was ok to tell me anything and then (R1) proceeded to tell me how yesterday morning (5/16/21), (V3) asked (R1) for lotion and put it on (R1's) private area and used his mouth on him. (R1) said he did not stop (V3) but (R1) did not know why (V3) was doing this to (R1). V7 also stated that R1 described the alleged perpetrator as a tall black man wearing gray shoes with a pink logo on the side. V7 stated that V7 immediately notified V1 (Administrator) about the allegation. On 5/25/21 at 9:33 A.M., V1 stated, On 5/17/21, V7 and V13 (CNA) made V2 (Director of Nursing) and myself aware of (R1's) allegations. We went and spoke with (R1) right away. (R1) stated (R1) was on the toilet when a black, male CNA came into (R1's) bathroom, asked for lotion, and started touching (R1's) penis with (V3's) hand. (R1) really liked how it felt, so (R1) did not stop (V3). (R1) stated (V3) assisted (R1) to the bed and continued to use (V3's) hands and mouth on (R1's) penis. V1 stated R1 is a fully cognitive young man. V1 stated R1 identified V3 as the CNA who inappropriately touched R1. On 5/27/21 at 12:38 P.M., V14 (R1's Friend) stated, Last Sunday (5/16/21), me and my dog picked (R1) up and went up to (local park and lake). (R1) said to me, 'I gotta (have to) tell you something.' I could tell (R1) was disturbed. (R1) told me that a male 'nurse' said he wanted lotion and then started rubbing (R1's) privates. (R1) also told me (V3) put his mouth on (R1's) genitals. (R1) was bothered by it and (R1) wanted to make sure it didn't happen to anyone else in the facility. (R1) told me (V1) was aware of the incident the next day (5/17/21). (R1) told me (R1) was very embarrassed by (the incident) and wanted to make sure (R1's) family did not know about it. The facility's Final Report to the local State agency, dated 5/22/21, states, Conclusion: As a result of the investigation the following conclusion was formed. On 5/17, (R1) reported to CNAs (V13 and V7) that a tall black male CNA had entered (R1's) room during the morning of Sunday, 5/16/21. (R1) stated that he was in the bathroom around 9:00 A.M. when this male CNA entered and asked (R1) where he kept his lotion. This male CNA then began to touch (R1's) genitals with the lotion and his hand. (R1) stated he did not think much of it until he looked down and noticed that this male CNAs mouth was around (R1's) penis while (R1) was on the toilet. (R1) stated that he chose not to stop this male CNA because he liked the way it felt. (R1) stated that this male CNA helped him transfer to his bed where they consensually continued. (R1) stated that this male CNA was wearing gray (brand) shoes with a pinkish/red logo on them. The police were then notified, and (R1) was offered to go to the hospital, to which he declined. (R1) stated that roommate (R2) was present in the room during this encounter. From the investigation, it was learned that there were two tall black male CNAs working around this 9:00 A.M. time. Both CNAs were interviewed by the police and (V1) and both denied the allegation. (V1) confirmed during an in-person interview that (V3) was wearing gray tennis shoes with a red logo on them. In both a phone interview and a police interview, (V3) confirmed that (V3) had helped (R1) from the restroom to his bed around 9:00 A.M. on 5/16/21 but denied the allegation. (R2) did confirm that there was a male CNA in his room around 9:00 A.M. that helped his roommate. (V3) is not allowed in the facility and (V3's) agency was updated with the above investigation. Phone calls were made to V3 (Certified Nursing Assistant/CNA) with messages left. No returned calls received. The Immediate Jeopardy was identified on 6/8/21 at 8:30 AM. The Immediate Jeopardy began on 5/16/21 when the facility failed to prevent V3 from sexually abusing R1. V1/Administrator was notified of the Immediate Jeopardy on 6/8/21 at 12:26 P.M. The surveyor confirmed through interview and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. (V3) has not entered the facility since the revelation of this incident and is not allowed to enter the facility at any point in the future. (V3's staffing agency) was notified of the (5/16/21) allegation and informed that this CNA (V3) is not allowed to enter the (skilled nursing facility). This was completed by (V1) through phone communication with V3's (staffing agency) on 5/17/21 at the onset of the investigation. 2. During the initial investigation (on 5/17/21), V1 (Administrator) interviewed all residents who were expected to have been cared for by V3 with no negative outcomes. These interviews were completed by (V1) on 5/21/21. 3. The facility will request background check information by all contracted staff members before they enter the facility to begin working. Ensured completion will be overseen by V1 and will take place immediately. V1, or his designee will monitor for compliance. The Interdisciplinary Team was educated on this plan and will assist with the monitoring for compliance in coordination with V1.

Based on observation, interview, and record review the facility failed to ensure that nursing call lights were answered in a timely manner for one of 12 residents (R15) reviewed for call lights in a sample of 14 and two residents on the supplemental sample (R20 and R21). This failure resulted in a normally continent resident being incontinent and verbalizing unnecessary embarrassment over incontinence. Findings include: Facility's "Call Light" policy documents, "1. Answer Call light promptly." On 2/19/15 at 11:15 A.M. E1 (Administrator) stated, "Prompt means as soon as they can." E1 also stated, "No one should turn a call light off if the resident's need has not been met." 1. R15's Brief Interview for Mental Status (BIMS), dated 12/18/14, notes R15 to be cognitively intact with no memory deficits. R15's Minimum Data Set (MDS), dated [DATE], notes R15 to be always continent of urine and bowel. On 2/17/15 at 2:30 P.M. R15 stated, "The call lights are not answered promptly here. The aides (Certified Nurses Aides/CNA) will take a while to answer the light, or they will cancel the light and then forget to come back to help me with going to the bathroom. One time I had to wait 55 minutes and I ended up having an accident in my pants, I even made a mess of my bowels. This was never an issue for me before. I always know when I need to go to the bathroom. I was upset and so embarrassed because of this episode. I will never forget that happening to me. I have to wait a long time a lot. I started asking them to leave my call light on until they actually take me to the bathroom because they will shut it off and then not come back." On 2/19/15 at 8:45 A.M., Z1 (R1's relative/POA) stated, (Z1) was on the phone with (R15) on January 27, 2015 when (R15) mentioned that (R15's) call light had been on for several minutes and no one had come to answer it yet. Z1 stated that after some time a staff member answered the light and R15 said R15 needed to go to the bathroom. The aide canceled the light and then did not return. Z1 instructed R15 to turn on the call light again. After several more minutes, a few other staff members came in to cancel the call light, but R15 was not toileted the entire 51 minutes of their phone conversation. Z1 stated, "(R15) told me (R15) ended up not being able to hold it and had an accident. (R15) was upset and very embarrassed. (R15) won't forget this and neither will I." On 2/19/15 at 12:15 P.M., E6 (Certified Nurses Aide/CNA) stated R15's call light was canceled before R15 was toileted. E6 also stated R15 "ended up being incontinent." E6 also stated R15 was not usually incontinent. On 2/19/15 at 10:18 A.M., in R15's bedroom, R15 stated, "I hit my light about ten minutes ago and still don't have help. I really need to go to the bathroom." At this time, R15's call light was not illuminated outside of R15's bedroom. R15 stated, "My call light isn't on because they came in, turned it off, and left. They have not come back yet to take me to the bathroom and I am scared I am going to have an accident." At 10:22 A.M., E7 (Certified Nurses Aide/CNA) finally entered R15's bedroom to assist R15 to the bathroom. The facility's log "Nurse Call Executive Information System: Detailed Patient Activity Report" documents R15's call light initially alarmed at 10:08 A.M. on 2/19/15. On 2/19/15 at 10:22 A.M. when E7 entered R15's room to toilet R15, E7 verified that E7 had canceled R15's call light at 10:10 A.M. and did not toilet R15 at that time. 2. On 2/19/15, at 9:12 A.M., R20 stated earlier this week R20 turned R20's call light on "to be changed" (was incontinent of urine). R20 stated a CNA answered R20's call light, told R20 "someone would be in", turned R20's call light off, and left the room. R20 stated R20 then waited at least an hour and no staff returned, so R20 turned R20's call light on again. R20 stated "I didn't like (waiting). It isn't good to sit in it (urine), I know that." 3. On 2/19/15, at 9:38 A.M., R21 stated R21 has had to wait up to a half an hour for R21's call light to be answered to use the restroom. R21 also stated "Once in awhile they (the staff) turn the call light off and say they'll be back with help, but they get busy or forget and don't come back."

Based on interview and record review the facility failed to separate and protect one resident from abuse (R21) in the supplemental sample. R21 was verbally and mentally abused during meals and when in room. The facility failed to separate R21 from the perpetrator (R16) for eight days during which time R21 and R16 shared the same room. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 2/15/13, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: The facesheet for R16 documents an admitted [DATE] and includes the following Diagnoses: [REDACTED]. MDS (Minimum Data Set) dated 11/15/12 for R16 documents a BIMS (Brief Interview for Mental Status) score of 10, indicating R16 was alert and oriented with periods of confusion. MDS dated [DATE] documents in section E0600 that R16 significantly disrupts care or the living environment. Nurse's Note dated 12/08/12 for R16 documents, "At 6:30 PM, I (E14/Certified Nursing Aide) went to put (R21) to bed. As I came into the room, (R16) complained that the room's lights were on. I turned off the lights by the sink and (R16)'s overhead light and told (R16) that the other light would be turned off when I put (R21) to bed. The curtain was drawn-it was not shining on his face. (R16) said it was fine, I adjusted his blankets and he thanked me. As I got (R21) ready for bed, washing him, (R21) made sounds he always does. (R16) began yelling, telling (R21) to shut up. He (R16) said (R21) was an animal, that he was not paying to live in a barn or a zoo. He (R16) said take that animal out of his room, get rid of him. He (R16) cussed repeatedly and was verbally and mentally abusive. (R21)'s reaction was immediate. (R21)'s face turned bright red and he yelled back at first. Then (R21)'s began to cry. His face was hot and red and tears were flowing. He began to moan like he was in pain and turned his face towards the wall. It was then (R16) said, 'What's that noise? A cow? Am I living in a damn barn?' I was washing (R21) as quickly as I could and told (R16) that he was being unkind, that this was (R21)'s room also. He (R16) yelled that it was his room first and that (R21) was a monster, an animal and that it was unfair that he had to share a room with someone like him making stupid noises. (R21) quieted down but continued to cry. I tried to quietly reassure (R21) that we care for him and that (R16)was simply being unkind, but it made little difference, I went and reported to (E16/Registered Nurse) our nurse and stated that it was unfair to (R21) to be trapped in there, unable to leave the room, while being verbally and mentally abused by (R16), unable to respond to (R16)'s comments. (E16/Registered Nurse) called E2/Director of Nursing and E1/Administrator immediately. I (E14/Certified Nursing Aid) continued getting people ready for bed and then (E16/Registered Nurse) told me (E1/Administrator) said we would have to move (R16) to another room. I was alarmed and I told (E16/Registered Nurse) this would make the situation worse, that (R16) would really go into a rage. Around 7:30 I (E14/Certified Nursing Assistant) I spoke with (E2/Director of Nursing) and she told me to document this with Nurse's Notes. I (E14/Certified Nursing Assistant) told her everything that had happened, stated that (R21) had not provoked (R16), and that (R16) was being verbally and mentally abusive. I (E14/Certified Nursing Assistant) said that the situation would only escalate if (R16) was forced out of his room and she told me to tell (E16/Registered Nurse) to not move anyone yet, that she would talk to (E1/Administrator). I (E16/Certified Nursing Assistant) let (E16/Registered Nurse) know that we were not to move anyone and that I headed to find television ear phones for (R21). I told her that this would not solve the problem, that (R16) was making complaint's about (R21)'s disabilities-unable to speak and only make sounds. (R16) also makes rude comments during meals about (R21)'s noises. I (E14/Certified Nursing Assistant) but we were unable to hook them to the television." Nurse's Note dated 12/08/12 for R16 documents, "CNA/Certified Nursing Assistant (E14) approached me (E16)and told me that (R21) was crying after being called a 'cow' and a 'monster' by his roommate (R16). (E14/CNA) had been doing (R21)'s HS (bedtime) cares when (R16) started making rude comments. (R16) complained of the lights being on and the noises his room mate makes. I (E16/Registered Nurse) went to check on both residents at this time. (R16) states to me that he can not get any rest because his room mate making noises. I (E16/Registered Nurse) check on (R21) and he is quiet in bed. His face is flushed and tear stains seen on his cheeks. I (E16/Registered Nurse) ask if he is OK, he makes no sound, does finally smile a little. I (E16/Registered Nurse) call (E1/Administrator) to ask if I may move (R21) due to (R16) being mean with comments as reported by CNA. She (E1/Administrator) tells me (R16) is the one who would have to move and go talk to him about it. She (E1/Administrator) said it could only be 'temporary'. E2/DON (Director of Nursing) calls for me. She (E2/DON) wants to know what E1/Administrator said, then she asks me what (R16) said and I told her I haven't been able to get back to him yet to see if he would move. E2/DON then asks to speak with E14/CNA. After that, (E14/CNA) told me not to do anything yet with the room change. She (E2/DON) is going to talk to (E1/Administrator). I go to (R16) and ask him if he would like to move to another room for the night. He (R16) becomes enraged, angry facial expressions-shakes his fist at me-yelling 'No, I am not moving! This is my room. I'm not leaving, move him. He is a b******. Leave me alone. (E2/DON) calls and asks for me and tells me to not only document all this to he but also in the resident charts and chart only the facts. I (E16/Registered Nurse) tell her what (R16) said about moving to another room. (E1/Administrator) calls and I tell her what (R16) said. She asks me if (R21) has the television on. I tell her yes, he likes it on. She (E1/Administrator) tells me to get (R21) some television headphones. I (E16/Registered Nurse) tell her that (R16) has not complained about the television but other stuff with (R21). (E1/Administrator) states, 'I am trying to come up with some solutions.' I (E16/Registered Nurse) ask what to do if I can not find head phones. She (E1/Administrator) said to borrow from someone. Tell her (E1/Administrator) I (E16/Registered Nurse) will call (E15/Maintenance Supervisor) if a problem, she (E1/Administrator) said not to. Ear phones have been found in maintenance room but unable to hook them up as a wire is missing. I (E16/Registered Nurse) call (E1/Administrator) to tell her. She (E1/Administrator) asks how they are doing and I tell her both are quiet. (R16) asleep (eyes shut) and (R21) is watching television and she (E1/Administrator) said okay." Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "If another resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from all other residents until further orders." On 2/19/13 at 8:05 AM, E14/CNA verified the incident on 12/8/12 when R16 was verbally and mentally abusing R2. E14/CNA stated that R16 said R21 sounded like a cow, that it sounded like a zoo in there and R21 didn't deserve to share a room with him. E14/CNA stated R21 turned his head away and started crying. E14/CNA felt R21 understood what was being said about him. On 2/19/13 at 8:35 AM, E16/Registered Nurse verified the incident on 12/8/12 when R16 was verbally and mentally abusing R21. E16/Registered Nurse verified that R21 was left in the same room as R21 even though there were rooms open. E16/Registered Nurse stated she was told by E1/Administrator those rooms had to be left open for admissions. The facility weekly census report documents that R16 and R21 remained room mates from 12/8/12 (date of the incident) until 12/16/12. Behavior Tracking Progress Notes dated 12/12/13 for R16 documents, "(R16) announced at the supper table that he has to put up with (R21) all night. (R16 and R21 were table mates.) That (R21) is noisy all night long. (R21) looked sad, so we quickly praised (R21) for being a fine fell ow that he is!" Behavior Tracking Progress Notes dated 12/13/13 for R16 documents, "(R16) yelling about us changing (R21) turning the light on." Behavior Tracking Progress Notes dated 12/17/13 (11-7 shift) for R16 documents, "Resident yelled at his room mate to shut up over there when room mate let out a sigh..." On 2/19/13 at 1:15 PM E1/Administrator verified that R16 was never supervised 1:1 or kept separate. On 2/19/13 at 1:15 PM E1/Administrator stated the reason R16 and R21 were not separated sooner is because R16 threw a fit and did not consider moving R21 from the room shared with R16. On 2/14/13 at 6:00 PM an Immediate Jeopardy was identified to have begun on 12/8/12 when R21 remained roommates with his perpetrator (R16). On 2/14/13 at 6:10 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. Initiated 2/14/2013, Completed 2/15/2013 The Administrator, Director of Nursing and all facility staff has received 1:1 directed inservicing regarding the (Corporate) policy on abuse and neglect. This inservicing was conducted by corporate staff. Points covered include: *Definition of Abuse *Definition of Neglect *Reporting responsibility *Reporting structure *Protection of the residents *Educated staff on facility policy/procedure on abuse/neglect investigations *To ensure compliance, the (Corporate) abuse policy will be discussed at each staff meeting as well as departmental meetings. In addition, (Corporate Staff) will conduct random audits of staff comprehension on weekly oversight visits. *Corporate staff will utilize the abuse investigation protocol to monitor overall compliance with facility abuse policy. *If a resident is the alleged perpetrator, actions will be taken immediately to evaluate both residents to determine the most suitable therapy and placement for both residents. *It is the (Corporate) philosophy that all residents requiring nursing home placement are inherently at risk to be abused... *A standardized assessment tool will be utilized to evaluate each resident for potential abuse. 2. Initiated 2/14/13, Completed 2/15/13 R16 was reassessed on 2/14/2013 by (Facility Staff) for any immediate risk to abuse others. Behavior tracking logs, Medication order changes and other clinical areas were reviewed. 3. Initiated 2/14/2013, Completed 2/15/2013 by MDS Coordinator Care plan for R16 was reviewed and revised with the following revisions: *Adapted dining room seating *Maintain R16 in a private room *Doorway motion alarm installed *All staff will be responsible for monitoring R16 on an hourly basis when mobile in wheelchair *Physician notified and evaluated *Systems approach through shift by shift behavior tracking for all residents with identified behaviors. *R16's behavior tracking have been reviewed by corporate staff. 4. Initiated 2/14/13, Completed 2/15/13 Initiated the following interventions to enhance safety of other residents: *R16 is in a room by himself *Motion alarm placed outside of R16's room *R16 will be monitored on an hourly basis *R16 will dine at a private table *R16 is observed during group activities *Discussion with R16's family regarding ongoing efforts for alternate placement Surveyor made random observations of R16 were made on 2/15/13 in group activities and in the dining area. On 2/15/13 R16's Physician verified medication changes. On 2/15/13 R16's care plan documented new interventions, medication changes and staff training and audit materials.

Noncompliance for this citation resulted in two deficient practices. A. Based on interview and record review the facility knowingly neglected to separate and protect one resident (R21) from verbal/mental abuse in the supplemental sample. The facility was aware that R21 was repeatedly verbally and mentally abused by R16 (R21's roommate) over an eight day time frame, and failed to separate the residents. B. Based on interview and record review, the facility failed to follow policy for procuring medications, resulting in the misappropriation of medication for one of 13 residents (R7) in the sample. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 2/15/13, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: A. The facesheet for R16 documents an admitted [DATE] and includes the following Diagnoses: [REDACTED]. MDS (Minimum Data Set) dated 11/15/12 for R16 documents a BIMS (Brief Interview for Mental Status) score of 10, indicating R16 was alert and oriented with periods of confusion. MDS dated [DATE] documents that R16 significantly disrupts care or the living environment. Nurse's Note dated 12/08/12 for R16 documents, "At 6:30 PM, I (E14/Certified Nursing Aide) went to put (R21) to bed. As I came into the room, (R16) complained that the room's lights were on. I turned off the lights by the sink and (R16)'s overhead light and told (R16) that the other light would be turned off when I put (R21) to bed. The curtain was drawn-it was not shining on his face. (R16) said it was fine, I adjusted his blankets and he thanked me. As I got (R21) ready for bed, washing him, (R21) made sounds he always does. (R16) began yelling, telling (R21) to shut up. He (R16) said (R21) was an animal, that he was not paying to live in a barn or a zoo. He (R16) said take that animal out of his room, get rid of him. He (R16) cussed repeatedly and was verbally and mentally abusive. (R21)'s reaction was immediate. (R21)'s face turned bright red and he yelled back at first. Then (R21)'s began to cry. His face was hot and red and tears were flowing. He began to moan like he was in pain and turned his face towards the wall. It was then (R16) said, 'What's that noise? A cow? Am I living in a damn barn?' I was washing (R21) as quickly as I could and told (R16) that he was being unkind, that this was (R21)'s room also. He (R16) yelled that it was his room first and that (R21) was a monster, an animal and that it was unfair that he had to share a room with someone like him making stupid noises. (R21) quieted down but continued to cry. I tried to quietly reassure (R21) that we care for him and that (R16)was simply being unkind, but it made little difference, I went and reported to (E16/Registered Nurse) our nurse and stated that it was unfair to (R21) to be trapped in there, unable to leave the room, while being verbally and mentally abused by (R16), unable to respond to (R16)'s comments. (E16/Registered Nurse) called E2/Director of Nursing and E1/Administrator immediately. I (E14/Certified Nursing Aid) continued getting people ready for bed and then (E16/Registered Nurse) told me (E1/Administrator) said we would have to move (R16) to another room. I was alarmed and I told (E16/Registered Nurse) this would make the situation worse, that (R16) would really go into a rage. Around 7:30 I (E14/Certified Nursing Assistant) I spoke with (E2/Director of Nursing) and she told me to document this with Nurse's Notes. I (E14/Certified Nursing Assistant) told her everything that had happened, stated that (R21) had not provoked (R16), and that (R16) was being verbally and mentally abusive. I (E14/Certified Nursing Assistant) said that the situation would only escalate if (R16) was forced out of his room and she told me to tell (E16/Registered Nurse) to not move anyone yet, that she would talk to (E1/Administrator)." Nurse's Note dated 12/08/12 for R16 documents, "CNA/Certified Nursing Assistant (E14) approached me (E16)and told me that (R21) was crying after being called a 'cow' and a 'monster' by his roommate (R16). (E14/CNA) had been doing (R21)'s HS (bedtime) cares when (R16) started making rude comments. (R16) complained of the lights being on and the noises his room mate makes. I (E16/Registered Nurse) went to check on both residents at this time. (R16) states to me that he can not get any rest because his room mate making noises. I (E16/Registered Nurse) check on (R21) and he is quiet in bed. His face is flushed and tear stains seen on his cheeks. I (E16/Registered Nurse) ask if he is OK, he makes no sound, does finally smile a little. I (E16/Registered Nurse) call (E1/Administrator) to ask if I may move (R21) due to (R16) being mean with comments as reported by CNA. She (E1/Administrator) tells me (R16) is the one who would have to move and go talk to him about it. She (E1/Administrator) said it could only be 'temporary'. E2/DON (Director of Nursing) calls for me. She (E2/DON) wants to know what E1/Administrator said, then she asks me what (R16) said and I told her I haven't been able to get back to him yet to see if he would move. E2/DON then asks to speak with E14/CNA. After that, (E14/CNA) told me not to do anything yet with the room change. She (E2/DON) is going to talk to (E1/Administrator). I go to (R16) and ask him if he would like to move to another room for the night. He (R16) becomes enraged, angry facial expressions-shakes his fist at me-yelling 'No, I am not moving! This is my room. I'm not leaving, move him. He is a b******. Leave me alone. (E2/DON) calls and asks for me and tells me to not only document all this to he but also in the resident charts and chart only the facts. I (E16/Registered Nurse) tell her what (R16) said about moving to another room." Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "If another resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from all other residents until further orders." On 2/19/13 at 8:05 AM, E14/CNA verified the incident on 12/8/12 when R16 was verbally and mentally abusing R2. E14/CNA stated that R16 said R21 sounded like a cow, that it sounded like a zoo in there and R21 didn't deserve to share a room with him. E14/CNA stated R21 turned his head away and started crying. E14/CNA felt R21 understood what was being said about him. On 2/19/13 at 8:35 AM, E16/Registered Nurse verified the incident on 12/8/12 when R16 was verbally and mentally abusing R21. E16/Registered Nurse verified that R21 was left in the same room as R21 even though there were rooms open. E16/Registered Nurse stated she was told those rooms had to be left open for admissions. The facility weekly census report documents that R16 and R21 remained room mates from 12/8/12 (date of the incident) until 12/16/12. Behavior Tracking Progress Notes dated 12/12/13 through 12/17/13for R16 documents, ongoing episode of verbal and mental abuse towards R21, with episode documented in the dining room and in the bedroom. On 2/14/13 at 1:45 PM, E1/Administrator could not explain the facility policy on abuse and neglect. On 2/14/13 at 1:45 PM, E2/DON could not remember how long R21 remained in the same room as R16 after the initial incident of abuse and could not explain why they were not separated immediately. On 2/19/13 at 1:15 PM E1/Administrator stated the reason R16 and R21 were not separated sooner is because R16 threw a fit and did not consider moving R21 from the room shared with R16. Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "A facility administrator, employee, or agent who becomes aware of alleged abuse or neglect of a resident shall also report the matter to the Department immediately." Abuse Investigation for incident involving verbal/mental abuse of R21 includes a fax confirmation sheet dated 12/11/12. The Occurrence Reporting to (State Agency) Form indicates the date of occurrence of the incident involving R21 was 12/8/12. On 2/14/13 at 6:00 PM an Immediate Jeopardy was identified to have begun on 12/8/12 when R21 remained roommates with his perpetrator (R16). On 2/14/13 at 6:10 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: Initiated 2/14/2013, Completed 2/15/2013 The Administrator, Director of Nursing and all facility staff has received 1:1 directed inservicing regarding the (Corporate) policy on abuse and neglect. This inservicing was conducted by corporate staff. Points covered include: *Definition of Abuse *Definition of Neglect *Reporting responsibility *Reporting structure *Protection of the residents *Educated staff on facility policy/procedure on abuse/neglect investigations *To ensure compliance, the (Corporate) abuse policy will be discussed at each staff meeting as well as departmental meetings. In addition, (Corporate Staff) will conduct random audits of staff comprehension on weekly oversight visits. *Corporate staff will utilize the abuse investigation protocol to monitor overall compliance with facility abuse policy. *If a resident is the alleged perpetrator, actions will be taken immediately to evaluate both residents to determine the most suitable therapy and placement for both residents. *It is the (Corporate) philosophy that all residents requiring nursing home placement are inherently at risk to be abused... *A standardized assessment tool will be utilized to evaluate each resident for potential abuse. Initiated 2/14/2013, Completed 2/15/2013 by MDS Coordinator Care plan for R16 was reviewed and revised with the following revisions: *Adapted dining room seating *Maintain R16 in a private room *Doorway motion alarm installed *All staff will be responsible for monitoring R16 on an hourly basis when mobile in wheelchair *Physician notified and evaluated *Systems approach through shift by shift behavior tracking for all residents with identified behaviors. *R16's behavior tracking have been reviewed by corporate staff Surveyor made random observations of R16 were made on 2/15/13 in group activities and in the dining area. On 2/15/13 R16's Physician verified medication changes. On 2/15/13 R16's care plan documented new interventions, medication changes and staff training and audit materials. B. physician's orders [REDACTED].o (orally) b.i.d. (twice daily) X 5 days." On 2-13-13 at 4:15 PM, E4/LPN (Licensed Practical Nurse) was passing medications to R14 and stated, "That ([MEDICATION NAME]) hasn't come from the pharmacy yet. It will be here at 6 PM and I will give it then." On 2-15-13 at 1:25 PM, E4/LPN stated that the [MEDICATION NAME] did not come with the regular pharmacy delivery on 2-13-13, so E4/LPN ordered the medication from a local pharmacy and gave it when it was delivered at approximately 8:30 PM. E4/LPN also stated that on 2-12-13, the day the medication order was written, E4 "borrowed" a dose of [MEDICATION NAME] from R7's supply and gave and gave it to R14. At that time E4 also stated, "I know we aren't supposed to do that." MAR (Medication Administration Record) for R14 documents that R14 received the [MEDICATION NAME] for the evening dose on 2-12-13 and morning dose for 2-13-13. E4/LPN stated that on 2-12-13, the day the medication order was written, E4 "borrowed" a dose of [MEDICATION NAME] from R7's supply and gave and gave it to R14. On 2-19-13 at 12:30 PM, E2/DON (Director of Nursing) stated that [MEDICATION NAME] is not available in the convenience box nor as a stock drug at the facility. E2/DON stated that E4/LPN had administered the [MEDICATION NAME] to R14 on 2-12-13 during the evening and that E4/LPN had "borrowed" the medication from a supply that had been dispensed by the pharmacy for R7. E2/DON also stated that the morning dose for 2-13-12 was administered to R14 by E5/LPN, who also "borrowed" the medication from R7's supply. Facility's "Medication Procurement" policy states, "All medications will be supplied by Green Tree Pharmacy...Medications that must be started prior to delivery from the pharmacy are supplied in the convenience box or emergency box...In an emergency situation, the facility may obtain medications from a designated back-up pharmacy." On 2-19-13 at 5:35 PM, E2/DON stated, "We are not supposed to do that. The nurses will be written up," in reference to the "borrowing" of medications from one resident's supply and administering them to another.

Based on interview and record review the facility failed to follow facility policy on abuse and neglect in five of five investigations reviewed for abuse. This failure resulted in the victim of verbal/mental abuse (R21) remaining roommates with the perpetrator (R16) for eight days, the administrator not being notified immediately of abuse allegations and a staff member accused of verbal abuse working with residents before the Abuse Investigation was concluded. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 2/15/13, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of staff training and corporate oversight. Findings include: 1. On 12/8/12 E14/CNA and E16/RN reported to E1/Administrator and E2/DON that R16 was verbally and mentally abusing R21. R21 remained roommates with R16 for eight additional days and was further subjected to mental and verbal abuse. Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "A facility administrator, employee, or agent who becomes aware of alleged abuse or neglect of a resident shall also report the matter to the Department immediately." Abuse Investigation for incident involving verbal/mental abuse of R21 includes a fax confirmation sheet dated 12/11/12. The Occurrence Reporting to (State Agency) Form indicates the date of occurrence of the incident involving R21 was 12/8/12. Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "When an allegation of suspected abuse is received that another resident of the long-term care facility is the perpetrator of the abuse, that resident's condition shall be immediately evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility." The facility weekly census report documents that R16 and R21 remained room mates from 12/8/12 (date of the incident) until 12/16/12, during which time documented episodes of verbal abuse of R21 were perpetrated by R16. On 2/19/13 at 1:15 PM E1/Administrator stated the reason R16 and R21 were not separated sooner is because R16 threw a fit and did not consider moving R21 from the perpetrator (R16). Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "If another resident is the suspected perpetrator of the abuse, then the suspected resident shall remain supervised 1:1 or kept On 2/19/13 at 1:15 PM E1/Administrator verified that R16 was never supervised 1:1 or kept separate. 2. Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, If the incident involves alleged abuse by an employee as the perpetrator of the abuse, then the Administrator shall immediately suspend the employee suspected to be involved in the alleged abuse without pay pending investigation of the incident." Occurrence Reporting to (State Agency) dated 3/8/12 documents, "Resident (R16) made an allegation staff member "hurt his arm." Occurrence Reporting to (State Agency) dated 3/8/12 documents, (Regarding abuse allegation on 3/8/12 involving R16) "Staff was suspended pending an investigation." On 2/14/13 at 1:45 PM, upon review of Abuse Investigation involving R16 on 3/8/12, E2/DON (Director of Nursing) could not identify the staff involved in the abuse investigation or verify that any staff were suspended. Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator." The same investigation contains no documentation indicating when E1/Administrator was notified. On 2/14/13 at 1:45 PM, E1/Administrator stated she was notified of allegation of abuse involving R16 when she came into work in the morning, but could not state what time she was notified. Facility policy titled "Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property and Injuries of Unknown Origin" documents, "The investigation shall include, if possible: Interviews with all involved parties and potential witnesses." Facility Daily Census dated 3/8/12 indicates R16 was roommates with R34. MDS (Minimum Data Set) dated 1/26/12 for R34 documents a BIMS (Brief Interview for Mental Status) score of 12, indicating R34 was able to be interviewed. Upon review of Abuse Investigation involving R16 on 3/8/12, there was no documentation indicating R34 was interviewed as a potential witness. On 2/14/13 at 1:45 PM, when E1/Administrator was asked why R34 was not interviewed, she stated "I didn't want to bother R34 with that." 3. Investigation for R24 dated 5/24/12 documents there was no documentation indicating when the Administrator was notified. Investigation for R24 dated 5/23/12 documents E2/DON (Director of Nursing) could not verify when the administrator was notified. Occurrence Reporting to (State Agency) dated 5/23/12 documents, "Resident (R24) made an allegation to a CNA, staff members were rude to her and hurt her arm when turning her in bed." Occurrence Reporting to (State Agency) dated 5/23/12 documents, (Regarding abuse allegation on 5/23/12 involving R24) "Staff was suspended pending an investigation." On 2/14/13 at 1:45 PM, upon review of Abuse Investigation involving R24 on 5/23/12, E2/DON (Director of Nursing) could not identify the staff involved in the abuse investigation or verify that any staff were suspended. 4. Facility Record of Complaint Form dated 11/4/12 documents, "(R22) complained of CNA (E18/CNA) being rough and not knowing what she was doing. States she just laughing. (R22) was very upset and does not want this CNA to care fore her." Investigation for R22 dated 11/4/12 documents evidence of a Record of Complaint Form and witness statements, but no evidence that the State Agency or the Administrator was notified. On 2/14/13 at 1:45 PM, E2/DON stated she did not identify this complaint as a potential abuse or neglect investigation. On 2/14/13 at 1:45 PM, E2/DON stated the State Agency was not notified and there was no documentation to confirm when the administrator was notified. 5. Investigation for E19/CNA and E20/CNA dated 11/8/12 documents no evidence that E18 notified the Administrator immediately of alleged verbal abuse. E18 made allegations of abuse when she was being terminated. Investigation for E20/CNA documents allegation of verbal abuse recorded on E18/CNA's Termination Summary. The Termination Summary is dated 11/8/12 at 9:30 AM. Employee Time Card Report documents E20 worked 11/8/12 from 3:43 AM to 1:07 PM and was not suspended. Witness Statement from E8/CNA involving the Abuse Investigation of E20 is dated 11/9/12. The Fax Confirmation to State Agency documenting the Final Report regarding allegations of verbal abuse by E20 is dated 11/9/12. On 2/14/13 at 6:00 PM an Immediate Jeopardy was identified to have begun on 3/8/12 when E1/Administrator failed to follow corporate policy regarding abuse investigations. On 2/14/13 at 6:10 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. Initiated 2/14/2013, Completed 2/15/2013 All facility staff has received 1:1 directed inservicing regarding the (Corporate) policy on abuse and neglect. This inservicing was conducted by corporate staff. Points covered include: *Definition of Abuse *Definition of Neglect *Reporting responsibility *Reporting structure *Protection of the residents *Per facility policy, a thorough and extensive investigation will be completed for each allegation brought forward. Per policy, any allegation of abuse by any staff member will be met with immediate removal from resident contact, and suspension from duty till the investigation is complete. Any allegation shall be reported to the state agency per policy/regulation. Any staff member found guilty of any form of abuse or neglect will be terminated, and a report filed with all appropriate agencies. *To ensure compliance, the (Corporate) abuse policy will be discussed at each staff meeting as well as departmental meetings. In addition, (Corporate Staff) will conduct random audits of staff comprehension on weekly oversight visits. *Corporate staff will utilize the abuse investigation protocol to monitor overall compliance with facility abuse policy. *If a resident is the alleged perpetrator, actions will be taken immediately to evaluate both residents to determine the most suitable therapy and placement for both residents. *It is the (Corporate) philosophy that all residents requiring nursing home placement are inherently at risk to be abused... *A standardized assessment tool will be utilized to evaluate each resident for potential abuse. 2. Initiated 2/14/13, Completed 2/15/13 R16 was reassessed on 2/14/2013 by (Facility Staff) for any immediate risk to abuse others. Behavior tracking logs, Medication order changes and other clinical areas were reviewed. 3. Initiated 2/14/2013, Completed 2/15/2013 On 2/14/13 the MDS coordinator reviewed R16's care plan for appropriateness of interventions related to behaviors. The following revisions to R16's care plan were made: *Adapted dining room seating *Maintain R16 in a private room *Doorway motion alarm installed *All staff will be responsible for monitoring R16 on an hourly basis when mobile in wheelchair *Physician notified and evaluated *Systems approach through shift by shift behavior tracking for all residents with identified behaviors. *R16's behavior tracking have been reviewed by corporate staff. 4. Initiated 2/14/13, Completed 2/15/13 Initiated the following interventions to enhance safety of other residents: *R16 is in a room by himself *Motion alarm placed outside of R16's room *R16 will be monitored on an hourly basis *R16 will dine at a private table *R16 is observed during group activities *Discussion with R16's family regarding ongoing efforts for alternate placement Surveyor made random observations of R16 were made on 2/15/13 in group activities and in the dining area. On 2/15/13 R16's Physician verified medication changes. On 2/15/13 R16's care plan documented new interventions, medication changes and staff training and audit materials.

Based on interview and record review, the facility failed to be effectively administered in order to attain or maintain the safety of each resident in an effort to maintain each resident's highest practicable physical, mental, and psychosocial well being. The facility was not administered in a way to protect residents from abuse and neglect, or in a way to develop a system process to identify facility issues and implement corrective action. These failures have the potential to affect all 49 residents in the facility. The facility failed to identify residents who were at risk for being abused and residents who were at risk for abusing others. The facility failed to verify the eligibility of all CNAs (Certified Nursing Assistants) prior to the first day of employment. The facility failed to immediately report allegations of abuse/neglect to both the administrator and the Illinois Department of Public Health. The facility failed to thoroughly investigate allegations of abuse and to completely document those investigations and their conclusions. The facility failed to protect residents while investigating allegations of both resident to resident and staff to resident abuse. The facility failed to prevent misappropriation of resident medications. The facility failed to have quarterly quality assessment and assurance committee meetings in order to identify and correct quality deficiencies. The facility failed to provide oversight and monitoring of staff performance related to infection control practices in the dietary department. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 because additional time is needed to monitor the efficacy of staff training and corporate oversight. Findings include: The CMS-672, Resident Census and Conditions of Residents, dated [DATE] and signed by E1/Administrator, notes the facility census to be 49 residents. 1. Facility Policy and Procedure Regarding Abuse, Neglect..," dated [DATE], states, in section 17, Screening, "Staffing levels will be determined by a review of resident need. A thorough analysis will encompass an in-depth assessment of the facility resident composition. Special attention will be given to identifying behavior that increases the resident's potential for abusing others, or self or being the victim of abuse. On [DATE] at 1:45 PM, E1/Administrator stated that no formal assessment of residents is routinely conducted to identify behaviors that put residents at risk for abusing others or being the victim of abuse. 2. Facility failed to check the status of two CNAs (Certified Nursing Assistant) for several months after their dates of hire, potentially exposing residents to staff who had a previous finding of abuse/neglect. Refer to F496. 3. In two of five abuse/neglect investigations, administration failed to immediately report the allegations to the state agency as required by facility policy. Refer to F226. 4. In four of five abuse/neglect investigations, staff failed to immediately report the allegations to the administrator as required by facility policy. The administrator failed to recognize those staff failures and take measures to correct them. Refer to F226. 5. In four of five abuse/neglect investigations, administration failed to protect the alleged victim of abuse while the investigation was ongoing. Refer to R226. 6. In one of five incidents, the administration failed to identify reported incident as potential abuse, therefore failing to investigate. In addition, in five of five facility investigations of allegations of abuse/neglect , the investigation was incomplete and lacked accurate documentation. Upon review of the investigation documentation, administration could not provide key elements, including dates, times, or the names of alleged perpetrators. In addition, administration could not provide the outcome of the investigation or any corrective measures taken. Refer to F226. 7. In two of five investigations, the administration failed to protect the resident victims from the potential from further abuse as follows: one resident who had been abused who was witnessed by staff to be verbally abused by roommate, was left with the roommate (perpetrator) for eight additional days; staff who had been accused of verbal abuse were not suspended pending investigation and were allowed to work an entire shift before it the allegation was determined to be unfounded. Refer to F226. 8. Two staff nurses (E4/LPN and E5/LPN) misappropriated a portion of the medication supply of one resident to use for another resident due to the failure of staff to obtain the medication by following the medication procurement policy and procedure. Both nurses, in addition to E2/ DON (Director of Nursing,) acknowledged knowing the policy and that it was inappropriate and against facility policy to do so. Refer to F425. 9. There was no Quality Assessment and Assurance Committee meeting held for more than one year. E1/Administrator was responsible for ensuring the meetings were held, but failed to do so when they could not be arranged with the schedule of the Medical Director. Refer to F520. 10. E17/Dietary Supervisor did not know the mechanism of action of the machine that was used for washing and sanitizing dishes. It was set up as a hot water sanitizer and regularly failed to achieve a high enough temperature to kill microorganisms, but E17 believed it was in chemical sanitizing mode and did not take action to correct the low temperatures until the failure was identified by survey staff. In addition, E17 was not aware that milk-based dietary supplements expired on ce they were thawed for 14 days, which was printed on the carton and failed to monitor that dietary staff was dating them once the were removed from the freezer. Refer to F371. On [DATE] at 6:00 PM an Immediate Jeopardy was identified to have begun on [DATE]. On [DATE] at 6:10 PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through interview and record review the facility took the following actions, which were initiated on [DATE] and completed on [DATE], to remove the Immediate Jeopardy: * The Administrator and Director of Nursing were inserviced by corporate staff regarding facility policies related to abuse, neglect and misappropriation of resident property. Information provided included the definitions of abuse and neglect, what the administrator's responsibilities are, what the reporting structure is, how the residents are to be protected while the investigations are ongoing, and how the investigation is to be conducted. * A plan was put in place for corporate supervision of the administrator until a corrective action plan is completed. Supervision will consist of review of all allegations received by the administrator as well as random, unannounced visits to the facility. * All allegations of abuse at the facility within the last year will be reviewed by three corporate nurses using a corporate investigation check list. * A corporate internal investigation will be conducted with disciplinary action occurring that is in proportion to the results of the investigation.