Every finding on record at Arlington Heights Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicate testing and effort, which include incorporating the recommendation from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for two (Residents #1 and #2) of three residents reviewed for PASRR assessments. The facility failed to submit a completed request for Nursing Facility Specialized Services (NFSS) in the LTC Online Portal within 20 business days of Resident #1 and #2's IDT meetings held on 04/22/26. This failure could place residents at risk of not receiving specialized services and equipment to help ensure their needs are met. Findings included: Review of Resident #1's Quarterly MDS Assessment, dated 06/10/26, reflected she was a [AGE] year-old female who had originally admitted to the facility on [DATE] and readmitted on [DATE]. Her BIMS score was a 10 which indicated she had mild cognitive impairment. Her active diagnoses included non-alzheimer's disease (cognitive disorders severe enough to interfere with daily life) and hemiplegia or hemiparesis (neurological conditions that affect motor function on one side of the body). Her MDS did not indicate her usage of a wheelchair. Review of Resident #1's undated care plan reflected the following: Focus: [Resident #1] has an ID Dx and is PASRR positive.Interventions: Specialized Services of HC, PT and OT will be provided per LA recommendations.Wheelchair to be replaced. Review of Resident #1's PASRR Evaluation, dated 03/27/23, reflected a positive PASRR status for Mental Illness, Intellectual Disability, and Developmental Disability. Review of Resident #1's HSP, dated 04/22/26, reflected the following: On 04/26/2023, [Resident #1's] PE recommended services included DME.Other resources and natural supports: Name of resource or natural support: DOR.Actions to be taken, such as referral and follow-up: HC will follow up with DOR on NFSS.NF Specialized Services to be Monitored by the SPT.Name of Service: CMWC.Outcome/Goal: Pending assessment. Observation and interview on 07/22/26 at 9:25 AM with Resident #1, she was in the hallway sitting in her wheelchair. Resident #1 refused to talk to the surveyor or answer any questions. Review of Resident #2's Quarterly MDS Assessment, dated 06/24/26, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. She did not have a BIMS score calculated nor was one assessed by staff, indicating she had severe cognitive impairment. Her active diagnoses included non-alzheimer's dementia (cognitive disorders severe enough to interfere with daily life) and seizure disorder or epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain). Her MDS did not indicate her usage of a wheelchair. Review of Resident #2's undated care plan reflected the following: Focus: [Resident #2] has ID and is PASRR positive.Interventions: Specialized Services HC & THERAPY SERVICES will be provided per LA recommendations.Wheelchair to be repaired, not yet eligible for a new custom chair due to 5 year time limit. Review of Resident #2's HSP, dated 04/22/26, reflected the following: On 04/26/24, PE recommendation services include, ILS, OT, PT, and DME.[Resident #2] and LAR would like to continue with HC, ILS, PT and OT. CMWC is requested.Name of Service: CMWC.Outcome/Goal: Pending assessment. Review of Resident #2's Level 1 PASRR Screening, dated 04/04/23, reflected a positive PASRR status for Intellectual Disability and Developmental Disability. Observation and interview on 07/22/26 at 9:20 AM with Resident #2, she was in her bed resting. Resident #2 was not able to answer any questions based on her cognitive condition. Interview on 07/22/26 at 8:48 AM with the DOR, she said she was a part of a meeting back in April 2026 where it was decided Residents #1 and #2 would have new wheelchairs. The DOR said the vendor originally came out on 04/28/26 to measure the residents for their wheelchairs for the initial assessments. The DOR said after that, there were multiple times the vendor was supposed to come back out and never did for one reason or another. The DOR said she had communicated with him regularly to request an update or ask him to come to the facility to complete the task so she could submit the NFSS forms timely. The DOR said she was only allowed to use the one DME company per the company's decision so she could not reach out to other DME companies/vendors. The DOR said she had not submitted Residents #1 and #2's NFSS forms yet because she was still waiting on the DME vendor to come to the facility and finish getting the measurements for her to submit the forms. The DOR said the purpose of the NFSS form was to get permission for the residents to receive the services. The DOR said the NFSS form was submitted through the LTC Online Portal by her since it was her responsibility. The DOR said if the NFSS forms were not submitted timely then the facility would be out of compliance. The DOR said she did not know she only had 20 business days to complete and submit the NFSS forms for Residents #1 and #2. Interview on the phone on 07/22/26 at 9:35 AM with the DME Vendor Rep, he said he had been working on getting Residents #1 and #2's measurements for their new wheelchairs for a while. The DME Vendor said he had been out to the facility around April 2026 and had not been able to come to the facility to finish the process for one reason or another since things came up and he could not make it out. The DME Vendor said usually he was able to get to the facility quickly and provide the measurements for them for the forms they have to submit. The DME Vendor said the DOR had been reaching out to him for updates and trying to get him to the facility to complete the tasks for Residents #1 and #2. Interview on the phone on 07/22/26 at 10:20 AM with Residents #1 and #2's RP, she said she was aware the facility was working towards getting the residents' new chairs, but was not sure where they were at in the process. Interview on the phone on 07/22/26 at 12:55 PM with Residents #1 and #2's HC, she said there was a meeting back in April 2026 where it was discussed that Residents #1 and #2 needed new wheelchairs. Residents #1 and #2's HC said she followed up with the facility recently, earlier this month (July 2026), about the status of the residents' new wheelchairs and was told they were still working through the process and the forms had not been submitted yet. Interview on 07/22/26 at 1:15 PM with the ADON, she said both the Administrator and DON were at a conference and were not at the facility. The ADON said she had no idea about any procedures related to PASRR services. The ADON said she only knew the DOR was responsible for submitting forms for it and was expected to follow the facility's policies for PASRR services. Review of the facility's policy, revised 03/06/19, titled PASRR Level 1 Screen Policy and Procedures did not address NFSS form submissions.

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 16 of 40 days (06/08/25, 07/05/2025, 07/06/25, 07/12/25, 07/19/25, 07/27/25, 08/09/25, 08/10/25, 08/31/25, 10/11/25, 10/12/25, 10/17/25, 10/18/25, 11/15/25, 12/06/25 and 12/07/25) reviewed during a look back period from 06/07/25 to 12/18/25 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 06/08/25, 07/05/2025, 07/06/25, 07/12/25, 07/19/25, 07/27/25, 08/09/25, 08/10/25, 08/31/25, 10/11/25, 10/12/25, 10/17/25, 10/18/25, 11/15/25, 12/06/25 and 12/07/25.This failure could place residents at risk of not having their nursing and medical needs met and improper care.Findings included:Record review of the facility's Timecard Reports from 06/07/25 to 12/18/25 reflected the following:- Sunday 06/08/25: ADON D: Shift In 20:37 (8:37 PM)- Shift Out 23:13 (11:13 PM); 2 hours and 36 minutes worked RN G: Shift In 22:00 (10:00 PM)- Shift Out 6:55 AM (Monday); 2 hours worked on 06/08/25.- Saturday 07/05/25: RN B: Shift In 17:53 (5:53 PM)- Shift Out 0:27 (12:27 AM) (Sunday); 6 hours and 7 minutes worked; andRN G: Shift In 22:15 (10:15 PM)- Shift Out 7:42 (Sunday); 1 hour and 45 minutes worked on 07/05/25.- Sunday 07/06/25: RN B: Shift In 17:15 (5:15 PM)- Shift Out 22:42 (10:42 PM); 5 hours and 27 minutes worked; and RN G: Shift In 22:22 (10:22 PM)- Shift Out 7:10 (Monday); 1 hour and 38 minutes worked on 07/06/25.- Saturday 07/12/25: RN H: Shift In 17:40 (5:40 PM)- Shift Out 6:12 AM (Sunday); 6 hours and 20 minutes worked on 07/12/25.- Saturday 07/19/25: RN H: Shift In 17:43 (5:43 PM)- Shift Out 6:33 AM (Sunday); 6 hours and 17 minutes worked on 07/19/25.- Sunday 07/27/25: ADON D: Shift In 8:28 AM - Shift Out 12:19 PM; 3 hours and 51 minutes worked and then returned at: Shift In 17:37 (5:37 PM) - Shift Out 23:22 (11:22 PM); 5 hours and 45 minutes worked.- Saturday 08/09/25:ADON D: Shift In 12:38 PM - Shift Out 17:23 (5:23 PM); 4 hours and 45 minutes worked; and RN F: Shift In 20:01 (8:01 PM) - Shift Out 00:01 (12:01 AM) (Sunday); 4 hours worked.- Sunday 08/10/25: ADON D: Shift In 6:51 AM - Shift Out 11:45 AM; 4 hours and 54 minutes worked; and RN F: Shift In 20:01 (8:01 PM) - Shift Out 00:01 (12:01 AM) (Monday); 4 hours worked on 08/10/25. - Sunday 08/31/25: RN G: Shift In 22:22 (10:22 PM) - Shift Out 6:52 AM (Monday); 1 hour and 38 minutes worked.- Saturday 10/11/25:RN H: Shift In 17:46 (5:46 PM)- Shift Out 6:37 AM (Sunday); 6 hours and 14 minutes worked on 10/11/25.- Sunday 10/12/25:RN B: Shift In 14:15 (2:15 PM)- Shift Out 18:24 (6:24 PM); 4 hours and 9 minutes worked; RN H: Shift In 17:53 (5:53 PM)- Shift Out 6:13 AM (Monday); 6 hours and 7 minutes worked on 10/12/25; and RN G: Shift In 22:11 (10:11 PM)- Shift Out 6:36 AM (Monday); 1 hour and 49 minutes worked on 10/12/25.- Saturday 10/17/25:RN H: Shift In 21:04 (9:04 PM)- Shift Out 6:11 AM (Sunday); 2 hours and 56 minutes worked on 10/17/25.- Sunday 10/18/25:RN H: Shift In 17:46 (5:46 PM)- Shift Out 8:14 AM (Monday); 6 hours and 14 minutes worked on 10/18/25.- Saturday 11/15/25:RN C: Shift In 4:54 AM- Shift Out 10:02 AM; 5 hours and 8 minutes worked.ADON D: Shift In 7:55 AM- Shift Out 11:18 AM; 3 hours and 23 minutes worked.- Saturday 12/06/25 RN H: Shift In 18:11 (6:11 PM)- Shift Out 6:34 AM (Sunday); 5 hours and 49 minutes worked on 12/06/25.- Sunday 12/07/25: ADON D: Shift In 13:42 (1:42 PM)- Shift Out 19:38 (7:38PM); 5 hours and 25 minutes worked; and RN H: Shift In 17:45 (5:45 PM)- Shift Out 6:20 AM (Monday); 6 hours and 15 minutes worked on 12/07/25.Interview on 12/11/25 at 8:59 AM, the Staffing Coordinator revealed she had been employed at the facility since April 2025 and took the Staffing Coordinator position in July 2025. She stated she was responsible for completing the nursing schedules. She stated ADON D reviewed the nursing schedules once they were completed. The Staffing Coordinator stated she was aware of the 8 consecutive hours; however, she was not aware that midnight was the cut off. She stated she was not made aware it had to be the same day and thought that as long as she had an RN for 8 consecutive hours it was fine. The Staffing Coordinator stated the potential risk of not having an RN for 8 consecutive hours would be something happening to a resident and an RN not being in the building to assist. Interview on 12/11/25 at 1:08 PM, ADON D revealed the Staffing Coordinator was responsible for completing the nursing schedules. She stated the DON was responsible for reviewing the schedules once completed. ADON D stated she would only assist with the schedules when someone calls off or to ensure they have enough coverage. Interview on 12/11/25 at 4:07 PM, the DON revealed the Staffing Coordinator was responsible for completing the nursing schedules. She stated she would review the schedules when Staffing Coordinator finds issues with coverage or needs to move staff around. The DON stated the Staffing Coordinator completes monthly schedules and prints the schedules a week in advance. She stated she was not aware of the 8 consecutive hours same day. The DON stated there was no potential risk to the residents because nursing staff had access to an RN and she was available if needed. Interview on 12/11/25 at 4:22 PM, the Administrator revealed the Staffing Coordinator was responsible for completing nursing schedules and the DON was responsible for reviewing them. He stated he was aware of the 8 consecutive hours; however, he was not aware it was not being scheduled correctly. He stated the potential risk would be patient care. Interview on 12/11/25 at 4:50 PM, the RCN revealed the facility did not have a policy for RN Coverage and followed the regulation for 8 hours daily.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 20 residents (Resident #33) reviewed for ADLs. The facility failed to ensure Resident #33 received showers/bed baths as scheduled for the months of November 2025 and December 2025. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.Findings included:Record review of Resident #33's annual MDS assessment, dated 10/05/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #33 had diagnoses of chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), non-Alzheimer's Dementia (brain disorder caused by damage to nerve cells in the brain), and diabetes mellitus (a chronic disease characterized by high level of sugar in the blood). He had a BIMS score of 15, which indicated his cognition was intact. Record review of Resident #33's care plan, revised 09/22/25, reflected: The resident has an ADL Self Care Performance Deficit. Goal: The resident will improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Interventions: Bathing: requires staff x1 for assistance. BATHING: Provide the resident with a sponge bath when a full bath or shower cannot be tolerated.Record review of Resident #33's November 2025 POC History reflected the resident was supposed to receive bathing/showers on Mondays, Wednesdays, and Fridays on the 6:00 AM-2:00 PM shift. It reflected: Turn in shower sheet to charge nurse during shift. In the Task section under Bathing it indicated Not applicable for Monday, Wednesday, and Friday. It was unknown if Resident #33 received a shower/bed bath or if the resident refused. Record review of Resident #33's Dember 2025 POC History reflected the resident was supposed to receive bathing/showers Mondays, Wednesdays, and Fridays on the 6:00 AM-2:00 PM shift. It reflected: Turn in shower sheet to charge nurse during shift. In the Task section under Bathing it indicated Not applicable for Monday, Wednesday, and Friday. It was unknown if Resident #33 had received any shower/bed bath or if the resident refused. Observation and interview on 12/09/25 at 10:37 AM revealed Resident #33 lying in bed. He stated he was doing well. Resident #33 stated he did not get showers, he preferred bed baths, and his days were Monday, Wednesday and Fridays. He stated the last time he received a bed bath was some day last week either Monday or Wednesday. He stated he did not get his bed baths on the days that he should. He stated when he requested a bed bath staff made an excuse and told him they were short of staff. Resident #33 denied having any skin issues. Interview on 12/11/25 at 11:06 AM, CNA K revealed she was the CNA assigned to Resident #33 today (12/11/25). She stated Resident #33's shower days were Monday, Wednesday, and Fridays during the 2:00 PM-10:00 PM shift. She stated most of the time Resident #33 refused his bed baths. CNA K stated they documented on the shower sheets and on the POC. Record review of facility shower binder located on 200 hall nurses station revealed no shower sheets for Resident #33. On 12/11/25 at 11:20 AM, ADON D was asked to provide Resident #33's shower sheets. The shower sheets were not provided prior to the survey team's exit.Interview on 12/11/25 at 1:13 PM, CNA L revealed she had been the CNA assigned to Resident #33 on the 2-10PM shift. She stated Resident #33's showers were provided during the 2:00 PM-10:00 PM shift; however, the resident did refuse his bed baths but not all the time. She stated if a bed bath was provided or if the resident refused, she documented it in the POC. She stated if the POC showed Not Applicable it meant the shower was not provided, and it did not happen. CNA L stated she had not completed any shower sheets for Resident #33. She stated there was no potential risk to the resident. Interview on 12/11/25 at 2:49 PM, CNA M revealed she was the 2:00 PM-10:00 PM CNA assigned to Resident #33 today (12/11/25). She stated she had provided Resident #33 with bed baths. She stated she had last given him a bed bath was sometime last month, but she could not remember the date. She stated Resident #33 had complained about not receiving his showers, and she reported it to the nurse. She stated she would provide Resident #33 with a bed bath upon his request. CNA M stated she documented in the POC. She stated if the POC showed Not Applicable it meant the shower was not provided or offered to the resident. She stated the potential risk if the resident did not receive his shower/bed bath would be lack of hygiene. Interview on 12/11/25 at 3:10 PM, LVN N revealed she was the nurse assigned to Resident #33. She stated Resident #33 was provided with his bed baths during her 2:00 PM-10:00 PM shift. LVN N stated Resident #33 was provided with his bed baths on his shower days; however, at times the resident refused. She stated staff documented on the shower sheets and on the POC. She stated she was not sure why Resident #33's POC showed Not applicable. She stated there was no potential risk to the resident because he was getting his bed baths. Interview on 12/11/25 at 3:17 PM, ADON D revealed they were no longer doing shower sheets and staff should be documenting in the POC. She stated based on the POC documentation she could not prove if Resident #33 received any of his showers. ADON D stated if it was not documented it did not happen. She stated if a resident refused a shower, the CNA must notify the nurse. ADON D stated the potential risk if showers were not provided would be infections. Interview on 12/11/25 at 4:00 PM, the DON revealed as far as she knew Resident #33 was receiving his bed baths. She stated his showers days were Monday, Wednesday, and Fridays. She stated the CNAs should document the showers in the POC. The DON stated she was not sure what the CNAs were clicking on the POC to show Not Applicable. She stated based on the documentation she could not confirm if Resident #33 received any of his showers. She stated it was the responsibility of the nurses in charge and ADON to ensure showers or bed baths were being provided to the residents. She stated if a resident refused a shower, the CNA must notify the nurse. She stated the potential risk if showers were not provided would be skin breakdowns. Record review of the facility's current, undated Bedbath Complete policy, reflected the following: The complete bedbath is performed for those residents on bedrest who need total or partial assistive care. Based on bedrest status, ability for movement in bed, skin integrity, and general condition, a complete bedbath can be performed daily or alternated with a partial bedbath.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 2 of 20 residents (Residents #14 and #76) reviewed for care plans. 1. The facility failed to develop a care plan addressing Resident #14's nail care refusal.2. The facility failed to develop a care plan addressing Resident #76's right hand contracture. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included:1. Record review of Resident #14's quarterly MDS reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The residents' diagnoses included diabetes, seizure disorder, history of TIA (a temporary blockage of blood flow to the brain; mini stroke) and cerebral infarction (blockage of blood vessel in the brain cutting off blood flow and oxygen). The resident had a BIMS of 5 which indicated his cognition was severely impaired. Record review of Resident #14's care plan dated 11/17/25 reflected the resident had ADL self-care performance deficit. Interventions included he required supervision to limited assistance of 1 staff for personal hygiene. The care plan did not address Resident #1's refusal of care. Observation and interview on 12/09/25 at 2:46 PM of Resident #14 revealed he was in his room sitting on his bed with the covers over his head. The resident removed the covers when he was spoken to, and it was noted four of his fingernails on his right hand were about three quarters of an inch long and the nail on his thumb was short. His fingernails on his pinky and ring finger of his left hand were about one inch long, and the three other fingernails were about half an inch long. The resident was asked if his fingernails had ever been cut, to which he replied, Yes, I have people that do that. He did not provide any further information. Resident #14 was asked if he wanted his fingernails cut, and he said he did. The resident then quickly put the covers back over his head. Interview on 12/10/25 at 1:41 PM, RN C revealed she had asked Resident #14 several times if she could cut his fingernails and each time the resident refused. RN C said the resident refused most care and only friends or family could convince him to get any type of care including showers. Observation on 12/10/25 at 1:45 PM revealed RN C went into Resident #14's room. She asked Resident #14 if she could cut his fingernails. The resident said he had people that did that for him but did not elaborate on who the people were. The resident then said no and pulled the covers back over his head. RN C said she thought she had documented in the resident's progress notes his refusals to have his fingernails cut. Interview on 12/10/25 at 1:47 PM, CNA I revealed he worked with Resident #14. He stated every time he asked if he could cut the resident's fingernails or give the resident a shower, the resident refused and always pulled his covers back over his head. Interview on 12/11/25 at 1:32 PM, ADON E revealed it was normal for Resident #14 to refuse all care including having his fingernails cut. She said each time they ask the resident he will agree and when they go to provide the care Resident #14 would refuse. ADON E said it was the responsibility of ADONs, DON and MDS Coordinators to update resident care plans but the bulk of them were done by the MDS Coordinators if they are told of any resident care concerns. ADON E said she was not aware Resident #14's care refusals were not documented or care planned. ADON E further stated it was important to care plan the residents' refusals because it painted a picture of their care, so the staff knew how to care for the residents. Interview on 12/11/25 at 12:29 PM, MDS Coordinator B revealed nursing staff were responsible for updating resident care plans for any care refusals. MDS Coordinator B said she would also update the care plan if staff made her aware of any issues/concerns. MDS Coordinator B stated she was not aware of Resident #14's care refusal, which included refusing nail care. She stated it was important to keep the care plans updated, so the staff knew what the resident's current plan of care was.2. Record review of Resident #76's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old resident who admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, other reduced mobility, and muscle weakness. The resident had a BIMS of 5 which indicated her cognition was severely impaired. Record review of Resident #76's care plan initiated on 05/07/25 did not reflect the resident had a right-hand contracture. Observation on 12/09/25 at 2:46 PM of Resident #76 revealed her right hand was contracted. The resident was asked if she could open her hand, and the resident tried but was not able to open it. There was no device in place for the right-hand contracture. Interview on 12/11/25 at 9:55 AM, LVN J stated Resident #76's right hand was contracted. LVN J stated Resident #76 did not have a device in place for contracture management because the resident would complain and pull out whatever they would put in place. LVN J said therapy worked with the resident for some time, and the resident was given a splint, but the resident would never keep it in place. Interview on 12/10/25 at 3:08 PM, the Director of Rehabilitation revealed they had worked with Resident #76's contracture. She said they had tried to put a splint in the resident's contracture, but Resident #76 would pull it out and never leave it in. Interview on 12/11/25 at 3:44 PM, ADON D revealed Resident #76 had been admitted to the facility with her right-hand contracture. ADON D said there should have been a care plan addressing Resident #76's hand contracture. ADON D stated the IDT should have noticed it during their weekly care plan meetings. ADON D did not know why it had not been caught. ADON D stated it was important to care plan the resident's contracture and its care to ensure the resident was getting the care she needed. Interview on 12/11/25 at 12:33 PM, MDS Coordinator B revealed she was not aware Resident #76's right hand was contracted. She said the resident's care plan should have reflected the contracture, care, and refusals to keep her splint in place. MDS Coordinator B said any nursing staff could update the care plan or she would do it if staff would let her know of the issue. MDS Coordinator B further stated it was important to have care plans updated so staff could follow their plan of care. Record review of the facility's undated policy titled Comprehensive Care Planning reflected the following: 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.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interviews and record reviews the facility failed to ensure residents were screened for mental illness and coordinate with the State mental health authority the need for services for 1 of 4 residents (Resident #99) reviewed for PASARR screening. The facility failed to recognize that Resident #99's PL1 was inaccurate, which resulted in the resident not being referred to the local authority for a PE. The failure placed residents with mental illness at risk of not receiving services they were entitled to receive. Findings included:Record review of Resident #99's admission MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of bipolar disorder. His BIMS score was 15, indicating he was cognitively intact. His Functional abilities assessment revealed he required substantial assistance with his ADLs. Record review of Resident #99's care plan, dated 12/14/25, reflected he had an ADL self-care deficit, he was on an anti-psychotic medication for bipolar disorder, and he had depression. Record review of Resident #99's PASRR Level 1 screening, dated 09/15/25, reflected he did not have a primary diagnosis of dementia, and there was no evidence of mental illness. Record review of Resident #99's EHR revealed no PASRR 2 assessment had been completed by the local mental health authority. Interview on 12/09/25 at 10:44 AM, Resident #99 denied any mental illness stating, I'm fine. He had no complaints about his care. Interview on 12/11/25 at 11:26 AM, MDS Coordinator A stated Resident #99 had been referred to the local mental health authority on 09/16/25 and had been evaluated by them on 12/09/25, but the resident refused services. Interview on 12/11/25 at 12:30 PM, MDS Coordinator B stated Resident #99 had not been referred to the local mental health authority. She discovered on 12/09/25 that Resident #99 had not been referred, so she initiated the referral at 12:21 PM on 12/09/25. She stated the resident's assessment was scheduled for 12/12/25. She stated the risk of not having him assessed could be him not receiving services he might qualify for. She stated she and the other MDS Coordinator were responsible for performing the MDS assessments and referring residents to the local authority if indicated. She stated she did not know why Resident #99 had not been referred for PASRR services in September 2025. She stated there had been confusion about the resident's insurance coverage, which might have contributed to him not being referred for PASRR services. Interview on 12/11/25 at 1:13 PM, RN C stated Resident #99 had no behavior issues. She stated the resident was very laid back and did not require a lot of interventions. She stated the CNAs helped him dress in the mornings, got him into his wheelchair, and he was independent after that. Record review of the facility's policy PASRR Level 1 Screen Policy, dated 03/06/19, reflected: It is the policy of [Corporate Entity] facilities to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via the portal timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goal and preferences for 1 of 20 resident (Resident #116) reviewed for pharmacy services.The facility failed to ensure Resident #116's intravenous medication bag and tubing was labeled with date, time, and initials.These failures could place residents at risk for medication error, delay in medication administration and infection.Findings included:Record review of Resident #116's admission MDS assessment, dated 12/02/25, reflected the resident was a [AGE] year-old male who was admitted to facility the on 11/29/25. Resident #116 had a diagnosis of septicemia (It is an infection caused by large amounts of bacteria entering the bloodstream). He had a BIMS score of 14, which indicated his cognition was intact. The MDS reflected that the resident was on intravenous medications.Record review of Resident #116's physician's orders dated 12/01/25 reflected an order for: Daptomycin Intravenous Solution Reconstituted 500 MG (Daptomycin [a cyclic lipopeptide antibiotic used to treat complicated bacterial infections]) Use 50 ml intravenously one time a day related to sepsis until 12/18/25.)Record review of Resident #116's Care Plan Report, initiated 11/30/25 and revised 12/10/25, reflected Resident #116 had an IV access with a goal of the resident not having any complications related to IV therapy. The care plan interventions included: administering IV fluids as ordered; administering IV medications as ordered; checking the dressing at the IV site daily to monitor for signs and symptoms of infection; flushing the ports/lines as ordered; changing the dressing every 7 days and PRN.Observation on 12/09/25 at 12:00 PM revealed Resident #116 in his room, lying in bed. He was observed to have a PICC line dated 11/29/25. The intravenous medication bag was hanging on the pole. The IV bag was not labeled with the date, time, and initials to indicate when it was hung. A second empty bag was also observed in the resident's room, and it also did not have a date, time or initials to indicate when it had been hung or administered. Observation and interview on 12/09/25 at 1:53PM with LVN O revealed she was not the one who hung the bag. She stated she saw the unlabeled, empty bag hanging on the pole. It was hung by the 2:00 PM-10:00 PM nurse. LVN O said the IV bag and the tubing were supposed to have the correct resident's name, date, time and initial of the nurse administering the medications. She stated failure to put the date, time, and initials could make Resident #116 miss the next dose or get an overdose since she was not aware when he got the last dose and that would lead to medication error. She stated failure to label the tubing with the date and time could lead to infections because the tubing was only good for 24 hours. Interview on 12/10/25 at 3:20 PM, LVN X revealed she was the one, who administered Daptomycin 500 mg/50 ml to Resident #116 during 2:00 PM-10:00 PM shift .She stated she was aware she was supposed to label the bag and the tubing with date, time, and initials, so other staff were aware when the bag was hung to prevent omission of a dose or overdose, but she did not. She stated she forgot. She stated failure to label the bag, and the tubing could lead to omission of a dose and not putting date on tubing's could lead to infection because tubing's are, good for 24 hrs. LVN X stated she had done training on IV administration. Record review revealed she had done skills checks on IV administration on 11/05/25.Interview on 12/11/25 at 9:40 AM, the ADON revealed she expected staff to date and initial intravenous bags and tubing when administering intravenous medications to prevent infection and medication error. She stated the tube should be changed every 24 hours. She stated she had done training with staff on labeling and putting initials on bags and tubing and nurses had done skill checks.Interview on 12/11/25 at 10:26 AM, the DON revealed she expected staff to date and initial intravenous bags and tubing when administering intravenous medications to prevent infection and medication error. She stated the tube should be changed every 24 hours. She stated she had done training with staff on labeling and putting initials on bags and tubing and, she had done skill checks with the nurse on 11/05/25.Record review of the facility's current Medications, Intravenous Infusion policy, dated 2003, reflected the following: . 7. Record the drug name, dose, rate, date, and time the drug was added on the container label.

Based on interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (Resident #114) reviewed for pressure ulcer treatment.The facility failed to ensure Resident #114 received wound care for his pressure ulcers on the weekend of 12/06/25-12/07/25.This failure could place the residents at risk of Infection and worsening wounds.Findings included:Record review of Resident #114's admission MDS assessment, dated 12/05/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The residents' diagnoses included methicillin resistant staphylococcus aureus infection (a type of staph that can be resistant to several antibiotics). Resident #114 had severe cognitive impairment with a BIMS score of 2. The MDS indicated that Resident #114 had four Stage 3 pressure ulcers that were present upon admission/entry to the facility. Record review of Resident #114's care plan, dated 12/04/25, reflected: Focus: [Resident#114] has a pressure ulcer or potential for pressure ulcer development and/or is at risk for impaired skin integrity: Right gluteal fold - pressure injury, sacrum - pressure injury, scrotum - pressure injury, left buttock - pressure injury, left right ankle - pressure injury hip - pressure injury. Goal: [Resident #114] Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD.Record review of Resident #114's Initial Wound Evaluation & Management Summary, dated 12/04/25, reflected the following wound assessments, treatment plans, and orders: Left hip pressure injury unstageable present upon admission - 9.00 cm x 7.00 cm x 0.80 cm - Cleanse with normal saline/wound cleanser. Pat dry apply Santyl (a topical medication used to remove dead tissue from wounds) and Hydrofera Blue (a type of wound dressing) and cover with bordered gauze/foam dressing daily and prn for soiled or dislodgment. Right gluteal fold pressure injury Stage 3 present upon admission - 3.50 cm (length) x 3.50 cm (width) x 0.70 cm (depth); Cleanse with normal saline/wound cleanser. Pat dry apply collagen and Hydrofera Blue then cover with bordered gauze/foam dressing daily and prn for soiled or dislodgement. Sacrum pressure injury Stage 3 present upon admission - 4.50 cm x 5.00 cm x 0.20 cm - Cleanse with normal saline/wound cleanser. Pat dry apply collagen and Hydrofera Blue and cover with bordered gauze/foam dressing daily and prn for soiled or dislodgment. Left buttock pressure injury Stage 3 upon present upon admission - 7.00 cm x 24.50 cm x 3.00 cm - Cleanse with normal saline/wound cleanser. Pat dry apply collagen and Hydrofera Blue and cover with bordered gauze/foam dressing daily and prn for soiled or dislodgment. Right ankle pressure injury Stage 3 present upon admission - 1.50 cm x 2.40 cm x 0.00 cm - Cleanse with normal saline/wound cleanser. Pat dry apply collagen and Hydrofera Blue and cover with bordered gauze/foam dressing daily and prn for soiled or dislodgment. Left ankle pressure injury unstageable present upon admission - 3.00 cm x 4.30 cm x 0.20 cm - Cleanse with normal saline/wound cleanser. Pat dry apply Santyl and Hydrofera Blue and cover with bordered gauze/foam dressing daily and prn for soiled or dislodgment.Record review of Resident #114's eTAR for December 2025 reflected there was no documentation showing that wound care was provided on Saturday (12/06/25) and Sunday (12/07/25) for any of Resident #114's wounds.Record review of Resident #114's Weekly Ulcer Assessment, dated 12/Interview on 12/09/25 at 11:50 AM, Resident #114 stated he had received his wound care from Monday to Friday, but he did not receive it on the weekend.Interview on 12/10/25 at 11:53 AM, ADON E, who worked on the weekend, revealed that she knew Resident#114 had multiple wounds. She stated she knew she was supposed to perform wound care on Resident#114 because the treatment nurse did not work on the weekends. She stated wound care treatment was on a different treatment administration record, and she thinks she missed it. ADON E stated she left early both days and she forgot to let the nurses that came to relieve her know that she had not performed wound care on Resident#114. ADON E stated failure to perform wound care on Resident#114 could lead to infection and more skin breakdown. She stated she had not done training on wound care. Interview on 12/10/25 at 1:34 PM, Wound Care Nurse F revealed Resident #114 admitted to the facility with multiple wounds. She stated her work schedule was from Monday-Friday. She stated weekend staff were supposed to have provided wound care during the weekend to Resident #114. She stated she saw Resident #114 on 12/05/25 and wound care was provided. She stated when she came on Monday 12/8/25 Resident#114 still had the old dressing she had put on 12/05/25. She stated wound care should have been completed on Saturday and Sunday. Wound Care Nurse F stated her expectation was the nurses or the wound care nurses were responsible for performing wound care. She stated she did not notify the management because she expected the management to go through the treatment records and check whether care was being provided. She stated failure to follow the doctors' orders could result in worsening wounds. Interview on 12/11/25 at 9:51 AM, ADON D stated it was the responsibility of the nurses to perform wound care when the Wound Care Nurse was not in the facility. She stated she expected her staff to follow the treatment orders. She stated she was not aware wound care was not performed on 12/06/25 and 12/07/25 until it was brought to her attention by the DON. She stated both she and the DON were responsible for checking the MARs and TARs to ensure care was being provided. She stated she knew she was supposed to be checking the wound care TARs, and she had not checked it for Resident #114, so it was missed. She stated the potential risk of not performing wound care was the wounds deteriorating and getting infected. She stated she had not done in-services on wound care.Interview on 12/11/25 at 10:30 AM, the DON revealed she was not aware wound care was not provided to Resident #114 over the weekend. She stated weekend staff were responsible for performing wound care on Resident #114, since they were aware treatment nurse only works Monday through Friday. She stated she expects her staff to follow the treatment orders. She stated the ADON was responsible for going behind nurses and ensuring the MAR/TAR were being checked off. She stated the potential risk could result in the wounds worsening and getting infected. She stated she had not done in-service on wound care.Interview on 12/11/25 at 12:42 PM, the Wound Care NP revealed when treatment orders were provided to the facility, the nurses or wound care nurse was supposed to follow them. The Wound Care NP stated if treatment was missed, Resident #114 was at risk for infection and the wound getting worse. Record review of the facility's current Pressure Injury: Prevention, Assessment and Treatment policy, dated 05/05/25, reflected: . 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will:1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician.

Based on observations and interviews, the facility failed to ensure each bed had suspended ceiling curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 3 of 21 residents (Residents #74, #95, and #99) reviewed for privacy curtains. The facility failed to ensure Residents #74, #95, and #99 were ensured full visual privacy.This could place the residents at risk of lower self-esteem. Findings included:1. Record review of Resident #74's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bone infection, multiple pressure ulcers, and cerebral palsy. Her BIMS score was 15, indicating she was cognitively intact. Her Functional Abilities assessment reflected she required staff assistance with all of her ADLs. Record review of Resident #74's care plan, dated 12/04/25, reflected she had bowel and bladder incontinence, had an ADL self-care deficit, and was at risk of skin breakdown. Observation on 12/09/25 at 10:27 AM revealed Resident #99 was in bed. The resident's privacy curtain was pulled closed, but the end of her bed was not covered by the curtain, which left the end of the resident's bed exposed. Interview on 12/11/25 at 10:20 AM Resident #99 stated she did not like having the end of her bed exposed. She stated she would be upset if someone came in while she was being changed. She stated she would like the curtain to provide full coverage, but she did not know that was an option. 2. Record review of Resident #95's quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke affecting the right side of his body, diabetes, and heart disease. His BIMS score was 12, indicating he was cognitively intact. His Functional Abilities assessment indicated he required limited assistance with his ADLs. Record review of Resident #95's care plan, dated 12/04/25, reflected he had an ADL self-care deficit. Observation on 12/09/25 at 11:09 AM revealed Resident #95 was in bed. The resident's privacy curtain was pulled closed, but the end of his bed was left exposed. Interview on 12/11/25 at 10:10 AM, Resident #95 stated having the end of his bed exposed did not really bother him, but he would not like someone walking in while he was changing. He stated the curtain had been that way since he was admitted . 3. Record review of Resident #99's admission MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stroke affecting the left side of his body, muscle weakness, and diabetes. His BIMS score was 15, indicating he was cognitively intact. His Functional Abilities assessment indicated he required substantial assistance with his ADLs. Record review of Resident #99's care plan, dated 12/14/25, reflected he had an ADL self-care deficit. Observation on 12/09/25 at 10:44 AM revealed Resident #99 was in bed. The resident's privacy curtain was partially closed. When the privacy curtain was fully closed, the curtain did not wrap around to cover the end of the resident's bed. Interview on 12/11/25 at 10:10 AM, Resident #99 stated he was not bothered about the end of his bed not being covered by the curtain. He stated the staff close the door when they are providing care, but he would not like it if someone came in and saw him exposed. Interview on 12/11/25 at 10:30 AM, the Regional Maintenance Specialist stated maintenance was responsible for hanging any privacy curtains that needed to be hung. He stated staff would have to notify them when a curtain needed to be hung. Interview on 12/11/25 at 10:40 AM, RN-C stated it was important for residents to have privacy when in bed to prevent them from being seen by their roommate or people from the hallway. She stated housekeeping was responsible for monitoring the curtains and replacing them as needed. Interview on 12/11/25 at 10:43 AM, the ADON stated the resident's needed privacy in their beds to prevent being embarrassed when staff are providing care. She stated the nurses and CNAs were primarily responsible for letting housekeeping know if a curtain needed to be placed or replaced, but any staff member could notify housekeeping. Interview on 12/11/25 at 10:46 AM, the DON stated it was important for residents to have privacy for their dignity while care was being provided. She stated the nurses and CNAs were responsible for letting housekeeping know if a curtain needed attention. Maintenance would then hang the curtain when it was ready. She stated there was not a policy addressing privacy curtains specifically.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete in accordance with accepted professional standards and practices for 1 of 20 residents (Resident #10) whose clinical records were reviewed for accuracy. The Social Worker failed to document in Resident #10's clinical record when the resident's family/legal representative was invited to participate in the resident's quarterly care plan meetings.The failure placed residents at risk of not having their care and services accurately documented. Findings included:Record review of Resident #10's significant change in status MDS assessment, dated 10/11/25, reflected the resident was a [AGE] year-old female who was admitted to facility the on 09/30/18. Resident #10 had a diagnosis of sequelae of cerebral infarction (long-term problems or consequences that linger long after a stroke), dysphasia (partial loss of language), gastrostomy status (a surgical opening into the stomach for nutritional support or gastric decompression), anxiety disorder a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and schizophrenia (a severe, chronic brain disorder that disrupts how a person thinks, feels, and behaves). She had a BIMS score of 00, which indicated his cognition was severely impaired. Record review of Resident 10's Care Plan Report, dated 10/27/25, reflected the resident wished to remain at facility for long term care. The care plan interventions included discussing options at each care plan meeting unless otherwise notified.Observation on 12/09/25 at 10:52 AM revealed Resident #10 in bed. An attempt was made to interview Resident #10, but she did not rouse when spoken to. Interview on 12/10/2025 at 9:02 AM, Resident #10's Family Member A revealed no concerns regarding the care that the resident was receiving at the facility. He stated he had received calls if there was any change in condition; however, he had never attended a care plan meeting in person or by phone. He stated he does not recall ever been told or been invited to any care plan meetings in the last year. He stated he would like to be invited so that he could be updated on the residents' care. Interview on 12/11/25 at 10:57 AM, the Social Worker revealed it was her responsibility for scheduling quarterly care plan meetings. She stated the MDS Coordinator, Therapy, Activity Director, Nursing and herself attend the care plan meetings. She stated residents and families were also invited to the care plan meetings. The Social Worker stated Resident #10 family had been invited several times; however, family does not attend. She stated she used to send letters home regarding the care plan meeting; however, she now calls the family. The Social Worker stated it usually takes about 3-4 attempts to contact Resident #10's family. The Social Worker stated she documents her attempts and will locate the documentation. Interview on 12/11/25 at 12:43 PM, the Social Worker revealed she was unable to locate the documentation of her attempts. The Social Worker stated she completed her telephone calls a week prior to the care plan meeting. She stated if there was no response, she would leave a voice message. She stated Resident #10 had been at the facility for years and the resident's Family Member had never attended a care plan meeting. She stated she had attempted to invite family; however, she had not documented her attempts. She stated family members should be invited to care plan meetings, so that the family were kept informed about the residents' condition and could address any concerns the family might have. She stated there was no potential risk if documentation was not completed. Interview on 12/11/25 at 4:05 PM, the DON revealed the Social Worker was responsible for scheduling care plan meetings. She stated the Social Worker should notify the family by phone or by letter to give them the option to attend. The DON stated any attempts should be documented. She stated the potential risk would be family not able to give input about the resident care. Interview on 12/11/25 at 4:20 PM, the Administrator revealed the Social Worker was responsible for scheduling care plan meetings. He stated family should be invited to attend. The Administrator stated the Social Worker should be documenting the attempts made, so they have proof that family was contacted. He stated the potential risk would be family not informed about the patient care. Record review of the facility's current, undated Documentation policy reflected the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed.

Based on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 20 residents (Resident #33) whose medications were reviewed for gradual dose reduction. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #33's Amitriptyline (used to treat depression) on 08/29/25. The facility failed to ensure this was communicated to the resident's primary care physician regarding the recommendation. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition.Findings included:Record review of Resident #33's annual MDS assessment, dated 10/05/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #33 had a diagnosis of depression (mood disorder that causes a persistent feeling of sadness and loss of interest),. He had a BIMS score of 15, which indicated his cognition was intact. The MDS Section N - Medications indicated he had taken antidepressants. Record review of Resident #33's care plan, revised 09/22/25, reflected: [Resident #33] received antidepressant medication. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Record review of Resident #33's current Order Summary Report, order date range 01/01/25-12/31/25, reflected the following: Amitriptyline HCl Tablet 100 MG Give 1 tablet by mouth one time a day related to major depressive disorder. The order date and start date for the Amitriptyline was 01/24/25. Record review of Resident #33's Medication Regimen Record review, dated 08/29/25 reflected: Gradual Dose Reduction Request: Medication: Amitriptyline HCI Tablet 100 MG Give 1 tablet by mouth one time a day. Per CMS regulations, residents who use psychotropic drugs must have gradual dose reduction attempts, unless clinically contraindicated, in an effort to discontinue these drugs.Record review of Resident #33's November and December 2025 MAR reflected he received amitriptyline everyday as ordered. Interview on 12/09/25 at 10:37 AM, Resident #33 stated he received all his medications as prescribed; however, he could not recall the name of his medications.Interview on 12/11/25 at 3:29 PM, ADON D revealed she was responsible for reviewing pharmacy recommendations. She stated Resident #33's August 2025 GDR was missed for his antidepressant medication. She stated she did not forward the Resident #33's August 2025 pharmacy recommendations for a GDR to the attending physician. ADON D stated the pharmacist completed their review, made a recommendation, and the attending physician was the one who would give the order to change the medication. She stated the potential risk if a GDR was not completed would be medications adjustments not being completed. Interview on 12/11/25 at 4:10 PM, the DON revealed ADON D was responsible for reviewing pharmacy recommendations. She stated she started working for the facility in August 2025. She stated she was unaware Resident #33's August pharmacy recommendation for a GDR was missed. She stated her expectations were for the pharmacy recommendation to be reviewed monthly, be sent to the physician for review and enter any new orders. The DON stated if a pharmacy recommendation was not followed up on or a GDR was not attempted, the potential risk would be not decreasing a medication that would be decreased or medication burden. Record review of facility Psychotropic Drugs policy, dated 10/25/17, reflected the following: The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the facility implements gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 1 resident (Resident #116) reviewed for PICC lines.1. The facility failed to ensure the dressing on Resident #116's PICC line (used to deliver medications and other treatments directly to the large central veins near heart) was changed every seven days as ordered by the physician, which resulted in the resident's PICC line dressing not being changed on 12/06/25.2. LVN X failed to perform hand hygiene during medication administration through Resident #116's PICC line.The failures could affect residents by placing them at risk for infections and cross-contamination. Findings included: Record review of Resident #116's admission MDS assessment, dated 12/02/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #116 had a diagnosis of septicemia (an infection caused by large amounts of bacteria entering the bloodstream). He had a BIMS score of 14, which indicated his cognition was intact. The MDS reflected that the resident was on intravenous medications.Record review of Resident #116's physician's orders dated 12/01/25 reflected: PICC Line (a long, thin tube that is inserted through a vein in the arm and passed through to the larger vein near the heart) Dressing Change q 7days one time a day every Mon PICC line dressing weekly. Record review of Resident #116's December 2025 TAR reflected there was no documentation reflecting his PICC line dressing had been changed on 12/06/25. There also was no documentation reflecting the resident had refused the dressing change.Record review of Resident #116's Care Plan Report, initiated 11/30/25 and revised 12/10/25, reflected Resident #116 had an IV access with a goal of the resident not having any complications related to IV therapy. The care plan interventions included: administering IV fluids as ordered; administering IV medications as ordered; checking the dressing at the IV site daily to monitor for signs and symptoms of infection; flushing the ports/lines as ordered; changing the dressing every 7 days and PRN.Observation and interview on 12/09/25 at 12:00 PM revealed Resident #116 in his room, in his bed. He was observed to have a PICC line dressing on his right arm dated 11/29/25. The dressing was peeling, and the surface of the dressing was dirty. Resident #116 stated the PICC line dressing was put on at the hospital, and it had not been changed since he had been at the facility. He stated no staff had requested to change the dressing. There were no signs or symptoms of infection noted at the PICC line site. Observation and interview on 12/09/25 at 1:53 PM with LVN O revealed Resident #116 had a PICC line in his right arm covered with a transparent dressing that was peeled and dated 11/29/25. LVN O revealed she was aware the dressing was supposed to be changed every 7 days and as needed when dirty. LVN O stated the dressing looked dirty on the surface. She stated she had tried to change Resident #116's PICC line dressing, but he had refused and did not want her to do it. She stated she notified ADON D and should have changed it before then since it was due every 7 days. She said she had not done training on PICC line dressings. Observation of the PICC line insertion site revealed it was clean with no signs of infection.Observation on 12/10/25 at 4:11 PM revealed LVN X administering the intravenous medication, Daptomycin 500 mg/50 ml (a cyclic lipopeptide antibiotic used to treat complicated bacterial infections), to Resident #116 via the resident's PICC line (a long, thin, flexible tube inserted into a vein in the arm, threaded up to a large vein near the heart, providing long-term IV access for medications). LVN X was observed putting on gloves and a gown before washing her hands. LVN X explained the procedure to Resident #116, she then positioned the resident and prepared the medications. She hung the IV bottle on the pole and connected the tubing. She then labeled both with the date, time, and her initials. Next, she removed her gloves and put on new gloves without washing her hands. She then cleansed the PICC line tip with an alcohol swab and connected the IV tubing. She allowed the medication to flow for 30 minutes. She then removed her gloves, left the room without washing her hands, and walked down the hall with the medication cart.Interview on 12/10/25 at 4:27 PM, LVN X revealed she forgot to perform hand hygiene before and after medication administration. LVN X stated she was expected to wash hands before and she put on gloves and gown and after medication administration, but she forgot. She stated failure to wash hands before and after contact could lead to cross contamination and infection. She stated she has done training on handwashing, but she could not recall when.Interview on 12/11/25 at 9:40 AM, the ADON D revealed she expected the nurses to check Resident #116's PICC line dressing and to change it if needed. She stated the nurses failed to do their job. She stated the PICC line dressing was supposed to be changed on 12/06/25, but they missed it. She stated she was responsible for checking behind the nurses and ensuring the PICC line dressing was changed, but she also missed it. She stated they had orders in the facility to change PICC line dressings every Monday and as needed. She stated failure to change a PICC line dressing as ordered would lead to infection. She also stated she expected staff to complete hand hygiene before contact with residents and after medication administration. She stated LVN X was supposed to complete hand hygiene when providing Resident #116 with care to prevent cross contamination and infection. She stated the nursing staff had been provided in-service training on hand hygiene and infection control. Interview on 12/11/2025 at 10:12 AM, the DON revealed she expected staff to change PICC line dressings every seven days and as needed to prevent infection. She stated it was the responsibility of the ADON to check after the nurses to ensure all orders were being followed. She stated she had not done training with staff on dressing changes before 12/09/25, but she had already started doing skill checks with some nurses. Records of the skill check assessments were provided, and LVN O was not in attendance. She stated LVN X was supposed to wash her hands before she put on a gown and gloves, after the procedure, and when her hands got contaminated. She stated failure to perform hand hygiene could place the resident at risk of infection.Record review of the facility's current Care of Central Venous Catheter, Dressing Change policy, dated 2003, reflected the following: Dressing changes are performed every 48hrs and as needed if gauze is used or every week if transparent dressing is used. sterile technique is used.Record review of the facility training records was requested on 12/11/25 and none was provided. Record review of the facility's current, undated Hand Washing policy reflected: . Hand hygiene continues to be the primary means of preventing the transmission of infection. When to perform hand hygiene Upon and after coming in contact with a resident's intact skin '

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1, who had dementia, was provided with adequate supervision to prevent her from eloping from the facility on 08/08/25. The resident was found half a block away from the facility. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/08/25 and ended on 08/08/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death. Findings included:Record review of Resident #1's admission Record, dated 09/04/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cerebral infarction unspecified (when the blood supply to part of the brain is blocked or reduced which prevents brain tissue from getting oxygen and nutrients and brain tissue begins to die), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), with unspecified severity and without behavioral disturbance; psychotic disturbance (a severe mental health condition characterized by a disconnection from reality); mood disturbance (mental health conditions that primarily affect a person's emotional state); and anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs). Record review of Resident #1's Optional State Assessment MDS Assessment, dated 07/13/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS (cognitive screening tool) score of 6. The MDS reflected the resident did not have wandering behaviors. Record review of Resident #1's Elopement Risk Evaluation, dated 07/17/25, which is used to assess the likelihood of a resident leaving a facility without the facility's knowledge and supervision, reflected the resident was at a moderate risk of elopement with a score of 6. Record review of Resident #1's Consent for Secured Unit, dated 08/08/25 reflected Resident #1 gave consent to be placed on the Secured Unit. Record review of Resident #1's Progress Notes from 07/10/25-08/07/25 reflected no documented evidence that she was exit-seeking or had made any elopement attempts. Record review of Resident #1's Progress Notes written by LVN K on 08/08/25 at 6:34 PM reflected: Today around 1500 [3:00 PM] [Resident #1] was found outside down the street by staff members after she escaped our facility by following an unknown someone who was exiting the building after they used the passcode that only staff knows. She was found with her walker outside and was brought back to the facility. We looked through the sign-out binder to see if anyone signed her out today and no one had signed her out. When I asked her roommate if she had any knowledge or warning from [Resident #1] that she was going to try and escape her roommate said 'Yes. [Resident #1] said she was getting out of here.' When I asked [Resident #1] why and how she escaped outside today she said, 'I don't want to be here anymore people are mean to me and call me names.' And when describing how she got out she said, 'Someone got out of a car, went to open the door, as that person was entering, another person exiting, and I followed that person out the door.' I called her Responsible Party to alert her to this elopement, she didn't answer my call, I left a voicemail. Record review of Resident #1's Care Plan, dated 09/05/25, reflected: Focus: [Resident #1] resides in secure unit related to High Risk for Elopement-8/8/25: Actual Elopement.Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the secured unit.Interventions: Admit to secure unit per DR orders. Assist and monitor resident for off unit activities if able.Involve resident in daily activities designed for secured unit. Monitor for s/s of depression, withdrawal from usual activities.Notify MD and family of any changes.Psych services per DR orders. Record review of the facility's Provider Investigation Report, completed by the Administrator on 08/15/25, reflected the following under the Investigation Summary section: On 8/8/2025 at 2:55pm.housekeeper saw what she thought was a resident outside the facility. She came to the administrator's office and wanted to report what looked like a resident outside. Admin started running down towards the exit door. Housekeeper used her car to go down the road. [Housekeeper M] located the resident halfway down the block. [Housekeeper M] placed resident in her car and picked up the admin as well. Admin asked resident, why she left the facility, and she stated she got kicked out. She would not elaborate on anything else. Resident was brought back to the facility around 2:59pm. Resident was placed on the secure unit after being interviewed by the DON. Admin reviewed cameras and resident left from the 300-hall main exit. Video shows the resident walking to the door, an outside transport company was delivering a new resident, opened the door, and let the resident out without asking the resident any questions or stopping the resident. The transport staff did not let anyone know of the resident walking out. Admin called transport company to inform them of the incident. We are still waiting for staff in servicing information. Codes to exit doors were changed. All doors were checked for proper functioning with no issues. Elopement drill was conducted. Elopement assessment on all residents conducted. Verified signage is still placed on exit doors. Sent a message to all employees on change of code to the door. Sent a message to all families about not letting any resident out of the facility and to make sure the door closes behind them. Further record review of the facility's Provider Investigation Report reflected the following: Provider Action Taken Post-Investigation: In service on Elopement response.In service on Elopement prevention.In service on Abuse/Neglect.In service on door alarms. Interview on 09/04/24 at 10:22 AM, with LVN K revealed that Resident #1 had not eloped previously or attempted eloping previously. LVN K stated that she was unaware that Resident #1 had eloped until she was notified by the ADON that she had gone. LVN K stated that she had not previously noticed Resident #1 watching the front door or exit seeking. Interview on 09/04/25 at 11:47 AM, 12:18 PM, and on 09/05/25 at 9:38 AM with Resident #1 was attempted, but the resident did not awaken from her sleep. Interview on 09/04/25 at 10:43 AM with Housekeeper M revealed at about 2:50 PM on 08/08/25 she had clocked out and exited the facility. Housekeeper M stated immediately after she left, she saw an elder with a walker walking in the middle of the street. Housekeeper M said the resident said she had been kicked out of where she lived, and so the Pope told her to leave. Housekeeper M asked the resident her name, but she was not familiar with the individual's name. Housekeeper M returned to the facility and went directly to the Administrator. Housekeeper M stated she told the Administrator the name given, but he did not recognize the name (he later learned that was not her first name). However, the Administrator immediately began walking down the street toward the resident while Housekeeper M drove her car to the resident. Housekeeper M asked the resident to get in the car, and she did. The Administrator arrived to them and recognized the resident and got into the car as well. They brought Resident #1 back to the facility where she was placed on the secured unit and notified the nurse. Housekeeper M stated she received messages on her phone regarding the elopement and was in-serviced on elopement response and elopement prevention. Housekeeper M also said that the facility codes were changed on the doors. Interview on 09/04/25 at 4:03 PM with the Administrator revealed he was in his office when a housekeeper came to him and said it looked like someone who may be a resident is on the corner outside. The Administrator stated he walked to the resident, and Housekeeper M took her car and together they found Resident #1 halfway down the block from the facility. The Administrator explained that a transportation driver did not ask questions, and he let her out the door when he entered the building. The alarm did not sound because the transportation driver used the code when entering the building. The Administrator stated he discovered Resident #1 was gone about five minutes after reviewing facility video footage. The Administrator also stated he did not have a copy of the video footage because the camera footage only saved nine days at any given time. The Administrator revealed when she was brought back to the facility, a nurse completed a skin assessment and pain assessment with no injuries found. The Administrator stated they completed an elopement assessment on Resident #1 and then placed her on the secured unit. The Administrator also said elopement assessments were completed on all residents with no residents triggering for elopement. The Administrator stated when a resident eloped, they could be injured by falling. The Administrator also revealed it was all staff's responsibility to monitor the facility's exit doors. The Administrator revealed that staff were in-serviced on Door Alarms, Elopement Prevention, Elopement Response, and Abuse/Neglect. The Administrator stated the facility sent a cover message to all staff on elopement prevention as well as a change in the code to the door alarms. The Administrator said the Maintenance Director checked all doors to ensure they were working. The Administrator stated all the door alarms were working correctly. The Administrator then revealed he started elopement drills which he continued five times per week for four weeks. The Administrator stated a QAPI was completed which revealed that the facility medical director was notified of the resident elopement. A review of the witness statements for the facility revealed no other staff had knowledge of Resident #1's elopement. Interview on 09/04/25 at 3:01 PM with the ADON revealed she was told by the Administrator that Resident #1 eloped through an exit door. The ADON said she collected the witness statements and gave them to the Administrator. The ADON also revealed the staff were in-serviced on listening for the door alarms, elopement prevention, elopement response, and abuse and neglect as well. The ADON stated everyone was supposed to be listening for the door alarms, and respond, and re-direct residents if needed to prevent residents from eloping from the facility. Then staff should notify the Administrator and the DON immediately, so the resident could be assisted back into the facility. Interview on 09/04/25 at 12:14 PM with CNA L revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:05 PM with CNA N revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior)Elopement Response (get the census and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found ), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:32 PM with CNA O revealed he had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 1:44 PM with CNA P revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 2:05 PM with CNA Q revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/04/25 at 2:28 PM with LVN R revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 9:49 AM with MA S revealed he had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response (call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 9:59 AM with CNA T revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:10 AM with CNA U revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:26 AM with LVN V revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention (observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:33 AM with CNA W revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect (physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). Interview on 09/05/25 at 10:53 AM with Social Services revealed she had been trained on the door alarms (new code is not to be given out to visitors or family and to immediately go to the doors to check for residents who have possibly eloped if the alarm sounds), Elopement Prevention(observe residents for agitation, exit seeking, anxious behavior), Elopement Response ( call a code orange, get the census, and staff take their individual assignments and look for the missing residents including inside the building and outside the building until the resident is found), and Abuse/Neglect(physical, verbal, mental with signs such as bruising and change in behavior and should notify the Administrator). The Administrator was notified on 09/05/25 at 12:35 PM, that a past non-compliance IJ had been identified related to the facility's failure to provide adequate supervision to prevent an elopement. It was determined this failure placed Resident #1 in an IJ situation on 08/08/25. Observation on 09/05/25 at 12:40 PM of the facility's exit doors and secured unit doors revealed they were locked and the keypads next to them had their green lights on indicating they were working properly. An attempt to push on the doors to open were unsuccessful. The doors stayed closed and never opened. There were signs posted on the doors which reflected the following: Reminder/Families If Resident is leaving the facility.Did you notify the Nurse? You must sign out in the Sign out book at the nurses' station prior to leaving the facility. Thank you, Management Attention!!! Staff and Visitors When Entering/Leaving Please Ensure the Door Fully Closes Behind You.Do Not Let Residents Out of the Door Without First Checking with the Nurse Thank you, Management . The facility implemented the following interventions: Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/08/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/13/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/21/25. Record review of an Elopement Drill/Actual Event Participation Log reflected a date of 08/25/25. Record review of the facility's Elopement Prevention QA Check List reflected a date of 08/08/25 and the following items reviewed/monitored:1. Doors 1-10 maglocks were secured and armed2. Doors with keypads codes have codes that are changed monthly3. All exit doors have alarms that are loud enough to be heard when opened4. All Door lock/alarm functions validated weekly in maintenance care5. Elopement policy in place6. Elopement policy reviewed in facility general orientation7. Elopement policy in-service at least annually8. Elopement risk assessments are completed upon admission/significant change/new behavior or elopement attempt9. Care plans with elopement risk interventions in place10. Secure Unit Windows have a device that allow them to open only six inches11. Secure unit present, exit doors must not have a delayed egress function. Instead do they release when any of the following occur:a. The fire alarm or sprinkler system activatesb. The facility loses powerc. A switch or button at the main nurses' station and at the monitoring station is activated. 12. Secure unit, courtyard doors have alarm/lock for going outside and NO alarm for coming inside13. Secure unit present, is there a manual fire alarm pull station located within five feet of each exit door with a sign indicating Pull to release door in emergency. Record review of the facility's Post Elopement Drill or Actual Elopement QAPI Evaluation Checklist reflected a date of 08/08/25. The QAPI evaluation checklist reflected that the facility followed its elopement response protocol, notified the family, notified the physician, notified the Administrator, and followed the procedure correctly. Record review of the facility's Elopement Risk Assessment Completed reflected a date of 08/11/25 and that Resident #1 had attempted to elope one or more times in the last week, was restless, ambulated independently, and lived on the secured unit Record review of facility's Monitoring Tool reflected staff were signing off that they had monitored all doors functioning, including the dining room door and alarms 5 times per week beginning 08/11/25 through 09/05/25. Record review of an in-service titled Elopement Response dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. The policy stated that the nurses were to use the census and divide the staff on the halls into assignments. The facility will call a code orange. The facility will look for the resident both inside and outside until the resident is found. Administration is to be notified immediately. Record review of an in-service titled Elopement Prevention dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. Staff are to monitor for anxiousness or exit seeking behaviors and alert their nurse to the behavior. The resident is to be re-directed until the behaviors change. Notify administration. Record review of an in-service titled Abuse and neglect dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. Staff is to monitor for the types of abuse/neglect and notify the abuse coordinator immediately if signs or symptoms are observed. Record review of an in-service titled Door exits/alarms ringing dated 08/08/25 reflected staff had been trained on the facility's policy and procedures by being provided the policy and procedure as well as being explained the policy and procedure. If a door alarm sounds, staff are to check the exits for residents that may have eloped. Staff are not to ignore the alarms. The door codes are not to be given out to visitors or family members. Record review of the facility's Elopement Response policy, revised January 2023, reflected: .1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms: A. Note: A resident is determined to be missing when he/she leaves the facility without the staff's knowledge.3. Should an employee observe a resident leaving the premises, he/she should A. Attempt to prevent the departure: B. Obtain assistance from other staff members in the immediate vicinity, but do not leave the resident alone, if necessary: C. Instruct another staff member to inform the charge nurse or Director of Nursing that a resident has left the premises; and D. Be courteous in preventing the departure and in returning the resident to the facility. 4. Should an employee discover the resident is missing from the facility (Code Orange) he/she should: A. Report to the charge nurse B. Determine if the resident is out on an authorized leave or pass. If not; C. Make a thorough search of the building(s) and premises. If not located; D. Notify the Administrator and the Director of Nursing; E. Notify the resident's responsible party. J. Make an extensive search of the surrounding area.Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented in the nurses' notes. Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #3 did not physically abuse Resident #2. On 07/17/25, Residents #2 and #3 physically attacked each other and Resident #2 suffered scratches to her left cheek and lip. The noncompliance was identified as PNC. The noncompliance began on 07/17/25 and ended on 07/17/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for abuse. Findings included: Record review of Resident #2's Quarterly MDS Assessment, dated 07/23/25, reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS (cognitive screening tool) score of 2. She was noted to have had physical behaviors directed towards others for 4 to 6 days. Her active diagnoses included non-Alzheimer's disease (a general term for any form of dementia that is not classified as Alzheimer's disease) and unspecified dementia (the specific type of dementia cannot be clearly identified). Record review of Resident #2's Care Plan, revised 07/17/25, reflected the following: Focus: The resident has a potential for psychosocial well-being problem r/t altercation with another resident.Interventions: Empty room at the end of the hall has been locked to prevent residents wandering in and out of the room.The resident needs assistance/supervision/support to identify causative and contributing factors.Focus: [Resident #2] has potential to demonstrate physical behaviors Dementia, Poor Impulse Control.Interventions: If [Resident #2] has physical behaviors towards another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Record review of Resident #2's Progress Notes reflected the following two entries:- LVN D wrote on 07/17/25 at 10:10 AM: Location of event: Hallway.Injury: Yes.Describe any injuries: scratches to cheek and lip.4 residents were walking the hallways peacefully, per CNA [Resident #2] and another resident went into an empty room at the end of the hall and closed the door in the other resident's face, other resident became agitated and pushed hard on the door. [Resident #2] opened the door and other resident grabbed her hair and pulled her out of the room. [Resident #2] started screaming and punching other resident while other resident pushed and pulled on other [Resident #2's] [sic] hair.Initial Treatment/New Orders: cleansed scratches no new orders from md.Resident Statement: 'I went into the room with my [family member] and shut the door, that's when she pushed the door a few times to get in, I opened the door and she hit me in the face and started fighting me'.Interventions: separation of residents. - LVN D wrote on 07/17/25 at 10:22 AM: Injury Follow-Up.Location of abrasion: left cheek and lip, Size of abrasion in cm: 5cm x2 and 1cm to lip. Record review of Resident #2's Weekly Skin Assessment, dated 07/17/25, reflected the following: .a. Bruise b. Yes. Aa. Note location, measurements of any bruise: under left eye non measurable still developing.c. Abrasion b. Yes. Cc. Note location, measurements of any abrasion: 5cm 2x to left cheek and 1cm to bottom lip. Observation on 09/04/25 at 11:30 AM of Resident #2 revealed she was walking up and down the hallway alone. Resident #2 was not able to answer any questions and just kept walking past the surveyor. Record review of Resident #3's Quarterly MDS Assessment, dated 07/10/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 01, indicating severe cognitive impairment. Her noted behaviors indicated she had physical behaviors towards other that occurred for 1 to 3 days. Her active diagnoses included non-Alzheimer's disease (a general term for any form of dementia that is not classified as Alzheimer's disease), anxiety disorder (a range of conditions that cause significant and uncontrollable feelings of anxiety and fear), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a severe mental health condition characterized by a loss of contact with reality, often manifesting as delusions and hallucinations). Record review of Resident #3's Care Plan, revised on 07/17/25, reflected the following: Focus: [Resident #3] has potential to demonstrate physical behaviors.Interventions: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.Empty room at the end of the hall has been locked to prevent residents wandering in and out of the room. Record review of Resident #3's Progress Notes reflected the following entry: LVN D wrote on 07/17/25 at 9:21 AM: Event- Other.4 residents were walking the hallways peacefully, per CNA two residents went into an empty room at the end of the hall and closed the door in [Resident #3's] face, [Resident #3] became agitated and pushed hard on the door, one resident opened the door and [Resident #3] grabbed her hair and pulled her out of the room. other [sic] resident started screaming and punching [Resident #3] while [Resident #3] pushed and pulled on other residents [sic] hair. nurse [sic] and CNAs ran to other end of the hall to separate residents and deescalate.Resident Statement: [Resident #3] is mostly nonverbal but was able to say 'i [sic] was just trying'. Observation and attempted interview on 09/04/25 at 12:31 PM with Resident #3 revealed she had just come back from being out on pass with her family and had a fast-food bag of food in her hands. Resident #3 was being guided to sit down in the dining room at a table to eat her food. Resident #3 was not able to answer any questions and instead just smiled at the surveyor. Record review of the facility's Provider Investigation Report, dated 07/23/25, reflected the following: Investigative Summary: [Resident #2] and [Resident #4] entered room [ROOM NUMBER], closed the door, and [Resident #3] was walking toward the room as well. [Resident #3] pushed the door twice, met resistance, and forced the door open. [Resident #2] was behind the door, [Resident #3] grabbed [Resident #2] by the hair and started hitting each other. Staff saw the altercation and ran to separate the residents. Both residents were assessed for pain, skin, and trauma informed assessment. [Resident #2] sustained a scratch in the lower left eye. [Resident #3] was placed 1:1.Staff were interviewed. Social/psych consult for both residents. Secure care consult for [Resident #3]. No resident shows signs of anxiousness or being scared.Facility investigation Findings: Confirmed. Record review of a Witness Statement, dated 07/17/25, completed by CNA W reflected the following: [Residents #2, #4, #3, and #5] was [sic] walking towards the end of the hall; [Residents #4 and #2] went inside room [ROOM NUMBER] and closed the door. [Resident #3] walked up to the door and pushed it twice and grabbed [Resident #2] by her hair. I yelled 'They fighting' [sic] [LVN D, CNA G], & myself ran down the hall; while [Resident #3] was punching [Resident #2] in the face, they were leaning against the wall in the corner still fighting. We broke the fight up and called [the Administrator], took [Resident #3] down the hall & sat inside an empty room and [Resident #2] at the nurse's desk. Interview on 09/04/25 at 11:53 AM with CNA E revealed he was not here when Residents #2 and #3 had an altercation on 07/17/25. CNA E said he was aware of both residents' triggers and signs they were beginning to get agitated. CNA E said Resident #2 walked up and down the hallway all day long and Resident #3 liked to walk around as well and would try to help others since she used to be a CNA herself. CNA E said staff assured Resident #3 that she did not need to help them with the other residents and distracted her with music. CNA E said he had never known or seen either Resident #2 or #3 have any physical behaviors towards another resident. CNA E said he knew to immediately intervene when two residents had an altercation with each other. CNA E said he was in-serviced after the incident to ensure he knew the facility's abuse policy and procedures as well. Interview on 09/04/25 at 12:20 PM with CNA F revealed she was not here when Residents #2 and #3 had an altercation on 07/17/25. CNA F said she had never seen or known Residents #2 or #3 to have any physical behaviors towards other residents. CNA F said Resident #3 was very caring and loving towards other residents and since she was a CNA in her past life she liked to try to help other residents. CNA F said Resident #2 was known to get upset at times but was easily calmed down through redirection and talking to her. CNA F said she was aware of both Residents #2 and #3 signs of agitation and knew how to calm them down. CNA F said she was in-serviced after the incident to ensure she knew the facility's abuse policy and procedures as well. Interview on 09/04/25 at 12:26 PM with LVN D revealed she saw Residents #2 and #3 trying to get into the last room at the end of the hallway. LVN D said Resident #2 went into the room first and when Resident #3 tried to go in it upset Resident #2. LVN D said she saw Resident #2 close the door to the room in Resident #3's face which made her upset. LVN D said Resident #3 went to push the door open again and Resident #2 slammed it shut on her. LVN D said Resident #3 opened the door again and grabbed Resident #2's hair and Resident #2 started punching Resident #3. LVN D said she saw Resident #3 stumble back into the wall behind them in the hall and by then staff were there separating the two residents. LVN D said Resident #2 ended up having scratches to her face and lip. LVN D said Resident #2 was hysterically crying and upset initially but afterwards she calmed down. LVN D said after about 15 minutes, neither resident remembered what had happened. LVN D said Resident #3 was placed on 1:1 monitoring and Resident #2 was on every 15 minute checks. LVN D said she had never seen either resident have physically aggressive behaviors towards any other resident before this incident occurred. LVN D said she was aware of both Residents #2 and #3 signs of agitation and knew how to calm them down. LVN D said she was in-serviced after the incident to ensure she knew the facility's abuse policy and procedures as well. Attempted phone interview on 09/04/25 at 1:05 PM with CNA G, who worked with Residents #2 and #3 on 07/17/25, was unsuccessful as she did not answer or call back prior to exit. Record review of a witness statement, dated 07/17/25, completed by CNA G reflected the following: I didn't see the beginning of what happened was [sic] at the nurses station when I heard someone say [Resident #2] and [Resident #3] were fighting ran [sic] down the hall to pull them apart. Phone interview on 09/04/25 at 1:11 PM with CNA H. who worked with Residents #2 and #3, revealed she had never seen either resident have physically aggressive behaviors towards any other resident before this incident occurred. CNA H said she was aware of both Residents #2 and #3 signs of agitation and knew how to calm them down. CNA H said she was in-serviced after the incident to ensure she knew the facility's abuse policy and procedures as well. Interview on 09/04/25 at 2:34 PM with Housekeeper I revealed she did not see how the situation started between Residents #2 and #3 on 07/17/25. Housekeeper I said she did see Resident #3 pulling Resident #2 by her hair out of a room, which was odd because they were just seen holding hands in the hallway. Housekeeper I said she saw staff intervening and separating the residents immediately but that was all she knew or saw. Interview on 09/04/25 at 3:50 PM with the Administrator revealed both Residents #2 and #3 had a habit of walking up and down the hallway. The Administrator said that Resident #2 liked to go into the last room on the right side of the hallway. The Administrator said Resident #2 walked into the room and Resident #3 walked in behind her. The Administrator said when Resident #3 walked in, Resident #2 closed the door on her and then Resident #3 pushed on the door harder. The Administrator said when the door opened, Resident #3 grabbed Resident #2 and they both started hitting each other. The Administrator said Resident #2 had a scratch under her eye that was superficial and did not require any further treatment. The Administrator said Resident #3 was placed on 1:1 monitoring since she initiated the first contact with Resident #2. The Administrator said staff were in-serviced on abuse, resident-to-resident altercations, and behaviors. The Administrator said the door to the room they tried going into was also now locked so that they could not go in there anymore. The Administrator said all residents had the right to be free from abuse, even from each other. The Administrator said all staff were responsible for ensuring that any resident in the facility was free from abuse. The Administrator said the incident that occurred between Residents #2 and #3 was considered physical abuse. The Administrator said if residents were not free from abuse they could suffer physical or mental anguish from the situation. The Administrator said he expected all staff to ensure residents were free from abuse. Record review of an in-service dated 07/17/25 and titled Approaching and calming residents with Dementia, revealed 90 staff had been in-serviced. Record review of an in-service dated 07/17/25 and titled Resident to Resident Abuse, revealed 90 staff had been in-serviced. Record review of the facility's Abuse/Neglect policy, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart.Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights.

Based on interview and record review, the facility failed to ensure a resident who enters the facility with an indwelling catheter receives appropriate treatment and services for 1 of 3 (Resident #1) reviewed for catheters.The facility failed to obtain physician orders to address the treatment and services that were to be provided to care for Resident #1's Foley catheter.The failure placed residents at risk for catheter complications and infection. Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. The MDS reflected Resident #1's cognition was intact with a BIMS score of 15, and his diagnoses included quadriplegia (a condition characterized by the loss of function or paralysis in all four limbs and sometimes the torso), neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associated with urination), and Stage 2 pressure ulcer of the right buttock (a shallow open wound, where the skin has broken down, revealing the dermis (the second layer of skin). The MDS reflected the resident was dependent upon staff for toileting hygiene, and he had a catheter for the entire 7 days of the assessment. Record review of Resident #1's care plan, dated 05/16/25, reflected it did not address the resident's Foley catheter.Record review of Resident #1's physician orders, dated 05/09/25, reflected there were no physician orders addressing the resident's Foley catheter.Record review on 07/15/25 at 11:07 AM of the Nurse Practitioner Notes, dated 05/21/25, reflected: ensure catheter securement device is in place to prevent pressure.Interview on 07/15/25 at 1:40 PM with LVN A revealed Resident #1 had been a resident at the facility for over a month. She stated she was aware he had a Foley catheter, but she was not sure of the orders to change the Foley catheter. She stated it was the admitting nurse's responsibility to put orders in and other nurses to notify the doctor if the orders were missing. She stated she had not noticed the Foley catheter orders were missing. She stated failure to have orders could result in the resident missing care and could cause infection. She stated she had done in-service training on documentation of orders, but she could not remember when.Interview on 07/15/25 at 3:18 PM with the Regional Compliance Nurse revealed her expectation was that the admitting nurse would ensure the orders were put in the electronic records system. She stated it was her responsibility and the ADON to follow-up the next morning and ensure all orders were correct, accurate, and entered on the MAR and TAR. She confirmed the orders were missed. She stated the facility failed to follow-up with the primary physician to get the Foley catheter orders from admission, since he did not come with Foley orders on his discharge orders. She stated failure to have orders could lead to the resident missing care like having his Foley catheter changed. She stated Foley catheters were only changed as needed or as instructed by the physician. She stated the facility had done training regarding the documentation of orders, but she did not provide evidence of the training. Interview with the ADON on 07/15/25 at 4:22 PM revealed it was her responsibility to follow-up on admissions and ensure the orders were correct. She stated she was also supposed to follow-up when there was a new order. She stated the orders for the resident's Foley catheter were missed. The risk of not having a physician order for the Foley catheter care was that it could lead to infection.Record review of the facility's Physician's Orders policy, dated 2015, reflected: Nurse will review the order and if needed contact the prescriber for any clarification.

Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #1's Foley catheter. This failure placed resident at risk of not receiving appropriate care. Findings included:Record review of Resident #1's MDS dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. The MDS reflected Resident #1's cognition was intact with a BIMS score of 15, and his diagnoses included quadriplegia (a condition characterized by the loss of function or paralysis in all four limbs and sometimes the torso), neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associated with urination), and Stage 2 pressure ulcer of the right buttock (a shallow open wound, where the skin has broken down, revealing the dermis (the second layer of skin). The MDS reflected the resident was dependent upon staff for toileting hygiene, and he had a catheter for the entire 7 days of the assessment. Record review of Resident #1's care plan, dated 05/16/25, reflected it did not address the resident's Foley catheter.Record review of Resident #1's physician orders, dated 05/09/25, reflected there were no physician orders addressing the resident's Foley catheter.Record review on 07/15/25 at 11:07 AM of the Nurse Practitioner Notes, dated 05/21/25, reflected: ensure catheter securement device is in place to prevent pressure.Interview on 07/15/25 at 1:40 PM, LVN A revealed Resident #1 had been a resident at the facility for over a month. She stated she was aware the resident had a Foley catheter, but she was not sure of the orders to change the Foley catheter. She stated she knew he had once gone to be seen by the urologist, but she did not document any notes. She stated she remembered Resident #1 telling her his Foley catheter was changed at the doctor's office. LVN A further stated staff was aware of Foley catheter care, which consisted of emptying the catheter bag each shift and cleansing the catheter even if it had not been cared planned. She stated it was the responsibility of the ADON and DON to care plan the Foley catheter for Resident #1. Interview attempted via telephone on 07/15/25 at 3:24 PM with Resident #1; however, the attempt was not successful. Interview on 07/15/25 at 4:36 PM, the Regional Compliance Nurse revealed it was the nurse's responsibility to initiate a baseline care plan upon a resident's admission. She stated she and the interdisciplinary team were responsible for updating care plans, since the facility did not have a Director of Nursing. She stated the interdisciplinary team was responsible for initiating care plans according to their disciplines. She stated to have a Foley catheter care planned there were supposed to be orders and assessments in the resident's record, and they were missed from admission. She stated she was supposed to have followed up to ensure the care plans were updated, but the care plan was missed. She stated the purpose of the care plan to ensure continuity of care.Record review of the facility's current, undated Comprehensive Care Planning policy, reflected:Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goal, and address the resident's medical, physical, mental and psychosocial needs. Comprehensive care Plans will be: -Developed within 7 days after completion of the comprehensive assessment.Prepared and /or contributed to by an interdisciplinary that includes, but is not limited to: -a. The Attending Physician.b. A Registered Nurse who has responsibility for the resident.c. A member of food and nutrition services staff.d. The Social Services Worker responsible for the resident.e. To the extent practicable, the participation of the resident and the resident's representative.f. Nursing assistants responsible for the resident's care.k. Other appropriate staff or professional or professional in discipline as determined by the resident's needs or as requested by the resident .

Based on observation, interview, and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately but not later than 2 hours after the allegation was made to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for abuse. LVN A failed to immediately report an abuse allegation to the Administrator, who was the facility's abuse coordinator, when she overheard CNA B verbally abusing Resident #1 in early May 2025. This failure could have caused residents to experience abuse by staff. Findings included: Record review of Resident #1's admission Record, dated 06/04/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 04/01/25, reflected she had a BIMS score of 06, which indicated severe cognitive impairment. Her active diagnoses included Non-Alzheimer's Dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities), Schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), and Borderline Personality Disorder (a mental health condition that affects the way people feel about themselves and others). Observation and attempted interview on 06/04/25 at 10:00 AM with Resident #1 revealed she was lying in bed in her room. Resident #1 did not answer any questions the surveyor asked, instead she just stared at the surveyor. Interview on 06/04/25 at 9:31 AM with LVN A revealed she worked with Resident #1 on the secured unit. LVN A said she saw CNA B go in to provide care to Resident #1 one day in early May 2025 and overheard the aide tell the resident, You need to get your pissy ass back in bed. LVN A said she wrote out a witness statement and turned it into the Administrator who was the Abuse Coordinator for the facility since this was an instance of verbal abuse. Interview on 06/04/25 at 10:15 AM with the Administrator revealed he had not received any witness statements regarding an abuse allegation and CNA B or Resident #1. Interview on 06/04/25 at 10:52 AM with CNA B revealed she cared for Resident #1 but had never abused her. CNA B said she never said anything verbally abusive towards Resident #1 or any other resident. CNA B said she felt like LVN A was trying to get her in trouble or fired because they did not get along as co-workers. CNA B said she no longer worked with Resident #1. Follow-up interview on 06/04/25 at 11:30 AM with LVN A revealed she wrote a witness statement informing the Administrator about the verbal abuse she witnessed by CNA B towards Resident #1. LVN A said the Administrator's door was closed at the time, but she put it under his door. LVN A said she never received any follow-up from the witness statement but did not bring it up again to the Administrator. LVN A said she thought she followed the procedure by filling out the witness statement and giving it to the Administrator. Interview on 06/04/25 at 12:57 PM with the Interim DON revealed when she interviewed LVN A about the abuse allegation regarding CNA B and Resident #1, LVN A said she wrote a witness statement and left it under the Administrator's door. The Interim DON said LVN A should have called the Administrator instead of just writing a witness statement, so she was immediately in-serviced on the facility's abuse policy. Interview on 06/04/25 at 2:26 PM with the Administrator revealed he interviewed LVN A about the abuse allegation regarding CNA B and Resident #1. The Administrator said LVN A told him she wrote a witness statement and then slipped it under his door while he was out on PTO. The Administrator said when he returned from PTO, there was nothing under his door. The Administrator said all staff knew to report all abuse to him immediately, which usually meant they would call or text him; even if he was out on leave or out of the building. The Administrator said the purpose of staff immediately reporting abuse allegations to him was to protect the residents from further abuse. The Administrator said if staff did not immediately report an abuse allegation to him then the same situation could happen with another resident. The Administrator said all staff were responsible for ensuring they reported any allegation of abuse to him immediately. The Administrator expected that all staff immediately report any abuse allegation to him. Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected: .E. Reporting .1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator [sic], state and/or adult protective services .2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called .

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 3 of 10 residents (Residents #2, #3, and #4) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2, #3, and #4 were free of abuse from Resident #1. Resident #1 hit Resident #2 and #3 with her doll in the face and head when she was upset and punched Resident #4 in the stomach after she approached her boyfriend. An Immediate Jeopardy (IJ) was identified on 02/11/25 at 3:47 PM. The IJ template was provided to the facility on [DATE] at 4:00 PM. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of physical abuse from other residents. Findings included: Record review of Resident #1's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), stroke, seizure disorder, and profound intellectual disabilities. Resident #1 was not able to complete a BIMS due to her impaired cognition and she was rarely understood by others and rarely/never understood others. The MDS further reflected Resident #1 was independent with walking and did not have any impairment to upper and lower extremities. Record review of Resident #1's care plan initiated on 06/16/23 reflected she had the potential to demonstrate physical behaviors related to poor impulse control. Resident #1 had poor impulse control and would utilize her baby doll to make contact with other residents in an aggressive way and would also get upset and physical when felt that others were talking to her boyfriend. Intervention included to analyze key times, places, circumstances, triggers, and what de-escalates the behaviors and document. Other interventions included to intervene before agitation escalated and guide away from source of distress and immediately intervene to protect the residents involved and call for assistance. Record review of Resident #2's Annual MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), stroke, hemiplegia (medical condition that causes paralysis or weakness on one side of the body), reduced mobility, and difficulty in walking. Resident #2 had a BIMS of 13 which indicated his cognition was intact. The MDS also reflected the resident had impairment on one side to his upper extremity and impairment on both sides to his lower extremity and used a wheelchair for mobility. Record review of Resident #3's Quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included coronary artery disease (condition in which the arteries that supply blood to the heart muscle become narrowed or blocked), stroke, difficulty in walking, and muscle weakness. Resident #3 had a BIMS of 8 which indicated his cognition was moderately impaired. The MDS further reflected the resident had impairment on one side to upper and lower extremities. Record review of Resident #4's annual MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, stroke, difficulty in walking, weakness and history of falling. Resident #4 had a BIMS of 7 indicating her cognition was severely impaired. The MDS further reflected the resident was independent with walking and most all ADL's. Record review of the facility's Provider Investigation Reports reflected the following: 12/05/24 On 11/25/24, [Resident #2] was sitting one table down from [Resident #1] in the main dining room. According to [Resident #2], [Resident #1] threw her doll at him. He in turn grabbed the doll and threw it on the floor. [Resident #1] got up and picked her doll up and started crying. [Housekeeper D] saw the altercation and intervened. According to her statement, [Resident #1] hit [Resident #2] several times but after interviewing [Resident #2], he was only struck by the doll when it was thrown at him ] 01/23/25 [Resident #3] was sitting one table down to [Resident #1] in the dining room during breakfast. After breakfast was complete, [Resident #1] was tapping her foot on the floor and [Resident #3] asked her to stop tapping so loud because he could not hear the TV. [Resident #3] turned back around to look at the TV and [Resident #1] took her doll and hit [Resident #3] in the forehead. Another resident saw the altercation and went to tell the nurse 01/26/25 [Resident #1] was sitting in her usual spot in the dining room. [Resident #4] went up to [Resident #1] to ask her a question. [Resident #1] responded by saying that is my boyfriend don't talk to my man and punched her with a closed hand. [Resident #4] retaliated by hitting [Resident #1]. Residents were pulling hair. Staff intervened and separated both residents Skin assessments were conducted with [Resident #4] showing a quarter size bruise to inner upper left arm. No injuries to [Resident #1] Record review of Resident #1's progress notes on the following dates reflected: 10/21/24 - documented by the Social Worker Visit with [Resident #1] regarding the incident where she threw her baby doll at another resident. She did not act like she knew what this SW was talking about. SW discussed with her that her baby is little and can get hurt. She needs to be a good Mom and not throw her baby. She said she knew not to hurt baby 11/15/24 - documented by LVN CC Resident continues with loud laughing, taunting other residents in dining room, yelling and crying @ random intervals. Was recently started on Klonopin in afternoon by psych 11/16/24 - documented by LVN E Res in dining room yelling and laughing at other residents, CNA approached and told her to go to her room, res then ran up to cna and grabbed her by her hair, and started hitting her in the face. Another staff member intervene and separates Res from staff 11/25/24 - documented by LVN CC Noted resident sitting in dining room, sticking her tongue out at several male residents and yelling at them get out of here, I don't like you and flipping them off with the middle finger of her left hand. Resident's chair was moved so that her back was turned toward the male residents and toward the TV so she can continue watching the program that was on. She was instructed that this behaviour is not acceptable and she can't remain in the dining room if she continues to act out toward other residents in this way. Resident stated I won't do it and was holding her baby doll and smiling as writer left at table Observation and interview on 02/11/25 at 9:58 AM of Resident #1 revealed she was sitting at a dining room table next to another male resident. The resident had 7 stuffed animals and two dolls in a chair next to her. The two dolls had a soft, cloth stuffing and the hands, feet, and head were a firm plastic/rubber material. Attempted to interview Resident #1 but she was only able to give simple 2 to 3 word sentences and did not recall any incident or altercations with other residents. Observation and interview on 02/11/25 at 10:05 AM with Resident #2 revealed he was in his room. He was slowly self-transferring from his wheelchair to the bed and appeared to have paralysis to the left side of body. Resident #2 was asked about the incident with Resident #1 and he said he was in his room and Resident #1 approached his door and took a few steps inside and threw her doll at him. Resident #2 said the doll hit his face so he then threw the doll back at Resident #1 and she then began to yell and curse. Resident #2 also said there was an incident where Resident #1 pushed his wheelchair with him in it against the wall but he was not hurt and there was no one around at that time nor did he tell anyone. Resident #2 further stated he was not afraid of Resident #1 just rather he was irritated at the things she did. He described Resident #1 as a rude person who cursed and yelled at others so he now preferred to keep his distance and did not go out to the dining room much to avoid Resident #1. Observation and interview on 02/11/25 at 10:52 AM with Resident #4 revealed she was in her room sitting on the side of her bed. She was asked about the incident with Resident #1 and she said she had approached Resident #1's male friend that was sitting with her at the dining room table and asked him for a quarter. At that time Resident #1 told Resident #4 to get away from her man and then stood up and punched her in the stomach so she then in return pulled Resident #1's hair and hit her back. Resident #4 stated she was not afraid but if Resident #1 was going to hit her, she was going to hit her back. Observation and interview on 02/11/25 at 10:22 AM with Resident #3 revealed he was sitting in the dining room listening to bible study and eating a snack. The resident was observed using a wheelchair and getting up to walk short distances. Resident #3 said Resident #1 has history of acting out in the mornings and said the day of the incident, 01/23/25, Resident #1 was hitting the bottom of the dining room table and he asked her to stop and that is when Resident #1 came around and hit him in the head with her doll. Resident #3 said the doll hurt his head when it made contact with his forehead because the doll contained some hard parts. Resident #3 further stated Resident #1 would get upset with different people when they would talk to her boyfriend who sat at her table and Resident #1 always started the fights. Resident #3 said he was not afraid of Resident #1 but the residents were annoyed with her behaviors. Interview on 02/11/25 at 12:08 PM with Housekeeper D revealed during the incident with Resident #2 she was across the hall and heard yelling but could not make out what was being said. As she turned she saw Resident #1 hitting Resident #2 on the head with her baby doll. This incident occurred outside of the rooms, as they used to be neighbors. Housekeeper D said she separated the residents and went to report the incident to the Administrator. The Housekeeper said had heard Resident #1 yell at other residents but that was the first time she had seen her become physical with them. Interview on 02/11/25 at 12:13 PM with LVN D revealed she was told by CNA F that Resident #1 was in the dining room, on 11/16/24, and she believed Resident #1 might have been trying to hit someone with her baby doll when CNA F tried to intervene. CNA F told her Resident #1 then grabbed CNA F's hair and began to hit her in the face with her other hand. LVN D further stated Resident #1 had a history of becoming verbal with others especially when other residents tried to talk to her male friend that sat with her at the dining room table. Interview on 02/11/25 at 12:29 PM with CNA F revealed she approached Resident #1 and told her to go to her room so she could change her. Resident #1's male friend told Resident #1 she needed to go with CNA F and CNA F touched her male friend on his shoulder and Resident #1 jumped up out of her chair and grabbed CNA F by the hair and began to punch her. CNA F said that had been the first time Resident #1 had hit her and it all happened because Resident #1 would become defensive if anyone was around her male friend. CNA F further stated Resident #1 had a history of hitting others with her baby dolls and cursing at staff and residents all day long. CNA F said it was difficult to prevent Resident #1 from hitting and yelling at others because she would not stay in her room and stayed in the dining room all day long. If and when they tried to redirect Resident #1 she would begin to yell and curse. CNA F also said Resident #2 now preferred to stay in his room to avoid Resident #1 and others resident would also get frustrated and leave the dining room so they did not have to hear Resident #1 yell out. Interview on 02/11/25 at 12:39 PM with the Weekend Supervisor revealed during the incident between Resident #1 and Resident #4, she was in the wound care office next to the dining room when she heard Resident #1 screaming. When they heard Resident #1, they usually knew something was going on because the resident had a history of swinging at people. When the Weekend Supervisor entered the dining room Resident #4 had Resident #1 by her hair and they were immediately separated and Resident #1 was put on 1:1 safety checks. The Weekend Supervisor said she had not worked at the facility long but had been told Resident #1 had a history of hitting but she had never witnessed it prior to that incident. Resident #1 would sit in the dining room all day and yell and scream random things at others and they would try to redirect the resident to her room but she always refused to go. The Weekend Supervisor further stated everyone just had to work around Resident #1. Interview on 02/11/25 at 12:50 PM with the Social Worker revealed they were seeing some regression with Resident #1's developmental disability and the resident had begun to throw her baby dolls at others and there were not patterns to her behaviors. The Social Worker described Resident to be very territorial of her space and of her male friend that sat with her and they tried to redirect her behavior if they saw it coming. She said Resident #1 has previously been treated for a UTI and they had discussed her behaviors with the PASSR representative. The Social Worker further stated she had spoken to Resident #1 after her physical incidents but due to her cognition the resident did not really seem to recall the incidents and forgot as soon as they occurred. Interview on 02/11/25 at 1:32 PM with the DON revealed he had only been working at the facility for less than 2 months and he had been made aware of the incidents between Resident #1 and Residents #3 and #4. The DON said they had inserviced staff in the past about techniques to deescalate physical altercations between the residents. Staff were also to frequently monitor Resident #1 and they had just adjusted the resident's medications. The DON said they had not tried to take Resident #1's dolls because that would infringe on her rights but they had encouraged her to not have so many baby dolls in the dining room. Interview on 02/11/25 at 1:42 PM with the Administrator revealed they had met and discussed to limit how many dolls Resident #1 kept and to make sure staff frequently monitored to prevent altercations with other residents. The Administrator said there had not been any injuries as a result of the incidents and also said Resident #1 would not let go of her baby dolls because she was really attached to them. Record review of the facility's policy titled Abuse/Neglect revised 03/2018 reflected the following: The resident has the right to be free of abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals An Immediate Jeopardy/Immediate Threat was identified on 02/11/25. The Administrator, DON and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 02/11/25 at 3:43 PM. The IJ template was provided to the facility on [DATE] at 4:00 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 02/12/25 at 9:44 AM and reflected the following: Plan for Removal: F600 Failure to Prevent Abuse and Neglect Interventions: Resident #1 was immediately placed on 1:1 supervision on 2.11.25 with facility staff. Resident #1 discharged to alternate facility with guardians' approval 2.11.25. Resident #1's baby doll with the plastic heads were immediately removed from Resident #1's possession and from resident #1's room on 2.11.25 by regional compliance nurse. Resident's #1's care plan was reviewed by Regional Compliance Nurse for appropriate interventions to prevent resident and staff altercations on 2.11.25. Resident #1's care plan was updated by the Regional Compliance Nurse to reflect additional interventions of 1:1 supervision and removal of baby dolls with hard plastic pieces on 2.11.25. IDT team will schedule a care plan meeting with Responsible Party, Physician, and Resident to review and evaluate interventions to prevent repeated altercations with staff and residents starting 2.11.25. The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics. Completed 2.11.25 o Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented to prevent abuse. o Behavior Management Policy- Managing behaviors and intervening appropriately. The Medical Director was notified on 2.11.25 of the immediate jeopardy. An ADHOC QAPI was held with the IDT Team on 2.11.25 to discuss the immediate jeopardy and plan of removal. In-services All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON to prevent resident to resident abuse and ensure appropriate response to aggressive behaviors. In-servicing initiated on 2.11.25 and will be completed by 2.12.25. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to starting their shift. o Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented. o Behavior Management Policy- Managing behaviors and intervening appropriately. Monitoring of the facility's Plan of Removal included the following: Observation on 02/12/25 at 10:04 AM revealed Resident #1 was no longer at the facility and had been discharged to another nursing facility. Record review of Resident #1's progress notes dated 02/11/25 documented by LVN C reflected the following Resident transferred to sister [facility] due to behaviors. Vitals within normal limits, medication and belongings sent with her. Guardian notified of transfer Record review of the facility's inservices titled Abuse/Neglect dated 02/11/25 reflected all facility staff were educated on the different types of abuse, abuse prevention and ensuring interventions were implemented to prevent abuse, and managing behaviors and intervening appropriately. If staff are to witness resident to resident abuse, they are to immediately intervene, ensure the residents are safe and report the incident to the Administrator. To prevent abuse, staff are to redirect residents away from aggressive or agitated behaviors and watch for signs of aggression. Interviews on 02/12/25 at 1:02 PM to 02/13/25 at 2:35 PM from staff from various shifts were the Administrator, DON ADON P, Weekend Supervisor, Social Worker, Transportation, BOM , Medical Records, Dietary Manager, PTA, OT, LVN A, LVN C, Housekeeper D, LVN E, CNA F, LVN G, MA I, MDS Nurse K, MDS Nurse L, CNA N, CNA O, MA Q, CNA R, Housekeeper T, Housekeeper U, CNA V, [NAME] W, [NAME] X, MA, Z, CNA AA, and CNA BB. All staff were able to identify the following: - The different types of abuse. - What to do if they witness resident to resident abuse. - What signs to watch for in residents to prevent resident to resident abuse/behaviors - Who to report any incidents of abuse - All staff stated there were no other residents they were aware of that were having consistent physical altercations in the facility. The Administrator was notified on 02/13/25 at 3:30 PM, the Immediate Jeopardy was removed. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interview and record review, the facility failed to ensure residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #5) reviewed for ostomy care. The facility failed to assist Resident #5 with colostomy care resulting in her colostomy leaking. This failure could place the resident at risk of skin irritation and breakdown from exposure to fecal matter. Findings included: Record review of Resident #5's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the rights side of her body, legal blindness, and rectal cancer requiring the creation of a colostomy (opeing in the intestines to allow feces to drain into a bag). Record review of Resident #5's quarterly MDS, dated [DATE] reflected a BIMS score of 10 indicating she was moderately cognitively impaired. Her Functional Status reflected she required set-up and clean up assistance with her toileting hygiene. Her Bowel and Bladder assessment indicated she had an ostomy. Record review of Resident #5's care plan, dated 12/22/24, reflected she had a visual impairment related to being legally blind, and ADL self-care deficit related to paralysis, and had an ostomy. Interview on 02/11/25 at 9:50 AM with Resident #5 revealed she often had to change her briefs because the staff took too long to respond to her call light. Resident #5 stated she thought staff knew if they waited, she would do it herself. She stated she did need staff assistance to make sure she was completely clean, and she needed assistance with applying her colostomy bag to make sure it was on properly to prevent it leaking. Resident #5 stated in the evening on 02/07/25 her colostomy bag was leaking, and she was trying to clean up with her wipes. She stated CNA B answered her call light and told her he would have to get the nurse to help her. She stated LVN A came to the resident's room and told her she could not help the resident because she was the only nurse monitoring the evening meal in the dining area. She stated LVN A put a new colostomy bag on the resident's overbed table and left. Resident #5 stated she waited for about 20 minutes, and no one came to help her, so she applied the bag herself and cleaned herself up. She stated she must not have applied it correctly because later that evening the bag began to leak again. She stated a nurse from the night shift helped her secure the bag properly. Interview on 02/11/25 at 3:25 PM with LVN A revealed she was called to Resident #5's room by CNA B from the dining area where she was monitoring the evening meal. LVN A stated Resident #5 told her she needed a new colostomy bag, so she put one on the resident's table. LVN A told her she could not help because she had to get back to the dining area. LVN A stated there was a second nurse on the hall, who was supposed to care for the residents, while she was in the dining area. LVN A stated she did not notify the other nurse that Resident #5 needed help. LVN A stated she did not follow-up with Resident #5 when she returned from the dining area. Interview on 02/11/25 at 3:28 PM with LVN C revealed she had not been made aware of Resident #5 needing assistance with her colostomy. She stated LVN A never had a conversation with her on 02/07/25, and the interview with the surveyor was the first she time she had been made aware of the situation. Interview on 02/12/25 at 10:35 AM with the DON revealed his expectation of the nurses would be if they could not assist a resident right away, they should have a conversation with their teammate and ask them to assist the resident. He stated that was why they had two nurses on the hall. The DON stated skin exposure to fecal matter could quickly lead to skin irritation and skin breakdown. Record review of the facility's Ostomy Care policy, dated 2003, reflected: .Goals 1. The resident will maintain continuous or intermittent drainage via bowel diversion without complications. 2. The resident will complete/receive correct and proper care of stoma, skin, and collection procedures. 3. The resident will be maintaining optimal skin integrity at stoma site. .18. Persistent leakage or poorly fitted appliances can cause injury to the stoma and skin breakdown

Based on interview and record review, the facility failed to ensure residents were treated with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #5) reviewed for resident rights. The facility failed to treat Resident #5 with dignity when staff failed to assist the resident with colostomy care, resulting in it leaking and causing her to feel embarrassed in front of her roommate. This failure could cause the resident embarrassment and a decreased sense of self-worth. Findings included: Record review of Resident #5's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the rights side of her body, legal blindness, and rectal cancer requiring the creation of a colostomy (opening in the intestine to drain feces into a bag). Record review of Resident #5's quarterly MDS, dated [DATE] reflected a BIMS score of 10 indicating she was moderately cognitively impaired. Her Functional Status reflected she required set-up and clean up assistance with her toileting hygiene. Her Bowel and Bladder assessment indicated she had an ostomy. Record review of Resident #5's care plan, dated 12/22/24, reflected she had a visual impairment related to being legally blind, and ADL self-care deficit related to paralysis, and had an ostomy. Interview on 02/11/25 at 9:50 AM with Resident #5 revealed she often had to change her briefs because the staff took too long to respond to her call light. Resident #5 stated she thought staff knew if they waited, she would do it herself. She stated she did need staff assistance to make sure she was completely clean, and she needed assistance with applying her colostomy bag to make sure it was on properly to prevent it from leaking. Resident #5 stated in the evening on 02/07/25 her colostomy bag was leaking, and she had tried to clean up with her wipes. She stated CNA B answered her call light and told her he would have to get the nurse to help her. She stated LVN A came to her room and told her she could not help because she was the only nurse monitoring the evening meal in the dining area. She stated LVN A put a new colostomy bag on the resident's overbed table and left. Resident #5 stated she waited for about 20 minutes and no one came to help her, so she applied the bag herself and cleaned herself up. She stated she must not have applied it correctly because later that evening the bag began to leak again. Resident #5 stated her colostomy was very smelly when being changed. She stated she was embarrassed by it leaking because she had a roommate, and the door to the hall was open. Resident #5 stated she usually changed it every other day when she was taking her shower to limit the smell affecting others. She stated a nurse from the night shift helped her secure the bag properly. Interview on 02/11/25 at 3:00 PM with CNA B revealed he responded to Resident #5's call light on 02/07/25. He stated the resident's colostomy bag was leaking and needed to be changed. He stated he told Resident #5 he would have to get the nurse as that was beyond his scope of practice. He notified LVN A, who was monitoring residents in the dining area, and she went to check on the resident. Interview on 02/11/25 at 3:25 PM with LVN A revealed she was called to Resident #5's room by CNA B from the dining area where she was monitoring the evening meal. LVN A stated Resident #5 told her she needed a new colostomy bag, so she put one on the resident's table. LVN A told her she could not help because she had to get back to the dining area. LVN A stated there was a second nurse on the hall, who was supposed to care for the residents, while she was in the dining area. LVN A stated she did not notify the other nurse that Resident #5 needed help. LVN A stated she did not follow-up with Resident #5 when she returned from the dining area. Interview on 02/11/25 at 3:28 PM with LVN C reveale she had not been made aware of Resident #5 needing assistance with her colostomy. She stated LVN A never had a conversation with her on 02/07/25, and the interview with the surveyor was the first she time she had been made aware of the situation. Interview on 02/12/25 at 10:35 AM with the DON revealed his expectation of the nurses would be if they could not assist a resident right away, they should have a conversation with their teammate and ask them to assist the resident. The DON stated that was why they had two nurses on the hall. He stated all residents deserved to be treated with respect and dignity. He stated LVN A did not treat Resident #5 with respect and dignity.

Based on interview and record review the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report for 8 (Residents #2, #3, #15, #23, #29, #39, #62, #71) of 10 residents reviewed for PASARR assessments. The facility failed to submit a Nursing Facility Specialized Services (NFSS) form request by the specific deadline for Residents #2, #3, #15, #23, #29, #39, #62, and #71. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #2's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected a BIMS of 06 indicating severe cognitive impairment. Resident #2 had diagnoses of anxiety disorder (significant and uncontrollable feelings), Depression (mental state of low mood), and Schizophrenia (mental disorders of hallucinations, delusions, disorganized thinking, and behavior). Review of Resident #2's care plan revealed she has a Mental Illness & Intellectual Disability Diagnosis and was PASRR positive. Diagnoses of Schizophrenia, Schizoaffective Disorder, Major Depressive Disorder, Developmental Disorder of Scholastic Skills. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included Specialized Services of Habilitation Coordinator, Physical Therapy and Occupational Therapy will be provided per Local Authority recommendations. [DATE] Local Authority Representative here in the facility will add Customized Manual Wheelchair and also Pressure Reducing Mattress (seat cushion and back support). Will continue with Physical Therapy & Occupational Therapy. Local Authority will be invited annually to the care plan meeting for review of Specialized Services. Review of Resident #3's face sheet, dated [DATE], reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #3's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected a BIMS of 11 indicating moderate cognitive impairment. Resident #3 had a diagnoses of anxiety disorder (significant and uncontrollable feelings), Psychotic Disorder (severe mental disorders that cause abnormal thinking and perceptions), and Schizophrenia (mental disorders of hallucinations, delusions, disorganized thinking, and behavior), Intellectual Disabilities (learning disability formally known as mental retardation). Review of Resident #3's care plan revealed he has a diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included Quarterly PASRR meeting held. Will continue with Habilitation Coordinator and Resident to be placed on Physical Therapy services. Specialized Services, Habilitative Services, will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services. Review of Resident #15's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #15's most recent Comprehensive MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a BIMS of 04 indicating severe cognitive impairment. Resident #15 had diagnoses of Non-Traumatic Brain Dysfunction (injuries caused by internal factors), anxiety disorder (significant and uncontrollable feelings), Major Depressive Disorder (clinical depression), Pseudobulbar Affect (uncontrollable episodes of crying or laughing). Review of Resident #15's care plan revealed she has a Diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included [DATE] PASRR here for Resident's Quarterly meeting/review. Specialized Services of Occupational Therapy with a specialized wheelchair will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services. Review of Resident #23's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #23's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a diagnoses of Anxiety Disorder (significant and uncontrollable feelings), Depression (mental state of low mood), Bipolar Disorder (mental disorder by periods of depression and periods of abnormally elevated mood), Psychotic Disorder (mental illness that cause a person to lose touch with reality), Schizophrenia (mental disorder by hallucinations, delusions, disorganized thinking and behavior), Mental Disorder (mental illness or psychiatric disability). Review of Resident #23's care plan revealed she has diagnoses of Mental Illness, Intellectual Disability and was PASRR positive. Diagnoses of Schizoaffective Disorder, Bipolar II Disorder, Psychosis, Developmental Disorder of Scholastic Skills, Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included Specialized Services Habilitation Coordinator and Therapy Services will be provided per Local Authority recommendations. [DATE] Local Authority Representative here in the facility discussed that will continue with Habilitation Coordinator and Physical Therapy. Local Authority will be invited annually to the care plan meeting for review of Specialized Services. Review of Resident #29's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Review of Resident #29's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a BIMS of 08 indicating moderate cognitive impairment. Resident #29 had diagnoses of Schizophrenia (mental disorder by hallucinations, delusions, disorganized thinking, and behavior), borderline personality disorder (emotionally unstable personality disorder), Mild Intellectual Disabilities (learning disability formerly mental retardation). Review of Resident #29's care plan revealed she has diagnoses of Mental Illness, Intellectual Disability and was PASRR positive. Diagnoses of Schizoaffective Disorder, Borderline Personality Disorder, Mild Intellectual Disabilities, Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included PASRR here for Resident's Quarterly meeting. Resident to continue Physical Therapy, Occupational Therapy, Habilitation Coordinator, and Independent Living Services. Resident will be receiving therapy and Habilitation Coordinator services. Specialized Services, and Resident is on ILS and Habilitative Services which will be provided per Local Authority recommendations. Review of Resident #39's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #39's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a diagnosis of Moderate Intellectual Disabilities. Review of Resident #39's care plan revealed she has diagnoses of Mental Illness, Intellectual Disability and Developmental Disability and was PASRR positive. Diagnoses of Scholastic Skills, Mental Disorder, Schizoaffective Disorder, Moderate Intellectual Disability, Personality Disorder, Psychosis, Major Depressive Disorder. Goal included resident will have specialized services recommended by local authority per PASRR. Specialized Services program as needed. Interventions included [DATE] PASRR here for Resident's Quarterly review. Resident to remain on Physical Therapy, Occupational Therapy and Habilitation Coordinator services. Specialized Services Habilitation Coordinator and Physical Therapy will be provided per Local Authority recommendations. [DATE] Local Authority Representative here in the facility Discussed that will continue with Habilitation Coordinator and Physical Therapy. Local Authority will be invited annually to the care plan meeting for review of Specialized Services Review of Resident #62's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #62's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected she had a BIMS of 02 indicating severe cognitive impairment. Resident #62 had diagnosis of Intellectual Disabilities (learning disability formerly mental retardation). Review of Resident #62's care plan revealed she has diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR Specialized Services program as needed. Interventions included Specialized Services will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services Review of Resident #71's face sheet, dated [DATE], reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #71's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected he had a BIMS of 08 indicating moderate cognitive impairment. Resident #71 had diagnosis of Intellectual Disabilities (learning disability formerly mental retardation). Review of Resident #71's care plan revealed he has diagnosis of Intellectual Disability and was PASRR positive. Goal included resident will have specialized services recommended by local authority per PASRR Specialized Services program as needed. Interventions included [DATE] PASRR here for Resident's Quarterly review. Resident to remain on Physical Therapy, Occupational Therapy, Habilitative Coordinator, and Independent Living Services. Specialized Services Occupational Therapy and Physical Therapy will be provided per Local Authority recommendations. Local Authority will be invited annually to the care plan meeting for review of Specialized Services Request for Residents #2, #3, #15, #23, #29, #39, #62, #71's NFSS forms revealed forms were not available. In an interview on [DATE] at 3:55 PM the Director of Rehabilitation stated she was hired mid [DATE]. The Director of Rehabilitation stated she had not been formally trained on the PASRR process however, she was responsible for filling out the NFSS forms, placing them in a box for the physician to sign, and after she got them back with the physician's signature she would then give the forms to the Administrator. The Director of Rehabilitation stated after the Administrator signed and reviewed the forms she would contact her supervisor, the Regional Operations Director, to let her know the forms were ready to upload along with the evaluations. The Director of Rehabilitation stated she was not sure how to upload the documents in the portal and that she had not been trained to do so, therefore her supervisor (Regional Operations Director) would ensure the forms were uploaded to the portal in a timely manner. The Director of Rehabilitation stated once the documents were uploaded, she would get an email from her supervisor to reflect which forms had been uploaded. According to the Director of Rehabilitation not getting the forms uploaded in a timely manner would place resident at risk of not getting the desired PASRR services. Record review of an email dated [DATE] reflected the Regional Operations Director emailed the Local Authority. The email revealed I am trying to help staff get PASSR up and going at the facility. I had some submitted prior and the Medicaid number failed. I also had some that were submitted as restart and should have been recertification. We have a new director at this site, and we are trying to get them completed. The original email was sent to the wrong person, and I was notified of the meeting today. I will be working on getting these corrected and up to date. Record review of an email dated [DATE] reflected the Local Authority responded to the Regional Operations Director. The email revealed, Since the authorizations have mostly been expired, you will need to do all the NFSS forms as NEW and start from the very beginning. It is recommended to do the recertifications about a month to two weeks BEFORE the expiration of the authorizations to ensure there is no lapses in the coverage dates. Since we are having PASRR meeting tomorrow, [DATE] you will have 20 business days to submit the services (NEW NFSS forms)- so that would make it a [DATE]th, 2024, deadline. 1. Resident #3 - Habilitation Coordinator and Physical Therapy 2. Resident #39 - Physical Therapy 3. Resident 71 - Physcial Threapy and Occupational Therapy 4. Resident #29 - needed services of Physical Therapy, Occupational Therapy and Speech Therapy 5. Resident #15 - Physical Therapy, Occupational Therapy, and Speech Therapy 6. Resident #62 - Physical Therapy and Occupational Therapy 7. Resident #2 - needs a customized manual wheelchair, Physical Therapy, Occupational Therapy 8. Resident #23 - Physical Therapy and Occupational Therapy. In an interview on [DATE] at 4:16 PM with the Regional Operations Director, she stated the Director of Rehabilitation was fairly new to the position, so she was responsible for ensuring NFSS documents were uploaded to the portal after they were filled out and signed by the physician and Administrator. The Regional Operations Director stated for some time there was an Interim Director of Rehabilitation at the facility and thought the documents from the [DATE] meeting may have gotten lost. The Regional Operations Director stated by the time she received the notice that they missed the deadline to upload the documents it was too late, and the forms were past due. She stated she did upload the documents to the portal once she found out, however, several documents were with errors, so they were kicked back. The Regional Operations Director stated she was currently working with the Local Authority to correct the errors and get the documents uploaded as quickly as possible. Regional Operations Director stated she did not see a risk to the residents as their services were going and they did not have a lapse in services. The Regional Director of Operations stated the Director of Rehabilitation was responsible for ensuring the NFSS documents were uploaded to the portal. Interview and record review on [DATE] at 4:30 PM with the Regional DON revealed she was not aware the PASARR forms for Residents #2, #3, #15, #23, #29, #39, #62, and #71 were late. Record review of the portal revealed the NFSS forms were not uploaded, and she could not clearly identify the last time they had been uploaded to the portal. The Regional DON said the purpose of submitting the forms on time was so that the resident had access to the agreed upon services. The Regional DON said she was not sure why the forms were late however she would speak with the Director of Rehabilitation who was responsible for uploading the NFSS forms to make sure they were submitted as soon as possible. In an interview on [DATE] at 4:45 PM with the DON revealed the facility did not have a PASARR policy that covered PASRR positive policy and procedures.

Based on observations, interviews, and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1 was provided with adequate supervision and free of potential harm when he eloped from the facility on 07/30/2024 without staff knowledge. The facility was informed of the elopement by a family member who reported the resident was found 8 miles from the facility. The facility failed to ensure staff rounded often to ensure all Resident #1 was in the facility prior to leaving at the end of their shift or upon starting their shift on 07/30/2024. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 08/02/2024 at 1:40 PM. The Immediate Jeopardy began on 07/30/2024 and ended on 07/31/2024. The facility had corrected the non-compliance before the surveyor began. These failures placed residents at risk of harm and, serious injury, or death. Findings included: Record review of Resident #1's Face Sheet dated 08/02/2024 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included alcohol abuse with alcohol-induced psychotic disorder (psychosis after the intake of alcohol), cognitive communication deficit (trouble reasoning and making decisions), cerebral infarction (disrupted blood flow to the brain), dysphasia (the ability to produce and understand language), vascular dementia, moderate (fourth stage of dementia - symptoms are more prominent), anxiety disorder (sudden feelings of anxiety or panic), major depressive disorder (persistent feelings of sadness and lack of interest), and gastrostomy status (surgical opening in the stomach for nutritional support). Record review of Resident #1's MDS assessment dated [DATE] reflected he had no BIMS score, which indicated severe cognitive delay. Staff assessment for mental status indicated short-term memory problems and difficulty in new situations for daily decision-making skills. Resident #1 had a feeding tube and was totally dependent for feeding. He was independent for transfers, walking, and dressing. Wandering behaviors were not exhibited. Record review of Resident #1's Care Plan dated 04/30/2023 and updated 07/30/2024, reflected, Focus: [Resident #1] has impaired cognitive function/dementia or impaired thought processes r/t cognitive deficit, cluster of septic arterial embolisms, substance abuse. [resident #1] does not typically verbally respond to BIMS and PHQ-9 questions. [Resident #1] has a communication problem r/t cognitive deficit, cluster of septic arterial embolisms, substance abuse. [Resident #1] speaks minimally and only to certain individuals. Interventions: Alternative interventions: promote use of non-verbal communication, ask yes or no questions when inquiring about wants/needs, provide sense of security, reduction of noise, approach with calming voice, validate non-verbal expressions of emotion, provide sensitivity to personal space. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. [Resident #1] needs assistance with all decision making. Refuses to use communication board. Focus: At risk for elopement as evidenced by: History of attempts to leave facility unattended, 4/30/24-went outside through front door, 7/30/24-went out through his window. Interventions: 15-minute checks. May need to go to a private room on secured unit temporarily until family is able to visit and calm [Resident #1's] frustration. Moved to secured unit. SW to try to move resident to another facility that has secured doors. UA collected, Assess/record/report to MD risk factors for potential elopement such as: Wandering, Repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital. Supervise closely and make regular compliance rounds whenever resident is in room. Determine the reason the resident is attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. Distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of the Elopement Risk assessment dated [DATE] and signed by LVN H, reflected, a score of 18, Elopement risk. Record review of the facility's incident report, dated 07/30/2024 at 7:15 AM and signed by the DON, reflected, The Director of Nurses received a call from resident's [family member] at 7:15am, [family member] stated that an employee at [a restaurant 8 miles away] had called her and told her [Resident #1] was there. DON immediately got van driver to go to [restaurant] to pick up resident When DON went to resident's room to talk with roommate, DON found [Resident #1's] window open and screen not in place. It appears resident went out his window. [Resident #1's] roommate stated [Resident #1] was in the room when he went to sleep, and he just found out resident was gone. Charge nurse stated the last time he seen [Resident #1] was between 4 and 4:30am. Van driver and [Resident #1] returned to the facility at approximately 8:15am. [Resident #1] returned Resident was immediately taken to the secured unit. [Resident #1] was able to ambulate into the facility into his new room. [Resident #1] appeared tired but otherwise appeared to be in good health. Intervention: Resident moved to secured unit into a room where the window opens up into a secured patio. In an interview on 08/02/2024 at 8:55 AM with the Administrator and DON, the DON stated Resident #1 eloped from the facility on 07/30/2024. She stated Resident #1 did not speak and did not have a BIMS because of his limited ability to communicate. She said and was discovered at a restaurant 8 miles from the facility by a worker who called Resident's family. She said Resident #1 carried a paper with family phone numbers on it. The DON said she received a call from Resident #1's family member at about 7:15 AM and immediately sent the van driver to pick up Resident #1. She stated RN E did not check on Resident #1 after an ordered treatment was provided at 4:15 AM. CNA C did not do walking rounds to check on residents at the end of his shift at 6:00 AM. She said LVN G and CNA A and CNA B came on shift at 6:00 AM and did not check on Resident #1 either. She stated she notified the MD who wanted a follow up when Resident #1 returned. She stated Resident #1 did have a decrease in Depakote recently due to recent labs that reflected abnormal liver function. She said that may have cause a change in Resident #1's behavior. She said Resident #1 had a follow up appointment with Psychiatry to reevaluate medications on 08/05/2024. The DON said staff were not aware Resident #1 was gone from the facility until she informed them after 7:15 AM. She said when she went into Resident #1's room, the curtains were in front of the window, but the window was open, and the screen pulled back. She said Resident #1's roommate said he did not hear anything as he was sleeping. The DON said Resident #1 first came to the facility in 2020 and was in the secured unit. She said during Covid-19, he was placed off the unit in a Hot Zone, for isolation. She said Resident #1 eloped through a window at that time as well. She said Resident #1 went to another facility then a group home, but the family wanted him to return to the facility outside the secured unit. The DON said when Resident #1 returned to the facility he was an elopement risk but did not show any elopement behaviors. She said the elopement assessment completed on 07/30/2024 was 20 which indicated elopement risk. She said the family has agreed to leave Resident #1 in the secured unit while they secure alternate placement and arrangements for him. The Administrator said staff did not complete rounds to ensure residents were in the facility and did not know Resident #1 had eloped. The DON stated RN E administered a water bolus at 4:00 AM on 07/30/2024 and did not see the resident after that. She said when she found out of the elopement at 7:15 AM, she called a Code Orange which meant elopement. The Administrator said he was informed at about 7:15 AM and directed a discussion with family to have Resident #1 placed in the secured unit, start in-services on walking rounds, abuse and neglect, and elopement procedures, and completed elopement assessments on all residents. An observation and interview on 08/02/2024 at 10:25 AM reveled Resident #1 in his room, in the secured unit, sat on his bed. Resident #1 only responded by nods to yes/no questions. There was a communication board in the corner of the room, Resident #1 nodded no when asked if he used it. The window in the room was open and screen was bent back on the left corner. Resident #1 laughed and nodded yes when asked if he did that. He nodded yes when asked if he opened the window and screen in his last room when he eloped. He nodded yes when asked if he walked 8 miles and a restaurant worker called his [family member]. He nodded yes when asked if he was tired, if it was dark, if he had shoes on. He nodded yes when asked if he liked the facility and no when asked if he wanted to leave again. He did not answer when asked if he knew where he was going or why he eloped. In an interview on 08/02/2024 at 10:37 AM, the Corporate Compliance Nurse stated the facility did fail to ensure Resident #1 was safe from the hazards of elopement, but the Administrator and DON have implemented all actions needed to correct the failure on 07/30/2024 and 07/31/2024. In an interview on 08/02/2024 at 10:55 AM, the SW stated she was unable to get a BIMS for Resident #1. She said she used pictures but his limited ability to communicate contributes to his sever cognitive ability. She said she was looking for a group home that met Resident #1's tube-feed needs. She said the DON already implemented in-services for all staff to address elopement and abuse and neglect on 07/30/2024. She said there was an elopement drill and all residents' elopement assessments were updated also on 07/30/2024. In an interview on 08/02/2024 at 11:03 AM, CNA A stated she came on shift on 07/30/2024 at 6:00 AM and did not do rounds to check on residents. She said she should have because she would have seen that Resident #1 was gone. She said she did not know Resident #1 was gone until the DON called an elopement drill. She stated she received in-servicing on elopement protocol and walking rounds throughout the shift and at the end of shifts to ensure all residents were okay. In an interview on 08/02/2024 at 11:10 AM, CNA B said she came on shift at 6:45 AM on 07/30/2024. She said she was called in to cover so she had been a little late. She said she did not check on the residents when she arrived and then the DON called an elopement drill. She said we all started checking rooms and were told that Resident #1 had eloped. She said Resident #1 would get frustrated and want to leave the facility sometimes. She said that would occur when people did not understand him. She said he had a communication board and computer but rarely used them for communication. She said she should check on residents regularly and when she came on shift to ensure residents were safe. She said she was in-serviced on doing rounds and elopement procedures. She said the DON completed the in-services on 07/30/2024. A telephone interview on 08/02/2024 at 11:33 AM with Resident #1's family member revealed a community member called her to say Resident #1 was in a restaurant near the city center. She said called the facility and informed the DON the Resident #1 was 8 miles from the facility at a restaurant. She said the DON sent staff to get Resident #1. The family member said Resident #1 returned to the facility outside the secured unit at her request. She said she wanted him to have the best quality of life possible. She said she knew he could get frustrated and want to leave the facility at times, but the staff were good at redirecting him. She said she did not know where else Resident #1 could live but did agree to place him in the facility's secured unit while the facility worked with her to find an alternate placement. She said the DON told her that staff had not checked Resident #1's room after about 4:00 AM and then they found the window open, and screen pulled back. In an interview on 08/02/2024 at 1:21 PM, the Maintenance Director stated he checked the door alarms weekly and checked them again on 07/30/2024. He said he repaired the screen in the room where Resident #1 eloped on 07/31/2024. He said the DON in-serviced all the staff on elopement procedures and checking on residents regularly. He said Resident #1 could have been hurt when he eloped and walked 8 miles before being found. He said all staff were responsible to ensure residents were safe. In an interview on 08/02/2024 at 2:45 PM, LVN I stated she worked on the secured unit. She said Resident #1 was on 15-minute checks until further notice from the DON. She stated the DON in-serviced all the staff on elopement protocol, walking rounds, and abuse and neglect. She said Resident #1's care plan had been updated on 07/30/2024 and all residents had an updated elopement risk assessment completed. She said she expected CNAs to tell her where they are at all times and ensure residents were supervised. She said it was all staff's responsibility to ensure residents were safe from accidents or hazards. In an interview on 08/02/2024 at 3:05 PM, Resident #1's roommate stated he had been sleeping when Resident #1 eloped. He stated he did not hear or see anything until the morning when the DON came to ask him about it. In an interview on 08/022024 at 3:10 PM, LVN G said she came on shift on 07/30/2024 at 6:00 AM. She said she had not rounded and did not check on all her residents that morning. She said she did not know Resident #1 was missing when she came to work but would have noticed had she checked on her residents that morning. She said the DON called an elopement drill at about 7:30 AM and that was when she found out Resident #1 had eloped. She said she expected the CNAs to check on residents too, but it was all staff's responsibility to ensure residents were safe and accounted for when they come on shift. She said the DON provided in-services to all staff on elopement procedures, abuse, and neglect, and rounding frequently. A telephone call on 08/02/2024 at 3:18 PM to LVN L revealed no response. In an interview on 08/02/2024 at 3:24 PM, the DON stated she did not give LVN G or RN I counseling because rounding had not been an issue in the past. She stated she planned on monitoring by taking turns with the ADONs and unit managers to do walking rounds. She said she will continue this until rounding becomes a habit for all staff. In an interview on 08/02/2024 at 3:45 PM, the Corporate Nursing Consultant stated she will conduct random checks in the halls and by reviewing documentation to ensure staff are following the facility's rounding expectations. She stated she will monitor resident's elopement risk assessment when there are change in condition or new admission / readmissions. She said monitoring will also be addressed in the facility's QAPI meetings. In a telephone interview on 08/02/2024 at 3:53 PM, CNA C stated Resident #1 was standing by the bed, watching television on 07/30/2024 at about 12:15 AM. He said when he looked into the room again at 3:15 AM, the lights were off, and he assumed Resident #1 was sleeping. He said she did not physically touch or see Resident #1. He said he should go into the room and check on all residents. He said he did not because he did not want to wake them up. CNA C said he completed his shift at 6:00 AM and did not know Resident #1 had eloped. He said he was in-serviced on elopement protocol, rounding and ensuring residents are safe, and abuse and neglect policy, on 07/31/2024. He said he understood that not checking on Resident #1 placed him at risk of harm because he was able to elope and walk 8 miles before being found. In a telephone interview on 08/03/2024 at 8:15 AM, RN E stated he last saw Resident #1 about 4:00 AM on 07/30/2024 when he gave the water bolus. He said he did not check on Resident #1 after that and left the facility at 6:00 AM when his shift ended. He said he did not know Resident #1 eloped and realized there was no excuse to ensure all residents were safe and accounted for at the end of his shift. He said he was in-serviced on rounding, elopement policy, and abuse and neglect. Record review of Resident #1's MAR dated 07/30/2024 and signed by RN E at 4:00 AM, reflected, Enteral Feed Order every 4 hours related to GASTROSTOMY STATUS Bolus with 200ml of water every 4 hours for hydration and tube patency. Record review of the facility's Provider Investigation Report, dated 07/30/2024, reflected the following: On 7/30/2024 at 7:15am, the [DON] answered the phone and [Family Member] let her know that she received a call from [restaurant employee] that [Resident #1] was lost. The DON immediately sent the van driver to pick [Resident #1] up. Once van driver arrived, he saw [Resident #1] sitting with police, van driver loaded [Resident #1] and brought him back to the facility. DON placed [Resident #1] in the secure unit; pain and skin assessment performed. No injuries and no distress when he returned. The last staff to see [Resident #1] was a nurse that documented a treatment at 4:30am. As soon as the DON was informed, she went to the [Resident #1's] room and noticed the window open and the screen push away from the room. The roommate was interviewed, and he did not see or hear anything since he was asleep. Elopement risk assessment completed for all other residents completed. Doctor was notified and in servicing initiated. The investigation was confirmed, and the following provider actions taken: In service on Elopement, Elopement Prevention QA checklist, Check the locking mechanisms or alarm is functioning properly, [Resident #1] was placed in our secure unit in a room that face an inner courtyard. On 08/02/24 at 12:30 PM, a search via AccuWeather, https://www.accuweather.com revealed the temperature on 07/30/2024 at 8:00 AM in [county], was 84 degrees F. Record review of the facility's policy titled, Elopement prevention, revised January 2023, reflected, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1.The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes. 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5.Interventions into elopement episodes will be entered onto the resident's care plan and medical record. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented in the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response). Record review of the facility's policy titled, Elopement response, revised 10/27/2010, reflected, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented . 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms .7. Post return resident evaluation and care: C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. 8. Documentation: An event note is to be made out on all residents who, without knowledge of the staff, leave the facility. Including the following: Date, Time resident was first determined missing, Responsible party notified and time, attending physician notified and time, Emergency Personnel, Condition of resident when located, where located and time located. Record review of the facility's policy titled, Abuse/neglect, revised, 03/29/2018, reflected, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .The facility will provide and ensure the promotion and protection of resident rights . Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 08/02/2024 at 1:40 PM. The Immediate Jeopardy began on 07/30/2024 and ended on 07/31/2024. The facility had corrected the non-compliance before the surveyor began. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the Elopement Risk assessment dated [DATE] and signed by the DON, reflected, a score of 20, Elopement risk. Record review of the facility's completed door alarms checks, dated 07/30/2024 and signed by the Maintenance Director, reflected all alarmed doors were checked and in working order. Record review of the facility's elopement risk assessment list dated 07/30/2024 and 07/31/2024, reflected updated elopement risk assessment were completed for each resident. Record review of the facility's, Elopement drill record, dated 07/30/2024, reflected, start: 7:15 AM and end: 7:30 AM. Notifications made and evaluated by the DON. Post Event Documentation Review: E1opement Risk Management Event Nurse's Note, Elopement Risk Assessment, Follow-up elopement nurse's notes. Care plan updated with actual elopement and at risk for elopement care plans. Record review of the facility's, Resident 15 min visual check sheet, dated 07/30/2024 at 8:00 AM - through 08/02/2024 at 2:15 PM, reflected Resident #1 was monitored for location and activity every 15 minutes for the time period and continues. Record review of the facility's in-service record, titled, Elopement, Abuse/Neglect, dated 07/30/2024 and administered by the DON to all staff, covered the elopement and Abuse/Neglect policies and, Walking rounds are to be conducted. At the beginning of your shift, At the end of your shift, as frequently as you can (but at least every 2 hours), Every resident must be a counted for every time you do a walking round, you must know where your residents are to keep them safe, you must have relief before you leave your shift. Interviews on 08/02/2024 from 10:00 AM to 4:00 PM with the Social Worker, Maintenance Director, HR Director, Dietary Manager, Housekeeping and Laundry Supervisor, Physical Therapist, CNAs A, B, C and D; RNs E and F; LVNs G, H, and I; and COTAs J and K, revealed they had received in-service training between 07/30/2024 and 07/31/2024. They stated the training had included how to properly secure the exit doors and reset the alarms. They were able to convey knowledge of the facility's policy on abuse/neglect and elopement policy and procedures.

Based on observations, interviews and record reviews, the facility failed to ensure that residents were free from neglect for one (Resident #1) of four residents reviewed for abuse and neglect. LVN B failed to ensure an allegation of abuse reported by Resident #1 as well as extensive bruising to the resident's right lower extremtiy and buttocks were reported immediately to the Administrator, which resulted in the alleged perpetrator continuing to work at the facility. Resident #1 verbalized fear for his life due to the continued presence of the alleged perpetrator. An Immediate Jeopardy (IJ) was identified on 09/06/18 at 4:35 p.m. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. The failure placed residents at risk for abuse and neglect. Findings included: Resident #1's Face Sheet dated 09/06/18 reflected the resident was newly admitted to the facility on [DATE]. He was a [AGE] year-old male with [DIAGNOSES REDACTED]. The resident did not have a completed MDS assessment available for review. Resident #1's Nurse Notes reflected: 08/13/18 8:24 p.m. - Resident returned from Psychiatric Hospital for persistent delusional disorder, generalized anxiety disorder, and dementia. Medications verified with physician. 08/19/18 9:22 a.m. - Nurse found resident on the floor in the shower room. Resident reported he was trying to pull down his pants and use the commode, but he tripped and fell . Assessment completed. No apparent injury. 08/21/18 10:09 a.m. - LVN O documented that Resident #1 went into another resident's room, took the pillows off the bed, placed the pillows on the floor, and sat down on them. The resident yelled out for help. Nurse assessed, and resident complained of pain to his right buttock. No injuries noted. Doctor evaluated resident. 08/25/2018 2:48 p.m. - LVN B documented that she was called to Resident #1's room by his family member. The resident had a bruise on buttocks with swelling. The bruise was reddish-purple, ran down back of his leg to back of the knee, and the area was swollen. Resident #1's Incident Reports reflected: 08/19/18 - Found resident on the floor in the shower room with his pants and brief halfway down his leg. Resident reported he was trying to use the commode and tripped. No apparent injury. Resident was placed on neurological check monitoring. 08/25/18 - LVN B was called to the resident's room and upon entrance, the resident's family member was beside him. The family member said to look as she pulled down Resident #1's shorts to expose a large purple-reddish bruise on his right buttock. Resident #1 explained to LVN B that someone had hit him, and he would cringe when he saw the person come to his room. LVN B asked who the person was that hurt him, and the resident said he forgot, but the person was black, big, and came in the evening or at night. Unit Manager and Administrator aware. Physician aware. - The incident report was signed by the Administrator on 08/27/18. Resident #1's Head to Toe Skin Checks Form, dated 08/25/18, completed by Unit Manager C reflected: Existing bruises to back of right buttock, right leg, and right knee. Resident #1's Shower Logs for (MONTH) (YEAR) reflected he refused all showers. Resident #1's Physician order [REDACTED].>08/08/18 Aspirin (blood thinner) 81 milligrams daily. 08/08/18 [MEDICATION NAME] (anti-psychotic medication) 5 milligrams intramuscularly every six hours as needed for [MEDICAL CONDITION] disorder. Resident #1's (MONTH) (YEAR) Medication Administration Records reflected: 08/20/18 9:46 a.m. [MEDICATION NAME] administered to right buttock. - LVN O 08/21/18 5:15 p.m. [MEDICATION NAME] administered to left buttock. - LVN A Resident #1's physician progress notes [REDACTED].>Late Entry for visit 08/22/18. Follow-up on fall. Now noted to have large bruising to right buttock extending down right knee posteriorly. Resident #1's photographs, provided by his family on 09/06/18 revealed severe bruising and swelling of his right buttock and right leg extending to the back of his right knee. An observation and interview with Resident #1 on 09/06/18 at 9:25 a.m. revealed the resident was awake, alert, and able to answer questions. He was ambulating independently with a steady gait in the secured unit of the facility. He reported he wanted to speak to the investigator in his room. Resident #1 walked to his room and pulled the door closed. The resident was asked if he had any issues with other residents, and he stated, No, just staff. The resident walked to his full-length mirror and pulled down the waistband of his pants to reveal a surgical scar on his right hip. He reported the area had healed, but that the area used to be bruised. The resident stated a staff, put me on the bed and beat the [***] out of my leg after he came in my room for no reason at all. The resident reported he could not remember the staff member's name, but that he worked in the evenings and that, He is an[***] . The resident stated, I'm scared of him. He has tried to hit me twice since then. I have to stay away from him. The resident reported the abuse had been reported to the state and thought the investigator was there to investigate his allegation. The resident was informed the facility Administrator would have to be notified of the allegation. The resident frantically said, No, he (the abuser) will kill me, he will shoot me! An interview with the Administrator on 09/06/18 at 11:00 a.m. regarding Resident #1 revealed she was not aware of any allegations of abuse. She reported the resident's memory had improved and she was surprised he had not reported the allegation of abuse. The Administrator reported she would immediately start the facility investigation. An interview with the family of Resident #1 on 09/06/18 at 11:25 a.m. revealed the resident had reported to them that a staff member had beat him up, but the resident did not know the date. The family member reported she told the resident that she was going to report the allegation to the state, but never did. The family member reported she was in the process of trying to get him moved to another facility and sent pictures of the injury to the Investigator to review. The family member reported according to the resident, the staff member that allegedly beat him was LVN [NAME] An interview with another family member of Resident #1 on 09/06/18 at 12:45 p.m. revealed they went to see the resident on 08/25/18. They reported the resident showed them bruises on the right buttock that extended down the right leg. The resident reported to the family that he was being abused by the mean, black, nurse who was constantly yelling at him and pushing him around. The family member reported the resident said the nurse pushed him to the floor and hit him. The family member reported she called in LVN B to assess the resident on 08/25/18. The family member reported Resident #1 had a fear of LVN A because according to the resident, LVN A would yell at him and push him. An interview with LVN B on 09/06/18 at 2:10 p.m. revealed she had assessed Resident #1 on 08/25/18 and saw his bruises. She said she did not know what had caused the bruising but did know he had fallen multiple times. She stated Resident #1 kept saying to her that someone hit him and punched him. LVN B revealed she notified the Administrator regarding the allegations the resident was hit by staff and orders for x-rays were obtained from the physician. LVN B stated she documented the injury and the allegation of abuse on the incident report and notified the Unit Manager and DON. An interview with the Medical Director on 09/10/18 at 10:25 a.m. revealed he was made aware of significant bruising on Resident #1 on 08/25/18 by a nurse. He stated he had already assessed the injury but was unsure of the date. The Medical Director revealed he thought the bruising was related to a fall on 08/21/18. The Medical Director stated Resident #1 made an allegation of abuse to him that seemed like a clear fabrication because the resident said a staff turned him onto his belly and slapped him with a paddle. The Medical Director revealed the nurse, unknown name, had reported the allegation to him also, but there was no perception that the allegation was taken seriously by any staff members. The Medical Director stated according to facility policy, allegations of abuse or neglect were supposed to be investigated and he did have x-rays performed on the resident which were negative for fracture. He said the resident did not name a specific staff member as the alleged perpetrator, gave a very generic description, and was unable to point out the staff member. An interview with Unit Manager C on 09/06/18 at 11:55 a.m. revealed she was supervising the building on 08/25/18 and was told Resident #1 had a bruise on him. She stated a skin assessment was performed and x-rays were taken with negative results. She said the DON was also notified. Unit Manager C revealed she thought the bruising was due to a fall Resident #1 had on 08/19/18. An interview with LVN A on 09/06/18 at 12:50 p.m. revealed he worked the 2:00 p.m.-10:00 p.m. shift and had worked on the secure unit on 08/20/18, 08/21/18, 08/22/18, and 08/23/18. He stated he returned to work on 08/27/18 and was told a bruise was found on Resident #1 after a fall he had. He revealed he had never hit a resident and that if he ever got frustrated with a resident he would take a break and call the DON. An interview with the DON on 09/06/18 at 2:30 p.m. revealed she saw the bruising on Resident #1 on Monday, 08/27/18 and Unit Manager C had contacted her about the injury over the weekend. The DON stated the resident told her that he did not know how the injury had happened and that an incident report and investigation had been completed. She reported she spoke to staff but did not speak to the resident's family. The DON revealed the injury was not self-reported to the state because they thought the injury was related to his fall on 08/19/18 and the resident also had a history of [REDACTED]. The DON stated she did not get a report from the nurses that someone had hit the resident. The DON revealed the facility policy was to self-report injuries of unknown origin with injury, but she thought the injury was related to his fall. An interview with the Administrator on 09/06/18 at 2:35 p.m. revealed LVN B did not notify her of an allegation of abuse for Resident #1. A subsequent interview with the Administrator on 09/07/18 at 3:35 p.m. revealed she found and re-reviewed the incident report for Resident #1. She reported it was dated 08/25/18 and LVN B did document Resident #1's allegation of abuse, but she missed it when the injury was discussed in morning meeting on 08/27/18. The Administrator reported LVN B did not call her to report the allegation of abuse. The facility's Abuse and Neglect Prohibition Policy, dated (MONTH) (YEAR), reflected: Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin .Prevention. 3. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. Protection. 1. The facility will protect residents from harm during the investigation. Investigation. 1. The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law. An Immediate Jeopardy (IJ) was identified on 09/06/18 at 4:35 p.m. and the Administrator was notified. A Plan of Removal was requested at that time: The facility's Plan of Removal was provided by the Administrator and reflected: Immediate action taken: On (MONTH) 6, (YEAR), LVN A was suspended and removed from the schedule pending the investigation. On (MONTH) 6, (YEAR), the Social Worker and Activity Director educated Resident #1 on Abuse and Neglect and gave him phone numbers for the compliance hotline and DADS hotline and told him to call if any other abuse occurred. Resident #1 was reassessed by Unit Manager C for pain and skin assessment on (MONTH) 6, (YEAR). Psychiatrist was notified on (MONTH) 6, (YEAR) and she stated she would be out to see Resident #1 on (MONTH) 7th, (YEAR) to address the fear expressed by the resident. Administrator would review cameras for any unusual events. Would be completed (MONTH) 7, (YEAR). Cameras will be reviewed on a case by case situation in the future for incidents. LVN B notified to come to the facility to be interviewed by Regional Consultant RN and ADON on (MONTH) 7th, (YEAR). LVN B was suspended pending investigation and removed from the schedule, appropriate discipline will be decided upon outcome of investigation. Coaching provided to DON for incident investigations and injuries of unknown origin. Completed (MONTH) 7, (YEAR). Nurse Managers will conduct five random skin assessments and validate the accuracy of the documented skin assessment per week for the next month and then randomly for the next 3 months. Showers will be completed three times weekly unless refused by the resident. Refusals must be documented on progress notes. Shower sheets will be monitored weekly during the At Risk Meeting. Any employee alleged to be involved in an instance of abuse and/or neglect will be interviewed and suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. In-services performed by Regional Consultant RN on Abuse, Neglect, and Exploitation to all staff. To be completed by (MONTH) 7, (YEAR). All staff will be in serviced prior to starting their next scheduled shift. Safe surveys and skin sweeps of residents to be completed (MONTH) 7, (YEAR). Documentation will be reviewed using the 24-hour report, incident and accident reports, and daily progress notes for accuracy of documentation. Administrator and Director of Nursing will be in-serviced on policies of Investigation of Unknown Origin Injuries on (MONTH) 6th, (YEAR) by Regional Consultant RN. Monitoring: All incident reports will be reviewed during morning meeting. All witness statements and incidents will be discussed thoroughly. Nursing designee will monitor incident reports during weekend days. Regional Consultant RN will review all Incident Reports and Investigations Monthly. All allegations or suspicion of Abuse, Neglect and Exploitation or Injuries of Unknown Origin will be investigated and reported to state authorities as described by policy and provider letter. Regional Consultant RN will review all investigations of allegations or suspicions of Abuse, Neglect and Exploitation or Injuries of Unknown Origin at the time investigation by facility is completed. All incident reports and investigations will be reviewed by the inter-disciplinary team and Medical Director at the Quality Assurance meeting each month. Monitoring interviews were started on 09/07/18 at 1:55 p.m. and continued through 09/10/18 at 10:30 a.m. with 21 staff members. The staff members for the 6:00 a.m. to 2:00 p.m. shift: MA F, CNA G, CNA J, MA L, CNA N, MA P, The staff members for the 2:00 p.m. to 10:00 p.m. shift: CNA D, CNA M, LVN Q, MA R, RN T The staff members who worked all three shifts: CNA E, CNA H, MA K, LVN O, LVN S Staff members who worked 8:00 a.m. to 5:00 p.m.: Administrator, DON, Unit Manager C, Activity Director, Unit Manager I The interviews revealed the staff had received in-service training regarding the following: - the Abuse and Neglect Policy; - whom to report allegations of abuse to; - signs and symptoms of abuse; - process to investigate and report abuse; and - incident and accident protocol. An interview with the Administrator on 09/10/18 at 9:40 a.m. revealed going forward she would carefully review incident reports for documented allegations of abuse and report/investigate accordingly. She reported she would also contact the police department to investigate the allegation of abuse for Resident #1 on 09/10/18. An interview with the DON on 09/10/18 at 10:00 a.m. revealed going forward she would investigate injuries of unknown origin more thoroughly. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal.

Based on observations, interviews and record reviews, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated for one, (Resident #1) of four residents reviewed for abuse. The facility failed to have evidence of a thorough investigation into the significant bruising and swelling of Resident #1's buttocks and legs and his allegation of physical abuse by a staff member. An Immediate Jeopardy (IJ) was identified on 09/06/18 at 4:35 p.m. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These deficient practices could affect all 124 residents by placing them at risk for abuse. Findings included: Resident #1's Face Sheet dated 09/06/18 reflected the resident was newly admitted to the facility on [DATE]. He was a [AGE] year-old male with [DIAGNOSES REDACTED]. The resident did not have a completed MDS assessment available for review. Resident #1's Nurse Notes reflected: 08/13/18 8:24 p.m. - Resident returned from Psychiatric Hospital for persistent delusional disorder, generalized anxiety disorder, and dementia. Medications verified with physician. 08/19/18 9:22 a.m. - Nurse found resident on the floor in the shower room. Resident reported he was trying to pull down his pants and use the commode, but he tripped and fell . Assessment completed. No apparent injury. 08/21/18 10:09 a.m. - LVN O documented that Resident #1 went into another resident's room, took the pillows off the bed, placed the pillows on the floor, and sat down on them. The resident yelled out for help. Nurse assessed, and resident complained of pain to his right buttock. No injuries noted. Doctor evaluated resident. 08/25/2018 2:48 p.m. - LVN B documented that she was called to Resident #1's room by his family member. The resident had a bruise on buttocks with swelling. The bruise was reddish-purple, ran down back of his leg to back of the knee, and the area was swollen. Resident #1's Incident Reports reflected: 08/19/18 - Found resident on the floor in the shower room with his pants and brief halfway down his leg. Resident reported he was trying to use the commode and tripped. No apparent injury. Resident was placed on neurological check monitoring. 08/25/18 - LVN B was called to the resident's room and upon entrance, the resident's family member was beside him. The family member said to look as she pulled down Resident #1's shorts to expose a large purple-reddish bruise on his right buttock. Resident #1 explained to LVN B that someone had hit him, and he would cringe when he saw the person come to his room. LVN B asked who the person was that hurt him, and the resident said he forgot, but the person was black, big, and came in the evening or at night. Unit Manager and Administrator aware. Physician aware. - The incident report was signed by the Administrator on 08/27/18. Resident #1's Head to Toe Skin Checks Form, dated 08/25/18, completed by Unit Manager C reflected: Existing bruises to back of right buttock, right leg, and right knee. Resident #1's Shower Logs for (MONTH) (YEAR) reflected he refused all showers. Resident #1's Physician order [REDACTED].>08/08/18 Aspirin (blood thinner) 81 milligrams daily. 08/08/18 [MEDICATION NAME] (anti-psychotic medication) 5 milligrams intramuscularly every six hours as needed for [MEDICAL CONDITION] disorder. Resident #1's (MONTH) (YEAR) Medication Administration Records reflected: 08/20/18 9:46 a.m. [MEDICATION NAME] administered to right buttock. - LVN O 08/21/18 5:15 p.m. [MEDICATION NAME] administered to left buttock. - LVN A Resident #1's physician progress notes [REDACTED].>Late Entry for visit 08/22/18. Follow-up on fall. Now noted to have large bruising to right buttock extending down right knee posteriorly. Resident #1's photographs, provided by his family on 09/06/18 revealed severe bruising and swelling of his right buttock and right leg extending to the back of his right knee. An observation and interview with Resident #1 on 09/06/18 at 9:25 a.m. revealed the resident was awake, alert, and able to answer questions. He was ambulating independently with a steady gait in the secured unit of the facility. He reported he wanted to speak to the investigator in his room. Resident #1 walked to his room and pulled the door closed. The resident was asked if he had any issues with other residents, and he stated, No, just staff. The resident walked to his full-length mirror and pulled down the waistband of his pants to reveal a surgical scar on his right hip. He reported the area had healed, but that the area used to be bruised. The resident stated a staff, put me on the bed and beat the [***] out of my leg after he came in my room for no reason at all. The resident reported he could not remember the staff member's name, but that he worked in the evenings and that, He is an[***] . The resident stated, I'm scared of him. He has tried to hit me twice since then. I have to stay away from him. The resident reported the abuse had been reported to the state and thought the investigator was there to investigate his allegation. The resident was informed the facility Administrator would have to be notified of the allegation. The resident frantically said, No, he (the abuser) will kill me, he will shoot me! An interview with the Administrator on 09/06/18 at 11:00 a.m. regarding Resident #1 revealed she was not aware of any allegations of abuse. She reported the resident's memory had improved and she was surprised he had not reported the allegation of abuse. The Administrator reported she would immediately start the facility investigation. An interview with the family of Resident #1 on 09/06/18 at 11:25 a.m. revealed the resident had reported to them that a staff member had beat him up, but the resident did not know the date. The family member reported she told the resident that she was going to report the allegation to the state, but never did. The family member reported she was in the process of trying to get him moved to another facility and sent pictures of the injury to the Investigator to review. The family member reported according to the resident, the staff member that allegedly beat him was LVN [NAME] An interview with another family member of Resident #1 on 09/06/18 at 12:45 p.m. revealed they went to see the resident on 08/25/18. They reported the resident showed them bruises on the right buttock that extended down the right leg. The resident reported to the family that he was being abused by the mean, black, nurse who was constantly yelling at him and pushing him around. The family member reported the resident said the nurse pushed him to the floor and hit him. The family member reported she called in LVN B to assess the resident on 08/25/18. The family member reported Resident #1 had a fear of LVN A because according to the resident, LVN A would yell at him and push him. An interview with LVN B on 09/06/18 at 2:10 p.m. revealed she had assessed Resident #1 on 08/25/18 and saw his bruises. She said she did not know what had caused the bruising but did know he had fallen multiple times. She stated Resident #1 kept saying to her that someone hit him and punched him. LVN B revealed she notified the Administrator regarding the allegations the resident was hit by staff and orders for x-rays were obtained from the physician. LVN B stated she documented the injury and the allegation of abuse on the incident report and notified the Unit Manager and DON. An interview with the Medical Director on 09/10/18 at 10:25 a.m. revealed he was made aware of significant bruising on Resident #1 on 08/25/18 by a nurse. He stated he had already assessed the injury but was unsure of the date. The Medical Director revealed he thought the bruising was related to a fall on 08/21/18. The Medical Director stated Resident #1 made an allegation of abuse to him that seemed like a clear fabrication because the resident said a staff turned him onto his belly and slapped him with a paddle. The Medical Director revealed the nurse, unknown name, had reported the allegation to him also, but there was no perception that the allegation was taken seriously by any staff members. The Medical Director stated according to facility policy, allegations of abuse or neglect were supposed to be investigated and he did have x-rays performed on the resident which were negative for fracture. He said the resident did not name a specific staff member as the alleged perpetrator, gave a very generic description, and was unable to point out the staff member. An interview with Unit Manager C on 09/06/18 at 11:55 a.m. revealed she was supervising the building on 08/25/18 and was told Resident #1 had a bruise on him. She stated a skin assessment was performed and x-rays were taken with negative results. She said the DON was also notified. Unit Manager C revealed she thought the bruising was due to a fall Resident #1 had on 08/19/18. An interview with LVN A on 09/06/18 at 12:50 p.m. revealed he worked the 2:00 p.m.-10:00 p.m. shift and had worked on the secure unit on 08/20/18, 08/21/18, 08/22/18, and 08/23/18. He stated he returned to work on 08/27/18 and was told a bruise was found on Resident #1 after a fall he had. He revealed he had never hit a resident and that if he ever got frustrated with a resident he would take a break and call the DON. An interview with the DON on 09/06/18 at 2:30 p.m. revealed she saw the bruising on Resident #1 on Monday, 08/27/18 and Unit Manager C had contacted her about the injury over the weekend. The DON stated the resident told her that he did not know how the injury had happened and that an incident report and investigation had been completed. She reported she spoke to staff but did not speak to the resident's family. The DON revealed the injury was not self-reported to the state because they thought the injury was related to his fall on 08/19/18 and the resident also had a history of [REDACTED]. The DON stated she did not get a report from the nurses that someone had hit the resident. The DON revealed the facility policy was to self-report injuries of unknown origin with injury, but she thought the injury was related to his fall. An interview with the Administrator on 09/06/18 at 2:35 p.m. revealed LVN B did not notify her of an allegation of abuse for Resident #1. A subsequent interview with the Administrator on 09/07/18 at 3:35 p.m. revealed she found and re-reviewed the incident report for Resident #1. She reported it was dated 08/25/18 and LVN B did document Resident #1's allegation of abuse, but she missed it when the injury was discussed in morning meeting on 08/27/18. The Administrator reported LVN B did not call her to report the allegation of abuse. The facility's Abuse and Neglect Prohibition Policy, dated (MONTH) (YEAR), reflected: Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin .Prevention. 3. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. Protection. 1. The facility will protect residents from harm during the investigation. Investigation. 1. The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law. An Immediate Jeopardy (IJ) was identified on 09/06/18 at 4:35 p.m. and the Administrator was notified. A Plan of Removal was requested at that time: The facility's Plan of Removal was provided by the Administrator and reflected: Immediate action taken: On (MONTH) 6, (YEAR), LVN A was suspended and removed from the schedule pending the investigation. On (MONTH) 6, (YEAR), the Social Worker and Activity Director educated Resident #1 on Abuse and Neglect and gave him phone numbers for the compliance hotline and DADS hotline and told him to call if any other abuse occurred. Resident #1 was reassessed by Unit Manager C for pain and skin assessment on (MONTH) 6, (YEAR). Psychiatrist was notified on (MONTH) 6, (YEAR) and she stated she would be out to see Resident #1 on (MONTH) 7th, (YEAR) to address the fear expressed by the resident. Administrator would review cameras for any unusual events. Would be completed (MONTH) 7, (YEAR). Cameras will be reviewed on a case by case situation in the future for incidents. LVN B notified to come to the facility to be interviewed by Regional Consultant RN and ADON on (MONTH) 7th, (YEAR). LVN B was suspended pending investigation and removed from the schedule, appropriate discipline will be decided upon outcome of investigation. Coaching provided to DON for incident investigations and injuries of unknown origin. Completed (MONTH) 7, (YEAR). Nurse Managers will conduct five random skin assessments and validate the accuracy of the documented skin assessment per week for the next month and then randomly for the next 3 months. Showers will be completed three times weekly unless refused by the resident. Refusals must be documented on progress notes. Shower sheets will be monitored weekly during the At Risk Meeting. Any employee alleged to be involved in an instance of abuse and/or neglect will be interviewed and suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. In-services performed by Regional Consultant RN on Abuse, Neglect, and Exploitation to all staff. To be completed by (MONTH) 7, (YEAR). All staff will be in serviced prior to starting their next scheduled shift. Safe surveys and skin sweeps of residents to be completed (MONTH) 7, (YEAR). Documentation will be reviewed using the 24-hour report, incident and accident reports, and daily progress notes for accuracy of documentation. Administrator and Director of Nursing will be in-serviced on policies of Investigation of Unknown Origin Injuries on (MONTH) 6th, (YEAR) by Regional Consultant RN. Monitoring: All incident reports will be reviewed during morning meeting. All witness statements and incidents will be discussed thoroughly. Nursing designee will monitor incident reports during weekend days. Regional Consultant RN will review all Incident Reports and Investigations Monthly. All allegations or suspicion of Abuse, Neglect and Exploitation or Injuries of Unknown Origin will be investigated and reported to state authorities as described by policy and provider letter. Regional Consultant RN will review all investigations of allegations or suspicions of Abuse, Neglect and Exploitation or Injuries of Unknown Origin at the time investigation by facility is completed. All incident reports and investigations will be reviewed by the inter-disciplinary team and Medical Director at the Quality Assurance meeting each month. Monitoring interviews were started on 09/07/18 at 1:55 p.m. and continued through 09/10/18 at 10:30 a.m. with 21 staff members. The staff members for the 6:00 a.m. to 2:00 p.m. shift: MA F, CNA G, CNA J, MA L, CNA N, MA P, The staff members for the 2:00 p.m. to 10:00 p.m. shift: CNA D, CNA M, LVN Q, MA R, RN T The staff members who worked all three shifts: CNA E, CNA H, MA K, LVN O, LVN S Staff members who worked 8:00 a.m. to 5:00 p.m.: Administrator, DON, Unit Manager C, Activity Director, Unit Manager I The interviews revealed the staff had received in-service training regarding the following: - the Abuse and Neglect Policy; - whom to report allegations of abuse to; - signs and symptoms of abuse; - process to investigate and report abuse; and - incident and accident protocol. An interview with the Administrator on 09/10/18 at 9:40 a.m. revealed going forward she would carefully review incident reports for documented allegations of abuse and report/investigate accordingly. She reported she would also contact the police department to investigate the allegation of abuse for Resident #1 on 09/10/18. An interview with the DON on 09/10/18 at 10:00 a.m. revealed going forward she would investigate injuries of unknown origin more thoroughly. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal.

Based on observations, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency in accordance with State law through established procedures for one, (Resident #1) of four residents reviewed for abuse. 1. LVN B failed to immediately report to the Administrator when Resident #1 reported he was physically abused by staff and had severe bruising to his buttocks and leg, which delayed the investigation to the alleged abuse. 2. The Administrator failed to immediately report to the State Survey Agency Resident #1's allegation of physical abuse when she signed the incident report which reflected the resident reported physical abuse. An Immediate Jeopardy (IJ) was identified on 09/06/18. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. The failure placed residents at risk for sustaining further neglect and placed at risk for abuse and neglect. Findings included: Resident #1's Face Sheet dated 09/06/18 reflected the resident was newly admitted to the facility on [DATE]. He was a [AGE] year-old male with [DIAGNOSES REDACTED]. The resident did not have a completed MDS assessment available for review. Resident #1's Nurse Notes reflected: 08/13/18 8:24 p.m. - Resident returned from Psychiatric Hospital for persistent delusional disorder, generalized anxiety disorder, and dementia. Medications verified with physician. 08/19/18 9:22 a.m. - Nurse found resident on the floor in the shower room. Resident reported he was trying to pull down his pants and use the commode, but he tripped and fell . Assessment completed. No apparent injury. 08/21/18 10:09 a.m. - LVN O documented that Resident #1 went into another resident's room, took the pillows off the bed, placed the pillows on the floor, and sat down on them. The resident yelled out for help. Nurse assessed, and resident complained of pain to his right buttock. No injuries noted. Doctor evaluated resident. 08/25/2018 2:48 p.m. - LVN B documented that she was called to Resident #1's room by his family member. The resident had a bruise on buttocks with swelling. The bruise was reddish-purple, ran down back of his leg to back of the knee, and the area was swollen. Resident #1's Incident Reports reflected: 08/19/18 - Found resident on the floor in the shower room with his pants and brief halfway down his leg. Resident reported he was trying to use the commode and tripped. No apparent injury. Resident was placed on neurological check monitoring. 08/25/18 - LVN B was called to the resident's room and upon entrance, the resident's family member was beside him. The family member said to look as she pulled down Resident #1's shorts to expose a large purple-reddish bruise on his right buttock. Resident #1 explained to LVN B that someone had hit him, and he would cringe when he saw the person come to his room. LVN B asked who the person was that hurt him, and the resident said he forgot, but the person was black, big, and came in the evening or at night. Unit Manager and Administrator aware. Physician aware. - The incident report was signed by the Administrator on 08/27/18. Resident #1's Head to Toe Skin Checks Form, dated 08/25/18, completed by Unit Manager C reflected: Existing bruises to back of right buttock, right leg, and right knee. Resident #1's Shower Logs for (MONTH) (YEAR) reflected he refused all showers. Resident #1's Physician order [REDACTED].>08/08/18 Aspirin (blood thinner) 81 milligrams daily. 08/08/18 [MEDICATION NAME] (anti-psychotic medication) 5 milligrams intramuscularly every six hours as needed for [MEDICAL CONDITION] disorder. Resident #1's (MONTH) (YEAR) Medication Administration Records reflected: 08/20/18 9:46 a.m. [MEDICATION NAME] administered to right buttock. - LVN O 08/21/18 5:15 p.m. [MEDICATION NAME] administered to left buttock. - LVN A Resident #1's physician progress notes [REDACTED].>Late Entry for visit 08/22/18. Follow-up on fall. Now noted to have large bruising to right buttock extending down right knee posteriorly. Resident #1's photographs, provided by his family on 09/06/18 revealed severe bruising and swelling of his right buttock and right leg extending to the back of his right knee. An observation and interview with Resident #1 on 09/06/18 at 9:25 a.m. revealed the resident was awake, alert, and able to answer questions. He was ambulating independently with a steady gait in the secured unit of the facility. He reported he wanted to speak to the investigator in his room. Resident #1 walked to his room and pulled the door closed. The resident was asked if he had any issues with other residents, and he stated, No, just staff. The resident walked to his full-length mirror and pulled down the waistband of his pants to reveal a surgical scar on his right hip. He reported the area had healed, but that the area used to be bruised. The resident stated a staff, put me on the bed and beat the [***] out of my leg after he came in my room for no reason at all. The resident reported he could not remember the staff member's name, but that he worked in the evenings and that, He is an[***] . The resident stated, I'm scared of him. He has tried to hit me twice since then. I have to stay away from him. The resident reported the abuse had been reported to the state and thought the investigator was there to investigate his allegation. The resident was informed the facility Administrator would have to be notified of the allegation. The resident frantically said, No, he (the abuser) will kill me, he will shoot me! An interview with the Administrator on 09/06/18 at 11:00 a.m. regarding Resident #1 revealed she was not aware of any allegations of abuse. She reported the resident's memory had improved and she was surprised he had not reported the allegation of abuse. The Administrator reported she would immediately start the facility investigation. An interview with the family of Resident #1 on 09/06/18 at 11:25 a.m. revealed the resident had reported to them that a staff member had beat him up, but the resident did not know the date. The family member reported she told the resident that she was going to report the allegation to the state, but never did. The family member reported she was in the process of trying to get him moved to another facility and sent pictures of the injury to the Investigator to review. The family member reported according to the resident, the staff member that allegedly beat him was LVN [NAME] An interview with another family member of Resident #1 on 09/06/18 at 12:45 p.m. revealed they went to see the resident on 08/25/18. They reported the resident showed them bruises on the right buttock that extended down the right leg. The resident reported to the family that he was being abused by the mean, black, nurse who was constantly yelling at him and pushing him around. The family member reported the resident said the nurse pushed him to the floor and hit him. The family member reported she called in LVN B to assess the resident on 08/25/18. The family member reported Resident #1 had a fear of LVN A because according to the resident, LVN A would yell at him and push him. An interview with LVN B on 09/06/18 at 2:10 p.m. revealed she had assessed Resident #1 on 08/25/18 and saw his bruises. She said she did not know what had caused the bruising but did know he had fallen multiple times. She stated Resident #1 kept saying to her that someone hit him and punched him. LVN B revealed she notified the Administrator regarding the allegations the resident was hit by staff and orders for x-rays were obtained from the physician. LVN B stated she documented the injury and the allegation of abuse on the incident report and notified the Unit Manager and DON. An interview with the Medical Director on 09/10/18 at 10:25 a.m. revealed he was made aware of significant bruising on Resident #1 on 08/25/18 by a nurse. He stated he had already assessed the injury but was unsure of the date. The Medical Director revealed he thought the bruising was related to a fall on 08/21/18. The Medical Director stated Resident #1 made an allegation of abuse to him that seemed like a clear fabrication because the resident said a staff turned him onto his belly and slapped him with a paddle. The Medical Director revealed the nurse, unknown name, had reported the allegation to him also, but there was no perception that the allegation was taken seriously by any staff members. The Medical Director stated according to facility policy, allegations of abuse or neglect were supposed to be investigated and he did have x-rays performed on the resident which were negative for fracture. He said the resident did not name a specific staff member as the alleged perpetrator, gave a very generic description, and was unable to point out the staff member. An interview with Unit Manager C on 09/06/18 at 11:55 a.m. revealed she was supervising the building on 08/25/18 and was told Resident #1 had a bruise on him. She stated a skin assessment was performed and x-rays were taken with negative results. She said the DON was also notified. Unit Manager C revealed she thought the bruising was due to a fall Resident #1 had on 08/19/18. An interview with LVN A on 09/06/18 at 12:50 p.m. revealed he worked the 2:00 p.m.-10:00 p.m. shift and had worked on the secure unit on 08/20/18, 08/21/18, 08/22/18, and 08/23/18. He stated he returned to work on 08/27/18 and was told a bruise was found on Resident #1 after a fall he had. He revealed he had never hit a resident and that if he ever got frustrated with a resident he would take a break and call the DON. An interview with the DON on 09/06/18 at 2:30 p.m. revealed she saw the bruising on Resident #1 on Monday, 08/27/18 and Unit Manager C had contacted her about the injury over the weekend. The DON stated the resident told her that he did not know how the injury had happened and that an incident report and investigation had been completed. She reported she spoke to staff but did not speak to the resident's family. The DON revealed the injury was not self-reported to the state because they thought the injury was related to his fall on 08/19/18 and the resident also had a history of [REDACTED]. The DON stated she did not get a report from the nurses that someone had hit the resident. The DON revealed the facility policy was to self-report injuries of unknown origin with injury, but she thought the injury was related to his fall. An interview with the Administrator on 09/06/18 at 2:35 p.m. revealed LVN B did not notify her of an allegation of abuse for Resident #1. A subsequent interview with the Administrator on 09/07/18 at 3:35 p.m. revealed she found and re-reviewed the incident report for Resident #1. She reported it was dated 08/25/18 and LVN B did document Resident #1's allegation of abuse, but she missed it when the injury was discussed in morning meeting on 08/27/18. The Administrator reported LVN B did not call her to report the allegation of abuse. The facility's Abuse and Neglect Prohibition Policy, dated (MONTH) (YEAR), reflected: Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin .Prevention. 3. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. Protection. 1. The facility will protect residents from harm during the investigation. Investigation. 1. The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law. An Immediate Jeopardy (IJ) was identified on 09/06/18 at 4:35 p.m. and the Administrator was notified. A Plan of Removal was requested at that time: The facility's Plan of Removal was provided by the Administrator and reflected: Immediate action taken: On (MONTH) 6, (YEAR), LVN A was suspended and removed from the schedule pending the investigation. On (MONTH) 6, (YEAR), the Social Worker and Activity Director educated Resident #1 on Abuse and Neglect and gave him phone numbers for the compliance hotline and DADS hotline and told him to call if any other abuse occurred. Resident #1 was reassessed by Unit Manager C for pain and skin assessment on (MONTH) 6, (YEAR). Psychiatrist was notified on (MONTH) 6, (YEAR) and she stated she would be out to see Resident #1 on (MONTH) 7th, (YEAR) to address the fear expressed by the resident. Administrator would review cameras for any unusual events. Would be completed (MONTH) 7, (YEAR). Cameras will be reviewed on a case by case situation in the future for incidents. LVN B notified to come to the facility to be interviewed by Regional Consultant RN and ADON on (MONTH) 7th, (YEAR). LVN B was suspended pending investigation and removed from the schedule, appropriate discipline will be decided upon outcome of investigation. Coaching provided to DON for incident investigations and injuries of unknown origin. Completed (MONTH) 7, (YEAR). Nurse Managers will conduct five random skin assessments and validate the accuracy of the documented skin assessment per week for the next month and then randomly for the next 3 months. Showers will be completed three times weekly unless refused by the resident. Refusals must be documented on progress notes. Shower sheets will be monitored weekly during the At Risk Meeting. Any employee alleged to be involved in an instance of abuse and/or neglect will be interviewed and suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. In-services performed by Regional Consultant RN on Abuse, Neglect, and Exploitation to all staff. To be completed by (MONTH) 7, (YEAR). All staff will be in serviced prior to starting their next scheduled shift. Safe surveys and skin sweeps of residents to be completed (MONTH) 7, (YEAR). Documentation will be reviewed using the 24-hour report, incident and accident reports, and daily progress notes for accuracy of documentation. Administrator and Director of Nursing will be in-serviced on policies of Investigation of Unknown Origin Injuries on (MONTH) 6th, (YEAR) by Regional Consultant RN. Monitoring: All incident reports will be reviewed during morning meeting. All witness statements and incidents will be discussed thoroughly. Nursing designee will monitor incident reports during weekend days. Regional Consultant RN will review all Incident Reports and Investigations Monthly. All allegations or suspicion of Abuse, Neglect and Exploitation or Injuries of Unknown Origin will be investigated and reported to state authorities as described by policy and provider letter. Regional Consultant RN will review all investigations of allegations or suspicions of Abuse, Neglect and Exploitation or Injuries of Unknown Origin at the time investigation by facility is completed. All incident reports and investigations will be reviewed by the inter-disciplinary team and Medical Director at the Quality Assurance meeting each month. Monitoring interviews were started on 09/07/18 at 1:55 p.m. and continued through 09/10/18 at 10:30 a.m. with 21 staff members. The staff members for the 6:00 a.m. to 2:00 p.m. shift: MA F, CNA G, CNA J, MA L, CNA N, MA P, The staff members for the 2:00 p.m. to 10:00 p.m. shift: CNA D, CNA M, LVN Q, MA R, RN T The staff members who worked all three shifts: CNA E, CNA H, MA K, LVN O, LVN S Staff members who worked 8:00 a.m. to 5:00 p.m.: Administrator, DON, Unit Manager C, Activity Director, Unit Manager I The interviews revealed the staff had received in-service training regarding the following: - the Abuse and Neglect Policy; - whom to report allegations of abuse to; - signs and symptoms of abuse; - process to investigate and report abuse; and - incident and accident protocol. An interview with the Administrator on 09/10/18 at 9:40 a.m. revealed going forward she would carefully review incident reports for documented allegations of abuse and report/investigate accordingly. She reported she would also contact the police department to investigate the allegation of abuse for Resident #1 on 09/10/18. An interview with the DON on 09/10/18 at 10:00 a.m. revealed going forward she would investigate injuries of unknown origin more thoroughly. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal.

Based on observations, interviews and record reviews the facility failed to implement written policies and procedures that prohibited and prevented abuse, neglect, and to investigate any such allegations for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to have evidence of a thorough investigation into the significant bruising and swelling of Resident #1's buttocks and legs and his allegation of physical abuse by a staff member. An Immediate Jeopardy (IJ) was identified on 09/06/18 at 4:35 p.m. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. The failure placed residents at risk for abuse and neglect. Findings included: The facility's current Abuse and Neglect Prohibition Policy, dated (MONTH) (YEAR), reflected: Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin .Prevention. 3. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. Protection. 1. The facility will protect residents from harm during the investigation. Investigation. 1. The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Resident #1's Face Sheet dated 09/06/18 reflected the resident was newly admitted to the facility on [DATE]. He was a [AGE] year-old male with [DIAGNOSES REDACTED]. The resident did not have a completed MDS assessment available for review. Resident #1's Nurse Notes reflected: 08/13/18 8:24 p.m. - Resident returned from Psychiatric Hospital for persistent delusional disorder, generalized anxiety disorder, and dementia. Medications verified with physician. 08/19/18 9:22 a.m. - Nurse found resident on the floor in the shower room. Resident reported he was trying to pull down his pants and use the commode, but he tripped and fell . Assessment completed. No apparent injury. 08/21/18 10:09 a.m. - LVN O documented that Resident #1 went into another resident's room, took the pillows off the bed, placed the pillows on the floor, and sat down on them. The resident yelled out for help. Nurse assessed, and resident complained of pain to his right buttock. No injuries noted. Doctor evaluated resident. 08/25/2018 2:48 p.m. - LVN B documented that she was called to Resident #1's room by his family member. The resident had a bruise on buttocks with swelling. The bruise was reddish-purple, ran down back of his leg to back of the knee, and the area was swollen. Resident #1's Incident Reports reflected: 08/19/18 - Found resident on the floor in the shower room with his pants and brief halfway down his leg. Resident reported he was trying to use the commode and tripped. No apparent injury. Resident was placed on neurological check monitoring. 08/25/18 - LVN B was called to the resident's room and upon entrance, the resident's family member was beside him. The family member said to look as she pulled down Resident #1's shorts to expose a large purple-reddish bruise on his right buttock. Resident #1 explained to LVN B that someone had hit him, and he would cringe when he saw the person come to his room. LVN B asked who the person was that hurt him, and the resident said he forgot, but the person was black, big, and came in the evening or at night. Unit Manager and Administrator aware. Physician aware. - The incident report was signed by the Administrator on 08/27/18. Resident #1's Head to Toe Skin Checks Form, dated 08/25/18, completed by Unit Manager C reflected: Existing bruises to back of right buttock, right leg, and right knee. Resident #1's Shower Logs for (MONTH) (YEAR) reflected he refused all showers. Resident #1's Physician order [REDACTED].>08/08/18 Aspirin (blood thinner) 81 milligrams daily. 08/08/18 [MEDICATION NAME] (anti-psychotic medication) 5 milligrams intramuscularly every six hours as needed for [MEDICAL CONDITION] disorder. Resident #1's (MONTH) (YEAR) Medication Administration Records reflected: 08/20/18 9:46 a.m. [MEDICATION NAME] administered to right buttock. - LVN O 08/21/18 5:15 p.m. [MEDICATION NAME] administered to left buttock. - LVN A Resident #1's physician progress notes [REDACTED].>Late Entry for visit 08/22/18. Follow-up on fall. Now noted to have large bruising to right buttock extending down right knee posteriorly. Resident #1's photographs, provided by his family on 09/06/18 revealed severe bruising and swelling of his right buttock and right leg extending to the back of his right knee. An observation and interview with Resident #1 on 09/06/18 at 9:25 a.m. revealed the resident was awake, alert, and able to answer questions. He was ambulating independently with a steady gait in the secured unit of the facility. He reported he wanted to speak to the investigator in his room. Resident #1 walked to his room and pulled the door closed. The resident was asked if he had any issues with other residents, and he stated, No, just staff. The resident walked to his full-length mirror and pulled down the waistband of his pants to reveal a surgical scar on his right hip. He reported the area had healed, but that the area used to be bruised. The resident stated a staff, put me on the bed and beat the [***] out of my leg after he came in my room for no reason at all. The resident reported he could not remember the staff member's name, but that he worked in the evenings and that, He is an[***] . The resident stated, I'm scared of him. He has tried to hit me twice since then. I have to stay away from him. The resident reported the abuse had been reported to the state and thought the investigator was there to investigate his allegation. The resident was informed the facility Administrator would have to be notified of the allegation. The resident frantically said, No, he (the abuser) will kill me, he will shoot me! An interview with the Administrator on 09/06/18 at 11:00 a.m. regarding Resident #1 revealed she was not aware of any allegations of abuse. She reported the resident's memory had improved and she was surprised he had not reported the allegation of abuse. The Administrator reported she would immediately start the facility investigation. An interview with the family of Resident #1 on 09/06/18 at 11:25 a.m. revealed the resident had reported to them that a staff member had beat him up, but the resident did not know the date. The family member reported she told the resident that she was going to report the allegation to the state, but never did. The family member reported she was in the process of trying to get him moved to another facility and sent pictures of the injury to the Investigator to review. The family member reported according to the resident, the staff member that allegedly beat him was LVN [NAME] An interview with another family member of Resident #1 on 09/06/18 at 12:45 p.m. revealed they went to see the resident on 08/25/18. They reported the resident showed them bruises on the right buttock that extended down the right leg. The resident reported to the family that he was being abused by the mean, black, nurse who was constantly yelling at him and pushing him around. The family member reported the resident said the nurse pushed him to the floor and hit him. The family member reported she called in LVN B to assess the resident on 08/25/18. The family member reported Resident #1 had a fear of LVN A because according to the resident, LVN A would yell at him and push him. An interview with LVN B on 09/06/18 at 2:10 p.m. revealed she had assessed Resident #1 on 08/25/18 and saw his bruises. She said she did not know what had caused the bruising but did know he had fallen multiple times. She stated Resident #1 kept saying to her that someone hit him and punched him. LVN B revealed she notified the Administrator regarding the allegations the resident was hit by staff and orders for x-rays were obtained from the physician. LVN B stated she documented the injury and the allegation of abuse on the incident report and notified the Unit Manager and DON. An interview with the Medical Director on 09/10/18 at 10:25 a.m. revealed he was made aware of significant bruising on Resident #1 on 08/25/18 by a nurse. He stated he had already assessed the injury but was unsure of the date. The Medical Director revealed he thought the bruising was related to a fall on 08/21/18. The Medical Director stated Resident #1 made an allegation of abuse to him that seemed like a clear fabrication because the resident said a staff turned him onto his belly and slapped him with a paddle. The Medical Director revealed the nurse, unknown name, had reported the allegation to him also, but there was no perception that the allegation was taken seriously by any staff members. The Medical Director stated according to facility policy, allegations of abuse or neglect were supposed to be investigated and he did have x-rays performed on the resident which were negative for fracture. He said the resident did not name a specific staff member as the alleged perpetrator, gave a very generic description, and was unable to point out the staff member. An interview with Unit Manager C on 09/06/18 at 11:55 a.m. revealed she was supervising the building on 08/25/18 and was told Resident #1 had a bruise on him. She stated a skin assessment was performed and x-rays were taken with negative results. She said the DON was also notified. Unit Manager C revealed she thought the bruising was due to a fall Resident #1 had on 08/19/18. An interview with LVN A on 09/06/18 at 12:50 p.m. revealed he worked the 2:00 p.m.-10:00 p.m. shift and had worked on the secure unit on 08/20/18, 08/21/18, 08/22/18, and 08/23/18. He stated he returned to work on 08/27/18 and was told a bruise was found on Resident #1 after a fall he had. He revealed he had never hit a resident and that if he ever got frustrated with a resident he would take a break and call the DON. An interview with the DON on 09/06/18 at 2:30 p.m. revealed she saw the bruising on Resident #1 on Monday, 08/27/18 and Unit Manager C had contacted her about the injury over the weekend. The DON stated the resident told her that he did not know how the injury had happened and that an incident report and investigation had been completed. She reported she spoke to staff but did not speak to the resident's family. The DON revealed the injury was not self-reported to the state because they thought the injury was related to his fall on 08/19/18 and the resident also had a history of [REDACTED]. The DON stated she did not get a report from the nurses that someone had hit the resident. The DON revealed the facility policy was to self-report injuries of unknown origin with injury, but she thought the injury was related to his fall. An interview with the Administrator on 09/06/18 at 2:35 p.m. revealed LVN B did not notify her of an allegation of abuse for Resident #1. A subsequent interview with the Administrator on 09/07/18 at 3:35 p.m. revealed she found and re-reviewed the incident report for Resident #1. She reported it was dated 08/25/18 and LVN B did document Resident #1's allegation of abuse, but she missed it when the injury was discussed in morning meeting on 08/27/18. The Administrator reported LVN B did not call her to report the allegation of abuse. An Immediate Jeopardy (IJ) was identified on 09/06/18 at 4:35 p.m. and the Administrator was notified. A Plan of Removal was requested at that time: The facility's Plan of Removal was provided by the Administrator and reflected: Immediate action taken: On (MONTH) 6, (YEAR), LVN A was suspended and removed from the schedule pending the investigation. On (MONTH) 6, (YEAR), the Social Worker and Activity Director educated Resident #1 on Abuse and Neglect and gave him phone numbers for the compliance hotline and DADS hotline and told him to call if any other abuse occurred. Resident #1 was reassessed by Unit Manager C for pain and skin assessment on (MONTH) 6, (YEAR). Psychiatrist was notified on (MONTH) 6, (YEAR) and she stated she would be out to see Resident #1 on (MONTH) 7th, (YEAR) to address the fear expressed by the resident. Administrator would review cameras for any unusual events. Would be completed (MONTH) 7, (YEAR). Cameras will be reviewed on a case by case situation in the future for incidents. LVN B notified to come to the facility to be interviewed by Regional Consultant RN and ADON on (MONTH) 7th, (YEAR). LVN B was suspended pending investigation and removed from the schedule, appropriate discipline will be decided upon outcome of investigation. Coaching provided to DON for incident investigations and injuries of unknown origin. Completed (MONTH) 7, (YEAR). Nurse Managers will conduct five random skin assessments and validate the accuracy of the documented skin assessment per week for the next month and then randomly for the next 3 months. Showers will be completed three times weekly unless refused by the resident. Refusals must be documented on progress notes. Shower sheets will be monitored weekly during the At Risk Meeting. Any employee alleged to be involved in an instance of abuse and/or neglect will be interviewed and suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. In-services performed by Regional Consultant RN on Abuse, Neglect, and Exploitation to all staff. To be completed by (MONTH) 7, (YEAR). All staff will be in serviced prior to starting their next scheduled shift. Safe surveys and skin sweeps of residents to be completed (MONTH) 7, (YEAR). Documentation will be reviewed using the 24-hour report, incident and accident reports, and daily progress notes for accuracy of documentation. Administrator and Director of Nursing will be in-serviced on policies of Investigation of Unknown Origin Injuries on (MONTH) 6th, (YEAR) by Regional Consultant RN. Monitoring: All incident reports will be reviewed during morning meeting. All witness statements and incidents will be discussed thoroughly. Nursing designee will monitor incident reports during weekend days. Regional Consultant RN will review all Incident Reports and Investigations Monthly. All allegations or suspicion of Abuse, Neglect and Exploitation or Injuries of Unknown Origin will be investigated and reported to state authorities as described by policy and provider letter. Regional Consultant RN will review all investigations of allegations or suspicions of Abuse, Neglect and Exploitation or Injuries of Unknown Origin at the time investigation by facility is completed. All incident reports and investigations will be reviewed by the inter-disciplinary team and Medical Director at the Quality Assurance meeting each month. Monitoring interviews were started on 09/07/18 at 1:55 p.m. and continued through 09/10/18 at 10:30 a.m. with 21 staff members. The staff members for the 6:00 a.m. to 2:00 p.m. shift: MA F, CNA G, CNA J, MA L, CNA N, MA P, The staff members for the 2:00 p.m. to 10:00 p.m. shift: CNA D, CNA M, LVN Q, MA R, RN T The staff members who worked all three shifts: CNA E, CNA H, MA K, LVN O, LVN S Staff members who worked 8:00 a.m. to 5:00 p.m.: Administrator, DON, Unit Manager C, Activity Director, Unit Manager I The interviews revealed the staff had received in-service training regarding the following: - the Abuse and Neglect Policy; - whom to report allegations of abuse to; - signs and symptoms of abuse; - process to investigate and report abuse; and - incident and accident protocol. An interview with the Administrator on 09/10/18 at 9:40 a.m. revealed going forward she would carefully review incident reports for documented allegations of abuse and report/investigate accordingly. She reported she would also contact the police department to investigate the allegation of abuse for Resident #1 on 09/10/18. An interview with the DON on 09/10/18 at 10:00 a.m. revealed going forward she would investigate injuries of unknown origin more thoroughly. While the IJ was removed on 09/08/18, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents. Van Driver A failed to properly secure Resident #1 in his wheelchair in the van. Resident #1's wheelchair flipped backwards during transport, and the resident was diagnosed with [REDACTED]. This failure could affect the five residents transported by Van Driver A by placing them at risk for injuries. Findings included: Review Resident #1's current, undated face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 01/10/18, revealed the resident had moderate cognitive impairment, used a wheelchair for mobility, required limited one-person assistance with transfers, and supervision for locomotion. Review of the Provider Investigation Report, signed by the Administrator and dated 01/28/18, revealed on 01/23/18 at approximately 2:30 p.m., Resident #1 fell backwards in his wheelchair while riding in the facility's van on his way to an appointment. The report details reflected the following: Resident family called and stated resident fell backwards in wheelchair while in the van. She stated resident has a goose egg on back of head and does not want to go in the van with driver again. Stated she is trying to kill me. Spoke with the van driver and she stated he did fall back in chair but appeared to be ok and wanted to continue on to the appointment so that is what they did. She stated there was something wrong with the strap not connecting. The immediate actions taken reflected the following: Van driver suspended pending investigation. Physician notified. Maint(enance) supervisor and social worker went to the dr. office to drive van back and encourage family to call 911 and have resident go to ER Observation of Resident #1 on 02/07/18 at 10:00 a.m. revealed the resident in his room, lying in bed with no apparent injuries. An interview with Resident #1 at that time revealed he was riding in the facility's van seated in his wheelchair when the wheelchair tipped backwards, and he hit his head. Resident #1 stated he did not think the Van Driver locked his wheelchair correctly on the van, which caused him to fall. Resident #1 stated he received a concussion from the fall and went to the hospital emergency room where they did a CT scan. Review of Resident #1's hospital emergency room notes from 01/23/18 revealed Resident #1 presented with complaints of a headache, neck pain, and back pain. The resident was diagnosed with [REDACTED]. He was discharged from the hospital the same evening with no new orders or precautions. Review of the Administrator's typed statement, dated 01/24/18, revealed the following: DON .received a call from (family member) of (Resident #1) stating that (Resident #1) was afraid of getting back into the van with our driver because on the way to the office the wheelchair fell back during the drive. (The family member) stated that (Resident #1) had a bump on his head and when the driver and (CNA B) had come in to the office but did not say anything to (the family member) or tell (the family member) that (Resident #1) had fallen. (The family member) stated that was the most frustrating. We then called (Van Driver) the driver and ask(ed) her what happened. She did explain she was going up a hill and that for some reason the strap did not hold and the resident in the wheelchair went backwards. She stated she pulled over and helped him up then ask(ed) if he was ok. He stated he was fine and they secured him then went on to the appointment Administrator sent Social Worker .and Maintenance Director to the appointment to talk with the (family member) and encourage resident and (family member) to go to the ER to be checked. 911 called and the resident (was) transported to the hospital .van driver suspended pending investigation. She (Van Driver) told (Maintenance Supervisor) that when she strapped him in that one of the straps did not click in. He ask(ed) her what about the other one and she could not explain that one Review of a typed statement, signed and dated by CNA B on 01/24/18, revealed the following: On Tuesday, January 23 2018, I was scheduled to accompany the resident to his doctor's appointment on the facility van. I stood outside the van while he was lifted inside by the Transportation Aide (Van Driver) and waited while she strapped him down. I did not visually observe her strapping the wheelchair down. After proceeding to get herself back out of the van and closing the doors we both got into the front of the van. We were at the stopped light .and as she made the left hand turn there (w)as a loud noise from the back of the van. I turned around and saw where the resident flipped backwards in the wheelchair. I asked him if he was okay and he said 'I hit my head.' We pulled over as soon as we could and she stopped the van in a parking lot. She went back to the resident and asked if he was okay and he again said 'I hit my head.' She pulled the wheelchair from under him and when I asked if she needed assistance she said 'No, I got it.' She made sure he could move his arms and legs before assisting him to a standing position as resident was already trying to stand up We had left (the) facility at around 1:30 PM as the appointment was for 2:00 PM and to the best of my knowledge the incident occurred at about 1:40--1:45 PM. It took between 2-3 minutes for us to maneuver through traffic to get to the parking lot that we stopped in. Interview with Van Driver A on 02/07/18 at 12:45 p.m. revealed she was driving Resident #1 to his doctor's appointment when the resident's wheelchair flipped backwards on 01/23/18. After this happened, she stated she pulled out of traffic and went to the back of the van to check on Resident #1. The resident stated he was okay, and he was able to move his arms and his legs. She stated Resident #1 was already in the process of standing himself up, so Van Driver A (who was a CNA) assisted him to a van seat and helped him buckle in. Van Driver A stated the resident complained of pain to his head, but he was smiling and seemed okay. Van Driver A stated she did not notice any issues with the securing mechanisms while getting Resident #1 in the van, but after the fall she noticed that one of the wheelchair straps that connected to the floor had come out of its track. Interview with CNA B on 02/07/18 at 1:45 p.m. revealed she was in the front passenger's seat of the van when the vehicle made a right-hand turn, and she heard a loud boom. She stated Van Driver A stopped the vehicle, and CNA B saw the wheelchair had flipped over backwards. She stated the Van Driver went to the back of the vehicle to check on Resident #1, and he told her, My head. My head. The Van Driver was then able to get the resident into the seat of the van, and they continued on to the doctor's office. When the Van Driver and CNA B arrived to the appointment, Resident #1 was complaining of pain to the back of his head. They met the resident's family member at the appointment and while in the waiting room, Resident #1 asked for a pen and paper, which he used to write a note to his family member. The resident's family member asked if something had happened on the drive and CNA B told the family member that there was an accident (the wheelchair fell backwards), and Resident #1 hit his head. Interview with Resident #1's family member on 02/07/18 at 3:05 p.m. revealed as soon as he/she met Resident #1 in the waiting room at the doctor's office the resident immediately asked for a pen and paper and started writing a note. CNA B saw what the resident was writing and said that there was a little accident on the drive over. The family member was upset because he/she felt there was ample time before that for either Van Driver A or CNA B to tell him/her about Resident #1's fall. The family member stated Resident #1 had a bump on his head, about the size of a golf ball so he/she agreed to send him to the ER after his doctor's appointment, for further evaluation. Interview with the Maintenance Supervisor on 02/07/18 at 1:30 p.m. revealed he examined the van at the doctor's office following the incident, and he thought the wheelchair flipped as a result of human error. He stated the securing mechanism had four point locks to secure the wheelchair to the floor of the van, and one of the straps was locked to the wheelchair but unsecured from the track on the van's floor. He stated the other strap was not secured to the wheelchair. When the Maintenance Supervisor asked Van Driver A about how the wheelchair was secured to the van, she could not explain why one strap was not secured to the wheelchair and how another came loose from its track. The Maintenance Supervisor said he thought the front right strap (which had come out of the track) must have been loose when initially secured, and he nor the driver could explain why the left strap was not attached to the wheelchair. The Maintenance Supervisor stated he checked the locking mechanism after the incident and all the straps were in working order so he concluded the mechanism failed as a result of human error. Interview with the Administrator on 02/07/18 at 9:30 a.m. revealed Van Driver A had gone through training a few weeks before this incident and should have been familiar with the facility's policies. The Administrator further stated Van Driver A had been terminated as a result of this incident, and the facility's van was not being used to transport residents, indefinitely. Review of a Disciplinary Action Record, dated 01/31/18, revealed the Van Driver's employment was terminated due to: Employee did not follow policy for injury. Review of the Securement Checklist log revealed Van Driver A signed acknowledgment that all safety procedures were completed and checked prior to every transport, including ensuring track fittings and straps were secure by pulling on them. A checklist was completed by Van Driver A on 01/23/18 at 1:30 p.m., prior to Resident #1's transport. The log revealed five residents, including Resident #1, were transported by Van Driver A.

Based on observation, interview, and record review, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents. Van Driver A and CNA B failed to seek immediate medical attention for Resident #1 when the resident's wheelchair fell backwards during transport in the facility's van on 01/23/18 and failed to ensure Resident #1 was not moved before the resident was assessed by a nurse, paramedic, or emergency medical technician for possible injury. Resident #1 was diagnosed with [REDACTED]. This failure could affect the five residents transported by Van Driver A by placing them at risk for injuries. Findings included: Review Resident #1's current, undated face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment, dated 01/10/18, revealed the resident had moderate cognitive impairment, used a wheelchair for mobility, required limited one-person assistance with transfers, and supervision for locomotion. Review of the Provider Investigation Report, signed by the Administrator and dated 01/28/18, revealed on 01/23/18 at approximately 2:30 p.m., Resident #1 fell backwards in his wheelchair while riding in the facility's van on his way to an appointment. The report details reflected the following: Resident family called and stated resident fell backwards in wheelchair while in the van. She stated resident has a goose egg on back of head and does not want to go in the van with driver again. Stated she is trying to kill me. Spoke with the van driver and she stated he did fall back in chair but appeared to be ok and wanted to continue on to the appointment so that is what they did. She stated there was something wrong with the strap not connecting. The immediate actions taken reflected the following: Van driver suspended pending investigation. Physician notified. Maint(enance) supervisor and social worker went to the dr. office to drive van back and encourage family to call 911 and have resident go to ER Observation of Resident #1 on 02/07/18 at 10:00 a.m. revealed the resident in his room, lying in bed with no apparent injuries. An interview with Resident #1 at that time revealed he was riding in the facility's van seated in his wheelchair when the wheelchair tipped backwards, and he hit his head. Resident #1 stated he did not think the Van Driver locked his wheelchair correctly on the van, which caused him to fall. Resident #1 stated he received a concussion from the fall and went to the hospital emergency room where they did a CT scan. Review of Resident #1's hospital emergency room notes from 01/23/18 revealed Resident #1 presented with complaints of a headache, neck pain, and back pain. The resident was diagnosed with [REDACTED]. He was discharged from the hospital the same evening with no new orders or precautions. Review of the Administrator's typed statement, dated 01/24/18, revealed the following: DON .received a call from (family member) of (Resident #1) stating that (Resident #1) was afraid of getting back into the van with our driver because on the way to the office the wheelchair fell back during the drive. (The family member) stated that (Resident #1) had a bump on his head and when the driver and (CNA B) had come in to the office but did not say anything to (the family member) or tell (the family member) that (Resident #1) had fallen. (The family member) stated that was the most frustrating. We then called (Van Driver) the driver and ask(ed) her what happened. She did explain she was going up a hill and that for some reason the strap did not hold and the resident in the wheelchair went backwards. She stated she pulled over and helped him up then ask(ed) if he was ok. He stated he was fine and they secured him then went on to the appointment. When ask(ed) why she did not follow the procedure and call 911 she stated he was ok so she did not think about it. Administrator sent Social Worker .and Maintenance Director to the appointment office to talk with the (family member) and encourage resident and (family member) to go to the ER to be checked. 911 called and the resident (was) transported to the hospital .van driver suspended pending investigation He ask(ed) her why she did not call 911 and she stated she was just not thinking right. Review of a typed statement, signed and dated by CNA B on 01/24/18, revealed the following: On Tuesday, January 23 2018, I was scheduled to accompany the resident to his doctor's appointment on the facility van. I stood outside the van while he was lifted inside by the Transportation Aide (Van Driver) and waited while she strapped him down. I did not visually observe her strapping the wheelchair down. After proceeding to get herself back out of the van and closing the doors we both got into the front of the van. We were at the stopped light .and as she made the left hand turn there (w)as a loud noise from the back of the van. I turned around and saw where the resident flipped backwards in the wheelchair. I asked him if he was okay and he said 'I hit my head.' We pulled over as soon as we could and she stopped the van in a parking lot. She went back to the resident and asked if he was okay and he again said 'I hit my head.' She pulled the wheelchair from under him and when I asked if she needed assistance she said 'No, I got it.' She made sure he could move his arms and legs before assisting him to a standing position as resident was already trying to stand up. Once she had gotten him up she assisted him to the seat and secured him with the seatbelt. We then proceeded to the doctor's office. During the drive I kept looking back at (the) resident and asking him if he was okay. Resident was then transported via wheelchair in to doctor's office and I stayed with him waiting for his (family member) to arrive When (the family member) came back to sit with us he (Resident #1) asked (family member) for a piece of paper and a pencil and wrote (the family member) a note. (The family member) asked me if something had happened and I told (the family member) about the incident in the van during the trip to the doctor's office. We had left (the) facility at around 1:30 PM as the appointment was for 2:00 PM and to the best of my knowledge the incident occurred at about 1:40--1:45 PM. It took between 2-3 minutes for us to maneuver through traffic to get to the parking lot that we stopped in. Interview with Van Driver A on 02/07/18 at 12:45 p.m. revealed she was driving Resident #1 to his doctor's appointment when the resident's wheelchair flipped backwards on 01/23/18. After this happened, she stated she pulled out of traffic and went to the back of the van to check on Resident #1. The resident stated he was okay, and he was able to move his arms and his legs. She stated Resident #1 was already in the process of standing himself up, so Van Driver A (who was a CNA) assisted him to a van seat and helped him buckle in. Van Driver A stated the resident complained of pain to his head, but he was smiling and seemed okay. Van Driver A stated she did not notice any issues with the securing mechanisms while getting Resident #1 in the van, but after the fall she noticed that one of the wheelchair straps that connected to the floor had come out of its track. The Van Driver stated as a CNA, she was taught not to move a resident, who had fallen, until a nurse had done an assessment. The Van Driver stated she did not call 911, while stopped in the parking lot, because she did not know she was supposed to call. She stated she also did not call the facility because she was not thinking right. Interview with CNA B on 02/07/18 at 1:45 p.m. revealed she was in the front passenger's seat of the van when the vehicle made a right-hand turn, and she heard a loud boom. She stated Van Driver A stopped the vehicle, and CNA B saw the wheelchair had flipped over backwards. She stated the Van Driver went to the back of the vehicle to check on Resident #1, and he told her, My head. My head. The Van Driver was then able to get the resident into the seat of the van, and they continued on to the doctor's office. When the Van Driver and CNA B arrived to the appointment, Resident #1 was complaining of pain to the back of his head. They met the resident's family member at the appointment and while in the waiting room, Resident #1 asked for a pen and paper, which he used to write a note to his family member. The resident's family member asked if something had happened on the drive and CNA B told the family member that there was an accident (the wheelchair fell backwards), and Resident #1 hit his head. CNA B stated her training as a CNA was to immediately call the nurse and not move a resident after a fall, but she did not know she could call 911 from the parking lot. She stated she kind of panicked. Interview with Resident #1's family member on 02/07/18 at 3:05 p.m. revealed as soon as he/she met Resident #1 in the waiting room at the doctor's office the resident immediately asked for a pen and paper and started writing a note. CNA B saw what the resident was writing and said that there was a little accident on the drive over. The family member was upset because he/she felt there was ample time before that for either Van Driver A or CNA B to tell him/her about Resident #1's fall. The family member stated Resident #1 had a bump on his head, about the size of a golf ball so he/she agreed to send him to the ER after his doctor's appointment, for further evaluation. Interview with the Administrator on 02/07/18 at 9:30 a.m. revealed Van Driver A had gone through training a few weeks before this incident and should have been familiar with the facility's policies. The Administrator further stated Van Driver A had been terminated as a result of this incident, and the facility's van was not being used to transport residents, indefinitely. Interview with the Administrator and DON on 02/07/18 at 12:00 p.m. revealed it was Van Driver A's responsibility to immediately call the facility after the fall, not CNA B's. Review of Van Driver A's personnel file revealed on 12/27/17 she completed training to drive the facility van. The training material reflected the following: .If you or a resident is involved in an incident/accident other than a vehicle accident: Immediately: Report all incidents/accidents no matter how minor to the Administrator and await instruction . This acknowledgment was signed by Van Driver A on 12/27/17. Review of the facility's Resident Transport policy, dated July, 2014, revealed the following: 2. In the event of an incident or unusual occurrence: .Immediately call the Administrator (not a designee) to report incident/accident and obtain further instruction . Review of the Securement Checklist log revealed Van Driver A signed acknowledgment that all safety procedures were completed and checked prior to every transport, including ensuring track fittings and straps were secure by pulling on them. A checklist was completed by Van Driver A on 01/23/18 at 1:30 p.m., prior to Resident #1's transport. The log revealed five residents, including Resident #1, were transported by Van Driver A.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and failed for residents one (Resident #1) of 15 residents reviewed for neglect. The PTA and CNA A failed to follow the facility's Abuse and Neglect Prohibition Policy when they failed to report to the Administrator they witnessed Resident #1's daughter verbally and mentally abuse the resident which resulted in resident crying and becoming distraught. CNA A, RN B, the SW, LVN C, and the PTA failed to follow the facility's Abuse and Neglect Prohibition Policy when they failed to report to the Administrator when Resident #1 made allegations of abuse and neglect about her daughter in which Residnet #1 expressed fearfulness of daughter. An Immediate Jeopardy was identified on 05/10/17. The Immediate Jeopardy was removed on 05/11/17. The facility remained out of compliance at severity level of actual harm, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 115 residents at risk of being abused or neglected due to the lack of response from staff when being told and witnessing possible abuse and neglect. Findings included: Review of the Abuse and Neglect Prohibition policy dated 02/17 reflected the following: Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Administrator .The facility administrator is the Abuse Prevention Coordinator . Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation .staff will be instructed to report any signs of stress from employees, family, and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate .The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator . Review of Resident #1's face sheet dated 05/11/17 reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 05/05/17 to the hospital for unrelated reasons. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Resident #1 required limited assistance of one person with bed mobility and transfers. She required extensive assistance of one person with toileting. Interview with the PTA on 05/10/17 at 2:30 p.m. revealed he had been Resident #1's therapist during her entire stay. He stated Resident #1 would be completely distraught around her daughter and he could see the fear in her eyes. He stated when the daughter was not visiting; she was very sweet and kind. The PTA stated about 10 days after Resident #1 was admitted (around 04/07/17) he witnessed Resident #1's daughter come in with fried okra for the resident. He stated the daughter proceeded to take some pieces of fried okra and shove them into Resident #1's mouth despite the mother saying she did not want any. Resident #1 stated the mother began to choke on the okra, but was able to swallow it. He further stated he did tell the Administrator about the okra incident a few days after and the Administrator had told him to keep him in the loop because he wanted to be involved. The PTA stated after the okra incident he saw four to five occasions (approximately 04/07/17 through 05/03/17) when the resident's daughter would yell at the mother telling her that she was not going to change her, give her oxygen, or bathe her when they got home. He stated each time Resident #1 became distraught and would break down in tears. He stated after the first four to five times of witnessing the daughter yelling at Resident #1, the therapy department did mention it to the Administrator around May 3rd or 4th. He further stated he told the Administrator on the day of her discharge (05/05/17) that he felt Resident #1 would die if she went home with the daughter. Interview with CNA A on 05/10/17 at 9:00 a.m. revealed she had worked with Resident #1 during her time at the facility. She stated Resident #1 was [AGE] years old, but she was still able to transfer by pivot and she had incontinent episodes. She stated Resident #1 was scared of her daughter and going home with her. Resident #1 told her that her daughter would withhold oxygen and yell at her. Resident #1 stated she did not want to go home. CNA A stated Resident #1's daughter was rude to both staff and her mother and would cuss and yell at staff in front of her mother. She stated she could understand why Resident #1 did not wish to go home with her daughter. Interview with CNA A on 05/10/17 at 12:33 p.m. revealed she had not told anyone about what Resident #1 would say about her daughter. She stated she did witness the daughter raise her voice to Resident #1, but since she was not cussing at Resident #1 she did not think it was abuse. She did not believe any of the accusations Resident #1 made about the daughter were abuse and that is why did not report it to anyone. Interview with RN B on 05/10/17 at 9:07 a.m. revealed she had been Resident #1's nurse during her stay at the facility. She stated Resident #1 was a very sweet old lady, but her daughter was very mean. She stated last Friday, Resident #1's daughter called 911 for her mother to be transported out of the facility. She stated Resident #1 did not appear to be in any distress and she did have some left arm swelling, but they had notified the doctor who had ordered an x-ray. She stated the x-ray could not be completed because the daughter took Resident #1 before it could be completed. She stated Resident #1 had told her she did not want to go with her daughter because she would give her cold showers, withhold oxygen, cuss her out, and did not want to help her get to the commode. Resident #1 stated to her she was scared of her daughter and her daughter would punish her if the staff said anything to her. RN B stated the SW did call Adult Protective Services (APS), but since Resident #1 was still in the facility they could not open a case until she went home. She stated they probably have not called APS again because they do not have a SW at the moment. She stated she did not tell the DON or Administrator about Resident #1's accusations. Interview with RN B on 05/10/17 at 12:29 p.m. revealed she never told the administrator about it because she did not think it was abuse. Interview with LVN C on 05/10/17 revealed she had only taken care of Resident #1 once, but when she did Resident #1 told her my daughter is going to kill me. Resident #1 did not elaborate and she thought it was strange. She stated she never told anyone. Review of RN B's nurse's note dated 03/30/17 at 9:12 a.m. reflected the following: Resident #1 confided that she had not been allowed an oxygen concentrator or oxygen administration while living with her daughter, but stated that she had needed it on a PRN basis. Resident stated that she would receive cold showers on a regular basis and 'was cussed at' when she would cry. Resident #1 also admitted that she would get cussed at by her daughter when she used her bedside commode, 'because it stunk.' Resident was assured that the staff are happy to assist her with any needs that she may have. Resident also voiced fear at daughter learning that she had informed us of the previous information, stating that 'She will find a way to punish me.' Resident was assured that her private information was confidential. Oxygen via NC will be given PRN. There is no labored breathing and resident denies SOB at this time. She is resting comfortably in bed in no distress. Interview with the Administrator on 05/10/17 at 2:50 p.m. revealed the PTA had come to him the day Resident #1 was discharged on [DATE] about how he was concerned with Resident #1 going home with the daughter, but he never mentioned the daughter was physically or verbally abusing Resident #1. He stated he never mentioned any incidents involving Okra or the couple of times the daughter yelled at the resident. Interview with the Administrator on 05/10/17 at 3:19 p.m. revealed if the PTA and other staff would of come forward about all the accusations, he would of investigated the matter further to protect the resident. Review of the SW social service's note dated 04/25/17 at 1:50 p.m. reflected the following: ST brought to LMSW attention that residents daughter may want to take her home. Possible APS case was open before on her daughter due to her age and being unable to successfully care for her. LMSW followed up with DON at APS to report this concern. He could not confirm or deny that there was a case before but advised to issue an AMA if daughter attempts to take out resident and then call APS again when discharged . Call ref # 708. Review of the SW social service's note dated 04/28/17 at 12:42 p.m. reflected the following: SW and the Ombudsman went to speak with resident about her daughter wanting her to move. Resident stated she did not want to leave and does not think her daughter can take care of her at home. SW asked if she would tell her daughter this and she said no, I do not want to make her upset. She then started getting tearful and said I just want to stay here. SW inquired if could talk to daughter and inform her she wishes to stay and resident got upset and said please don't, I want to make her happy. Resident's daughter plans to meet with SW Monday to discuss taking her out. SW has followed up with staff in regards to this. Interview with the Administrator on 05/10/17 at 1:37 p.m. revealed he was never told by any staff their concerns related to Resident #1's daughter and the accusations Resident #1 had made against her daughter. He stated on 05/03/17, he went with the social worker to Resident #1's room because she was concerned about the resident being able to go home. He stated he was never told by any staff about the accusations of possible abuse from the daughter and did not know Resident #1 had told staff about the daughter mistreating her. He stated he did think there was an open APS case, but they could not do anything since the resident was in the facility. He stated they did not call APS after she left, but he did call the hospital and let them know Resident #1 did not feel safe physically to go home. He stated he never followed up with him about Resident #1's discharge plans. He did not think she was being abused, but then again no one had told him the accusations. He stated he did not know if the resident was being abused by the daughter in the facility because he never investigated the Resident #1's concerns. He stated he was the Abuse Coordinator and all staff were to report to him any allegations of abuse or neglect immediately. An IJ was identified on 05/10/17 at 1:37 p.m. The Administrator was informed of the IJ and a Plan of Removal was requested. The facility's Plan of Removal, accepted on 05/11/17 at 9:40 a.m. reflected: On May 10, 2017 the Administrator was in-serviced on Abuse and Neglect by the District Director of Operations on reporting Abuse and Neglect. On May 10, 2017 The facility Abuse Coordinator conducted an in-service covering Abuse and Neglect with a focus on reporting abuse and neglect allegations regardless of the timeline of when the resident or patient is in the facility. No employees are to provide care until they have been in-serviced on reporting abuse and neglect. Monitoring: The facility will ensure that if a resident alleges that abuse or neglect has occurred by a person outside of the facility that the abuse coordinator is made aware and investigates the claim. The facility will utilize Ambassador rounds for each resident to ensure the safety of each resident in the facility. Each resident's Ambassador will meet with them 5 days a week to serve as a resident advocate on all issues any resident may have. All concerns and grievances will be brought up and discussed during the morning department head meeting at 9:00 AM Monday through Friday. Target completion date will be 5/11/2017 or prior to the next scheduled shift. Interviews with RA D, CNA E, HK F, LVN G, CNA A, and RN B on 05/11/17 from 10:20 a.m. to 10:38 a.m. revealed they had been in-serviced about abuse and neglect prior to starting their shifts. They were able to give examples of each type of abuse and were able to name some signs and symptoms of possible abuse. They all stated they would report any concerns or observations of abuse or neglect from anyone to the Administrator immediately. Review of the staff in-service dated 05/10/17 and 05/11/17 revealed the staff were being in-serviced over the abuse prohibition policy and when to report abuse/neglect. Review of the sign in sheet compared to the in-service sign in sheet revealed all staff on the floor had been in serviced over abuse and neglect. Review of the in-service provided to the Administrator from Corporate RN reflected he had been in-serviced regarding abuse and neglect on 05/10/17. Interview with the Administrator on 05/11/17 at 9:51 a.m. revealed he had been in-serviced over what and when allegations or observations of abuse needed to be reported to him and other entities, including the State. He stated he was the abuse prevention coordinator and he was in serviced about ensuring the staff are telling him about all allegations or observations of abuse immediately, even if the accusation is from visitors of family. On 05/11/17, the IJ was removed. On 05/11/17, at 9:40 a.m. the Administrator was informed the IJ was removed. While the IJ was removed on 05/11/17, the facility remained out of compliance at severity level of actual harm, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. Review of the Arlington Heights Room Roster dated 05/09/17 reflected there were 115 residents.

Based on interview and record review, the facility failed to ensure each resident was free from abuse and neglect for one (Resident #1) of 15 residents reviewed for abuse. PTA failed to report abuse and neglect of Resident #1 by the resident's daughter which resulted in Resident #1 becoming distraught and crying. CNA A, RN B, the SW, LVN C, and the failed to report multiple incidents of possible abuse and neglect of Resident #1 by the resident's daughter to the Administrator. These incidents resulted in Resident #1 expressing fearfulness of daughter. An Immediate Jeopardy was identified on 05/10/17. The Immediate Jeopardy was removed on 05/11/17. The facility remained out of compliance at severity level of actual harm, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 115 residents at risk of being abused or neglected due to the lack of response from staff when being told and witnessing possible abuse and neglect. Findings included: Review of Resident #1's face sheet dated 05/11/17 reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 05/05/17 to the hospital for unrelated reasons. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Resident #1 required limited assistance of one person with bed mobility and transfers. She required extensive assistance of one person with toileting. Interview with the PTA on 05/10/17 at 2:30 p.m. revealed he had been Resident #1's therapist during her entire stay. He stated Resident #1 would be completely distraught around her daughter and he could see the fear in her eyes. He stated when the daughter was not visiting; she was very sweet and kind. The PTA stated about 10 days after Resident #1 was admitted (around 04/07/17) he witnessed Resident #1's daughter come in with fried okra for the resident. He stated the daughter proceeded to take some pieces of fried okra and shove them into Resident #1's mouth despite the mother saying she did not want any. Resident #1 stated the mother began to choke on the okra, but was able to swallow it. He further stated he did tell the Administrator about the okra incident a few days after and the Administrator had told him to keep him in the loop because he wanted to be involved. The PTA stated after the okra incident he saw four to five occasions (approximately 04/07/17 through 05/03/17) when the resident's daughter would yell at the mother telling her that she was not going to change her, give her oxygen, or bathe her when they got home. He stated each time Resident #1 became distraught and would break down in tears. He stated after the first four to five times of witnessing the daughter yelling at Resident #1, the therapy department did mention it to the Administrator around May 3rd or 4th. He further stated he told the Administrator on the day of her discharge (05/05/17) that he felt Resident #1 would die if she went home with the daughter. Interview with CNA A on 05/10/17 at 9:00 a.m. revealed she had worked with Resident #1 during her time at the facility. She stated Resident #1 was [AGE] years old, but she was still able to transfer by pivot and she had incontinent episodes. She stated Resident #1 was scared of her daughter and going home with her. Resident #1 told her that her daughter would withhold oxygen and yell at her. Resident #1 stated she did not want to go home. CNA A stated Resident #1's daughter was rude to both staff and her mother and would cuss and yell at staff in front of her mother. She stated she could understand why Resident #1 did not wish to go home with her daughter. Interview with CNA A on 05/10/17 at 12:33 p.m. revealed she had not told anyone about what Resident #1 would say about her daughter. She stated she did witness the daughter raise her voice to Resident #1, but since she was not cussing at Resident #1 she did not think it was abuse. She did not believe any of the accusations Resident #1 made about the daughter were abuse and that is why did not report it to anyone. Interview with RN B on 05/10/17 at 9:07 a.m. revealed she had been Resident #1's nurse during her stay at the facility. She stated Resident #1 was a very sweet old lady, but her daughter was very mean. She stated last Friday, Resident #1's daughter called 911 for her mother to be transported out of the facility. She stated Resident #1 did not appear to be in any distress and she did have some left arm swelling, but they had notified the doctor who had ordered an x-ray. She stated the x-ray could not be completed because the daughter took Resident #1 before it could be completed. She stated Resident #1 had told her she did not want to go with her daughter because she would give her cold showers, withhold oxygen, cuss her out, and did not want to help her get to the commode. Resident #1 stated to her she was scared of her daughter and her daughter would punish her if the staff said anything to her. RN B stated the SW did call Adult Protective Services (APS), but since Resident #1 was still in the facility they could not open a case until she went home. She stated they probably have not called APS again because they do not have a SW at the moment. She stated she did not tell the DON or Administrator about Resident #1's accusations. Interview with RN B on 05/10/17 at 12:29 p.m. revealed she never told the administrator about it because she did not think it was abuse. Interview with LVN C on 05/10/17 revealed she had only taken care of Resident #1 once, but when she did Resident #1 told her my daughter is going to kill me. Resident #1 did not elaborate and she thought it was strange. She stated she never told anyone. Review of RN B's nurse's note dated 03/30/17 at 9:12 a.m. reflected the following: Resident #1 confided that she had not been allowed an oxygen concentrator or oxygen administration while living with her daughter, but stated that she had needed it on a PRN basis. Resident stated that she would receive cold showers on a regular basis and 'was cussed at' when she would cry. Resident #1 also admitted that she would get cussed at by her daughter when she used her bedside commode, 'because it stunk.' Resident was assured that the staff are happy to assist her with any needs that she may have. Resident also voiced fear at daughter learning that she had informed us of the previous information, stating that 'She will find a way to punish me.' Resident was assured that her private information was confidential. Oxygen via NC will be given PRN. There is no labored breathing and resident denies SOB at this time. She is resting comfortably in bed in no distress. Interview with the PTA on 05/10/17 at 2:30 p.m. revealed he had been Resident #1's therapist during her entire stay. He stated Resident #1 would be completely distraught around her daughter and he could see the fear in her eyes. He stated when the daughter was not visiting; she was very sweet and kind. The PTA stated about 10 days after Resident #1 was admitted (around 04/07/17) he witnessed Resident #1's daughter come in with fried okra for the resident. He stated the daughter proceeded to take some pieces of fried okra and shove them into Resident #1's mouth despite the mother saying she did not want any. Resident #1 stated the mother began to choke on the okra, but was able to swallow it. He further stated he did tell the Administrator about the okra incident a few days after and the Administrator had told him to keep him in the loop because he wanted to be involved. The PTA stated after the okra incident he saw four to five occasions (approximately 04/07/17 through 05/03/17) when the resident's daughter would yell at the mother telling her that she was not going to change her, give her oxygen, or bathe her when they got home. He stated each time Resident #1 became distraught and would break down in tears. He stated after the first four to five times of witnessing the daughter yelling at Resident #1, the therapy department did mention it to the Administrator around May 3rd or 4th. He further stated he told the Administrator on the day of her discharge (05/05/17) that he felt Resident #1 would die if she went home with the daughter. Interview with the Administrator on 05/10/17 at 2:50 p.m. revealed the PTA had come to him the day Resident #1 was discharged on [DATE] about how he was concerned with Resident #1 going home with the daughter, but he never mentioned the daughter was physically or verbally abusing Resident #1. He stated he never mentioned any incidents involving Okra or the couple of times the daughter yelled at the resident. Interview with the Administrator on 05/10/17 at 3:19 p.m. revealed if the PTA and other staff would of come forward about all the accusations, he would of investigated the matter further to protect the resident. Review of the SW social service's note dated 04/25/17 at 1:50 p.m. reflected the following: ST brought to LMSW attention that residents daughter may want to take her home. Possible APS case was open before on her daughter due to her age and being unable to successfully care for her. LMSW followed up with DON at APS to report this concern. He could not confirm or deny that there was a case before but advised to issue an AMA if daughter attempts to take out resident and then call APS again when discharged . Call ref # 708. Review of the SW social service's note dated 04/28/17 at 12:42 p.m. reflected the following: SW and the Ombudsman went to speak with resident about her daughter wanting her to move. Resident stated she did not want to leave and does not think her daughter can take care of her at home. SW asked if she would tell her daughter this and she said no, I do not want to make her upset. She then started getting tearful and said I just want to stay here. SW inquired if could talk to daughter and inform her she wishes to stay and resident got upset and said please don't, I want to make her happy. Resident's daughter plans to meet with SW Monday to discuss taking her out. SW has followed up with staff in regards to this. Interview with the Administrator on 05/10/17 at 1:37 p.m. revealed he was never told by any staff their concerns related to Resident #1's daughter and the accusations Resident #1 had made against her daughter. He stated on 05/03/17, he went with the social worker to Resident #1's room because she was concerned about the resident being able to go home. He stated he was never told by any staff about the accusations of possible abuse from the daughter and did not know Resident #1 had told staff about the daughter mistreating her. He stated he did think there was an open APS case, but they could not do anything since the resident was in the facility. He stated they did not call APS after she left, but he did call the hospital and let them know Resident #1 did not feel safe physically to go home. He stated he never followed up with him about Resident #1's discharge plans. He did not think she was being abused, but then again no one had told him the accusations. He stated he did not know if the resident was being abused by the daughter in the facility because he never investigated the Resident #1's concerns. He stated he was the Abuse Coordinator and all staff were to report to him any allegations of abuse or neglect immediately. Review of the facility's Abuse and Neglect Prohibition policy dated 02/17 reflected the following: Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator .The facility administrator is the Abuse Prevention Coordinator . Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation staff will be instructed to report any signs of stress from employees, family, and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate .The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator . An IJ was identified on 05/10/17 at 1:37 p.m. The Administrator was informed of the IJ and a Plan of Removal was requested. The facility's Plan of Removal, accepted on 05/11/17 at 9:40 a.m. reflected: On May 10, 2017 the Administrator was in-serviced on Abuse and Neglect by the District Director of Operations on reporting Abuse and Neglect. On May 10, 2017 The facility Abuse Coordinator conducted an in-service covering Abuse and Neglect with a focus on reporting abuse and neglect allegations regardless of the timeline of when the resident or patient is in the facility. No employees are to provide care until they have been in-serviced on reporting abuse and neglect. Monitoring: The facility will ensure that if a resident alleges that abuse or neglect has occurred by a person outside of the facility that the abuse coordinator is made aware and investigates the claim. The facility will utilize Ambassador rounds for each resident to ensure the safety of each resident in the facility. Each resident's Ambassador will meet with them 5 days a week to serve as a resident advocate on all issues any resident may have. All concerns and grievances will be brought up and discussed during the morning department head meeting at 9:00 AM Monday through Friday. Target completion date will be 5/11/2017 or prior to the next scheduled shift. Interviews with RA D, CNA E, HK F, LVN G, CNA A, and RN B on 05/11/17 from 10:20 a.m. to 10:38 a.m. revealed they had been in-serviced about abuse and neglect prior to starting their shifts. They were able to give examples of each type of abuse and were able to name some signs and symptoms of possible abuse. They all stated they would report any concerns or observations of abuse or neglect from anyone to the Administrator immediately. Review of the staff in-service dated 05/10/17 and 05/11/17 revealed the staff were being in-serviced over the abuse prohibition policy and when to report abuse/neglect. Review of the sign in sheet compared to the in-service sign in sheet revealed all staff on the floor had been in serviced over abuse and neglect. Review of the in-service provided to the Administrator from Corporate RN reflected he had been in-serviced regarding abuse and neglect on 05/10/17. Interview with the Administrator on 05/11/17 at 9:51 a.m. revealed he had been in-serviced over what and when allegations or observations of abuse needed to be reported to him and other entities, including the State. He stated he was the abuse prevention coordinator and he was in serviced about ensuring the staff are telling him about all allegations or observations of abuse immediately, even if the accusation is from visitors of family. On 05/11/17, the IJ was removed. On 05/11/17, at 9:40 a.m. the Administrator was informed the IJ was removed. While the IJ was removed on 05/11/17, the facility remained out of compliance at severity level of actual harm, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. Review of the Arlington Heights Room Roster dated 05/09/17 reflected there were 115 residents.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for one (Resident #1) of 15 residents reviewed for abuse and neglect. PTA failed to report abuse and neglect of Resident #1 by the resident's daughter which resulted in Resident #1 becoming distraught and crying. CNA A, RN B, the SW, LVN C, and the failed to report multiple incidents of possible abuse and neglect of Resident #1 by the resident's daughter to the Administrator. These incidents resulted in Resident #1 expressing fearfulness of daughter. An Immediate Jeopardy was identified on 05/10/17. The Immediate Jeopardy was removed on 05/11/17. The facility remained out of compliance at severity level of actual harm, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 115 residents at risk of being abused or neglected due to the lack of response from staff when being told and witnessing possible abuse and neglect. Findings included: Review of Resident #1's face sheet dated 05/11/17 reflected Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 05/05/17 to the hospital for unrelated reason. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Resident #1 required limited assistance of one person with bed mobility and transfers. She required extensive assistance of one person with toileting. Interview with the PTA on 05/10/17 at 2:30 p.m. revealed he had been Resident #1's therapist during her entire stay. He stated Resident #1 would be completely distraught around her daughter and he could see the fear in her eyes. He stated when the daughter was not visiting; she was very sweet and kind. The PTA stated about 10 days after Resident #1 was admitted (around 04/07/17) he witnessed Resident #1's daughter come in with fried okra for the resident. He stated the daughter proceeded to take some pieces of fried okra and shove them into Resident #1's mouth despite the mother saying she did not want any. Resident #1 stated the mother began to choke on the okra, but was able to swallow it. He further stated he did tell the Administrator about the okra incident a few days after and the Administrator had told him to keep him in the loop because he wanted to be involved. The PTA stated after the okra incident he saw four to five occasions (approximately 04/07/17 through 05/03/17) when the resident's daughter would yell at the mother telling her that she was not going to change her, give her oxygen, or bathe her when they got home. He stated each time Resident #1 became distraught and would break down in tears. He stated after the first four to five times of witnessing the daughter yelling at Resident #1, the therapy department did mention it to the Administrator around May 3rd or 4th. He further stated he told the Administrator on the day of her discharge (05/05/17) that he felt Resident #1 would die if she went home with the daughter. Interview with CNA A on 05/10/17 at 9:00 a.m. revealed she had worked with Resident #1 during her time at the facility. She stated Resident #1 was [AGE] years old, but she was still able to transfer by pivot and she had incontinent episodes. She stated Resident #1 was scared of her daughter and going home with her. Resident #1 told her that her daughter would withhold oxygen and yell at her. Resident #1 stated she did not want to go home. CNA A stated Resident #1's daughter was rude to both staff and her mother and would cuss and yell at staff in front of her mother. She stated she could understand why Resident #1 did not wish to go home with her daughter. Interview with CNA A on 05/10/17 at 12:33 p.m. revealed she had not told anyone about what Resident #1 would say about her daughter. She stated she did witness the daughter raise her voice to Resident #1, but since she was not cussing at Resident #1 she did not think it was abuse. She did not believe any of the accusations Resident #1 made about the daughter were abuse and that is why did not report it to anyone. Interview with RN B on 05/10/17 at 9:07 a.m. revealed she had been Resident #1's nurse during her stay at the facility. She stated Resident #1 was a very sweet old lady, but her daughter was very mean. She stated last Friday, Resident #1's daughter called 911 for her mother to be transported out of the facility. She stated Resident #1 did not appear to be in any distress and she did have some left arm swelling, but they had notified the doctor who had ordered an x-ray. She stated the x-ray could not be completed because the daughter took Resident #1 before it could be completed. She stated Resident #1 had told her she did not want to go with her daughter because she would give her cold showers, withhold oxygen, cuss her out, and did not want to help her get to the commode. Resident #1 stated to her she was scared of her daughter and her daughter would punish her if the staff said anything to her. RN B stated the SW did call Adult Protective Services (APS), but since Resident #1 was still in the facility they could not open a case until she went home. She stated they probably have not called APS again because they do not have a SW at the moment. She stated she did not tell the DON or Administrator about Resident #1's accusations. Interview with RN B on 05/10/17 at 12:29 p.m. revealed she never told the administrator about it because she did not think it was abuse. Interview with LVN C on 05/10/17 revealed she had only taken care of Resident #1 once, but when she did Resident #1 told her my daughter is going to kill me. Resident #1 did not elaborate and she thought it was strange. She stated she never told anyone. Review of RN B's nurse's note dated 03/30/17 at 9:12 a.m. reflected the following: Resident #1 confided that she had not been allowed an oxygen concentrator or oxygen administration while living with her daughter, but stated that she had needed it on a PRN basis. Resident stated that she would receive cold showers on a regular basis and 'was cussed at' when she would cry. Resident #1 also admitted that she would get cussed at by her daughter when she used her bedside commode, 'because it stunk.' Resident was assured that the staff are happy to assist her with any needs that she may have. Resident also voiced fear at daughter learning that she had informed us of the previous information, stating that 'She will find a way to punish me.' Resident was assured that her private information was confidential. Oxygen via NC will be given PRN. There is no labored breathing and resident denies SOB at this time. She is resting comfortably in bed in no distress. Interview with the Administrator on 05/10/17 at 2:50 p.m. revealed the PTA had come to him the day Resident #1 was discharged on [DATE] about how he was concerned with Resident #1 going home with the daughter, but he never mentioned the daughter was physically or verbally abusing Resident #1. He stated he never mentioned any incidents involving Okra or the couple of times the daughter yelled at the resident. Interview with the Administrator on 05/10/17 at 3:19 p.m. revealed if the PTA and other staff would of come forward about all the accusations, he would of investigated the matter further to protect the resident. Review of the SW social service's note dated 04/25/17 at 1:50 p.m. reflected the following: ST brought to LMSW attention that residents daughter may want to take her home. Possible APS case was open before on her daughter due to her age and being unable to successfully care for her. LMSW followed up with DON at APS to report this concern. He could not confirm or deny that there was a case before but advised to issue an AMA if daughter attempts to take out resident and then call APS again when discharged . Call ref # 708. Review of the SW social service's note dated 04/28/17 at 12:42 p.m. reflected the following: SW and the Ombudsman went to speak with resident about her daughter wanting her to move. Resident stated she did not want to leave and does not think her daughter can take care of her at home. SW asked if she would tell her daughter this and she said no, I do not want to make her upset. She then started getting tearful and said I just want to stay here. SW inquired if could talk to daughter and inform her she wishes to stay and resident got upset and said please don't, I want to make her happy. Resident's daughter plans to meet with SW Monday to discuss taking her out. SW has followed up with staff in regards to this. Interview with the Administrator on 05/10/17 at 1:37 p.m. revealed he was never told by any staff their concerns related to Resident #1's daughter and the accusations Resident #1 had made against her daughter. He stated on 05/03/17, he went with the social worker to Resident #1's room because she was concerned about the resident being able to go home. He stated he was never told by any staff about the accusations of possible abuse from the daughter and did not know Resident #1 had told staff about the daughter mistreating her. He stated he did think there was an open APS case, but they could not do anything since the resident was in the facility. He stated they did not call APS after she left, but he did call the hospital and let them know Resident #1 did not feel safe physically to go home. He stated he never followed up with him about Resident #1's discharge plans. He did not think she was being abused, but then again no one had told him the accusations. He stated he did not know if the resident was being abused by the daughter in the facility because he never investigated the Resident #1's concerns. He stated he was the Abuse Coordinator and all staff were to report to him any allegations of abuse or neglect immediately. Review of the facility's Abuse and Neglect Prohibition policy dated 02/17 reflected the following: Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator .The facility administrator is the Abuse Prevention Coordinator . Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation staff will be instructed to report any signs of stress from employees, family, and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate .The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator . An IJ was identified on 05/10/17 at 1:37 p.m. The Administrator was informed of the IJ and a Plan of Removal was requested. The facility's Plan of Removal, accepted on 05/11/17 at 9:40 a.m. reflected: On May 10, 2017 the Administrator was in-serviced on Abuse and Neglect by the District Director of Operations on reporting Abuse and Neglect. On May 10, 2017 The facility Abuse Coordinator conducted an in-service covering Abuse and Neglect with a focus on reporting abuse and neglect allegations regardless of the timeline of when the resident or patient is in the facility. No employees are to provide care until they have been in-serviced on reporting abuse and neglect. Monitoring: The facility will ensure that if a resident alleges that abuse or neglect has occurred by a person outside of the facility that the abuse coordinator is made aware and investigates the claim. The facility will utilize Ambassador rounds for each resident to ensure the safety of each resident in the facility. Each resident's Ambassador will meet with them 5 days a week to serve as a resident advocate on all issues any resident may have. All concerns and grievances will be brought up and discussed during the morning department head meeting at 9:00 AM Monday through Friday. Target completion date will be 5/11/2017 or prior to the next scheduled shift. Interviews with RA D, CNA E, HK F, LVN G, CNA A, and RN B on 05/11/17 from 10:20 a.m. to 10:38 a.m. revealed they had been in-serviced about abuse and neglect prior to starting their shifts. They were able to give examples of each type of abuse and were able to name some signs and symptoms of possible abuse. They all stated they would report any concerns or observations of abuse or neglect from anyone to the Administrator immediately. Review of the staff in-service dated 05/10/17 and 05/11/17 revealed the staff were being in-serviced over the abuse prohibition policy and when to report abuse/neglect. Review of the sign in sheet compared to the in-service sign in sheet revealed all staff on the floor had been in serviced over abuse and neglect. Review of the in-service provided to the Administrator from Corporate RN reflected he had been in-serviced regarding abuse and neglect on 05/10/17. Interview with the Administrator on 05/11/17 at 9:51 a.m. revealed he had been in-serviced over what and when allegations or observations of abuse needed to be reported to him and other entities, including the State. He stated he was the abuse prevention coordinator and he was in serviced about ensuring the staff are telling him about all allegations or observations of abuse immediately, even if the accusation is from visitors of family. On 05/11/17, the IJ was removed. On 05/11/17, at 9:40 a.m. the Administrator was informed the IJ was removed. While the IJ was removed on 05/11/17, the facility remained out of compliance at severity level of actual harm, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. Review of the Arlington Heights Room Roster dated 05/09/17 reflected there were 115 residents.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for one (Residents #1) of seven residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 was free from neglect when it allowed CNA A, who had a history of [REDACTED]. CNA A had a [MEDICAL CONDITION] while providing care for Resident #1and pulled his catheter with the fully inflated bulb out as she fell . Resident #1 suffered significant pain and bleeding. He was sent to the hospital where he was admitted . The resident now has to have an Urologist remove and put in his catheter monthly. The resident also suffers from anxiety when staff performed catheter care. 2. The facility failed to report to State Survey Agency when CNA A had a [MEDICAL CONDITION] while caring for Resident #1. 3. The facility failed to investigate when CNA A had a [MEDICAL CONDITION] and injured Resident #1. 4. The facility failed to protect Resident #1 and other residents when CNA A was allowed to continue to work. An Immediate Jeopardy (IJ) was identified on 01/18/17. While the IJ was removed on 01/19/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, because the facility was still monitoring the implementation of the Plan of Removal. These failures could affect all 115 residents, who resided in the facility, by placing them at risk for abuse, injuries, fear, and a decreased quality of life. Findings included: Facility abuse and neglect policy dated July, 2016 reflected: Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Administrator .The facility will conduct an investigation of any alleged abuse/neglect .in accordance with state law. Review of Resident #1's face sheet dated 01/18/17 revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 08/23/16 revealed Resident #1 was taken to a local hospital emergency roiagnom on [DATE] and admitted to the hospital. As a result of this incident, the resident must now travel monthly to a hospital ER to have the Foley catheter changed by a Urologist. The resident must stay in the hospital after the Foley catheter is changed for 1 - 2 ½ days before returning to the facility. A review of Resident #1's MDS assessment dated [DATE] revealed he had an indwelling catheter and a BIMS score of 15. The resident had [DIAGNOSES REDACTED] and required Extensive assistance in all activities of daily living. Staff provided guided maneuvering while in bed or on alternate furniture. He was totally dependent on staff to move between surfaces including to or from bed, chair, wheelchair, standing position. He required full staff performance every time during the entire 7-day period. The activity of daily walking in room and corridor did not occur at any time. The resident required two person physical assist for dressing which includes putting clothing on, fastening and taking off all items of clothing, including donning/removing socks when worn. His dressing includes putting on and changing his hospital gown. Eating required set-up only. Toileting was total dependence every time over each seven day period. The resident had a Foley catheter which required staff to change the towel and bed linen when the catheter leaked. He required a two person assistance to turn him and place him on bedpan. He also required two person physical assist to perform personal hygiene. An interview on 01/19/17 at 8:20 AM with Resident #1 revealed CNA A had pulled out his Foley catheter during a [MEDICAL CONDITION] a few months ago. He said that the CNA was holding his Foley catheter tubing, got a weird look on her face, and fell to the floor dislodging his Foley catheter. He stated that there was significant pain and he experienced bleeding from his penis. He said that even after treatment, he continues to experience pain and leaking around the catheter. He said he still cringes thinking about it or when someone does catheter care for him. He said CNA A has frequent [MEDICAL CONDITION] and has had a few in his room since the incident. He said the other day she was coming to turn off his oxygen machine because it was beeping and had a [MEDICAL CONDITION] in front of his bathroom. He said CNA A was the only aide on his hall most of the time. He has asked not to have her work with him to the Administrator and DON, but she continues to work his hall. He said he cringes every time she comes to help him or when anyone touches his catheter and that his catheter leaks a lot more since the incident. An interview on 01/20/17 at 10:07 AM with CNA A revealed she had worked at the facility for [AGE] years as a Certified Nursing Assistant and has had [MEDICAL CONDITION] since she was [AGE] years old. She sometimes knew when a spell ([MEDICAL CONDITION]) was about to come on and sometimes she did not. She stated on the day of the catheter incident, she was providing care and she had a [MEDICAL CONDITION] and fell backwards. She woke up on the floor. She said the resident had called from his cell phone for help. LVN B was in the room when she awakened and sent the resident to the hospital. She stated prior to the incident, she was running out of medications and that is probably why she had a [MEDICAL CONDITION]. She stated she still has some [MEDICAL CONDITION] on the medications, but they were very rare. She stated she worked on Station 3 at nights and did not normally transfer residents. She said she will get a nurse or the other CNA to transfer anyone if they need to. She stated that she cannot drive because of her [MEDICAL CONDITION]. Interview with LVN C on 01/18/17 at 12:15 PM revealed CNA A was working the night shift when she had a [MEDICAL CONDITION] and was holding Resident #1's Foley catheter line in her hands when she fell to the floor, a result of the [MEDICAL CONDITION]. When this occurred, she pulled the resident's Foley catheter out. He said CNA A was a hard worker but that she has [MEDICAL CONDITION] all the time while at work. He stated that when she smiles you know she is about to have a [MEDICAL CONDITION]. After the [MEDICAL CONDITION] she gets up and goes to do her work. She is a good CNA and a hard worker, just has [MEDICAL CONDITION]. He stated that CNA A has [MEDICAL CONDITION] no matter what area that she is working on. A review of CNA A's employee file revealed three different Certified Nursing Assistant job descriptions had been signed by her on 09/17/95, 12/06/96, and 09/03/05. None of these agreements mention any reasonable accommodation for her disability or any restriction on duties she could perform. No records referring to incident involving Resident #1 were found. Her date of hire was 03/03/78. Review of nurses' notes from 01/18/17 revealed Resident #1 was sent to a local hospital at 9:02 AM because Resident #1's Foley is leaking and the towel has to be changed more frequently than q1h. Resident will be sent to (local hospital) through the ED for a possible Foley catheter change. A review of Resident #1's medical records revealed no documentation for the incident on 08/21/16. Review of the Incident and Accident log revealed no documentation that this Incident had occurred. An interview with the DON on 01/18/17 at 12:00 PM revealed there was not an incident report because it came up in conversation. She said she spoke to CNA A to encourage her to go get help. She said her only investigation of the incident was to talk to CNA A. She said she was aware that CNA A had [MEDICAL CONDITION] while working and that she sometimes calls the facility at night to inquire about CNA A and will have someone check on her. She stated she believes the [MEDICAL CONDITION] which caused the incident was because CNA A was running out of her [MEDICAL CONDITION] medication. In interview with the Administrator on 01/19/17 at 9:00 AM revealed the facility did not investigate or report the incident involving Resident #1, but realized now it should have been reported to DADS. He said CNA A had been a very good employee for many years and no other incidents had taken place. A review of the timecard records for CNA A revealed she worked full time as a CNA from the day of the incident on 08/21/16 through 01/17/17. An IJ was identified on 01/18/17 at 2:17 PM. The Administrator and DON were informed of the IJ on 01/18/17 at 2:35 PM and a Plan of Removal was requested. The facility's Plan of Removal (PoR), accepted on 01/19/17 at 10:20 AM, reflected: The PoR ' s Immediate action taken: --On January 18, 2017 CNA A was removed from the schedule for doing any direct patient care. CNA A has been notified to obtain a fitness for duty from a physician stating she is physically able to provide direct patient care without posing a risk to our residents. She will not work in the capacity of a Certified Nurses Aid or any position providing direct patient care. --CNA A will not be allowed to return to work at the facility until she receives clearance from a physician. The PoR ' s Monitoring plan: --The facility will obtain from her physician what routine checkups will be required in order to maintain her fitness for duty and obtain those as noted. --As of 1/18/2017 CNA A has been given a 30 day window to see her physician to get a duty of release to return to work. After providing a Dr's release she will be offered a non-direct care position if available. She will not be allowed to provide direct care. --If any employee in the future has an adverse event that requires medical attention in the facility they will be required to provide a fitness for duty release from their physician prior to returning to active duty providing direct care. Review of the facility punch records revealed CNA A did not work from 01/18/17 through 01/20/17. Observation of staff on 300 hall at various times from 01/18/17 through 01/20/17 revealed CNA A did not work. On 01/19/17 the IJ was removed. On 01/19/17 at 10:20 AM, the Administrator was informed the IJ was removed. While the IJ was removed on 01/19/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. The Resident Census and Condition of Residents, Form CMS-672, provided and signed by the DON on 01/17/17, reflected a census of 115.

Based on observation, interview and record review, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of seven residents reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from neglect when it allowed CNA A, who had a history of [REDACTED]. CNA A had a [MEDICAL CONDITION] while providing care for Resident #1and pulled his catheter with the fully inflated bulb out as she fell . Resident #1 suffered significant pain and bleeding. He was sent to the hospital where he was admitted . The resident now has to have an Urologist remove and put in his catheter monthly. The resident also suffers from anxiety when staff perform catheter care. An Immediate Jeopardy (IJ) was identified on 01/18/17. While the IJ was removed on 01/19/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, because the facility was still monitoring the implementation of the Plan of Removal. These failures could affect all 25 residents, who resided in the 300 hall, by placing them at risk for neglect, injuries, fear, and a decreased quality of life. Findings included: Review of Resident #1's face sheet dated 01/18/17 revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 08/23/16 revealed Resident #1 was taken to a local hospital emergency roiagnom on [DATE] and admitted to the hospital. As a result of this incident, the resident must now travel monthly to a hospital ER to have the Foley catheter changed by a Urologist. The resident must stay in the hospital after the Foley catheter is changed for 1 - 2 ½ days before returning to the facility. A review of Resident #1's MDS assessment dated [DATE] revealed he had an indwelling catheter and a BIMS score of 15. The resident had [DIAGNOSES REDACTED] and required Extensive assistance in all activities of daily living. Staff provided guided maneuvering while in bed or on alternate furniture. He was totally dependent on staff to move between surfaces including to or from bed, chair, wheelchair, standing position. He required full staff performance every time during the entire 7-day period. The activity of daily walking in room and corridor did not occur at any time. The resident required two person physical assist for dressing which includes putting clothing on, fastening and taking off all items of clothing, including donning/removing socks when worn. His dressing includes putting on and changing his hospital gown. Eating required set-up only. Toileting was total dependence every time over each seven day period. The resident had a Foley catheter which required staff to change the towel and bed linen when the catheter leaked. He required a two person assistance to turn him and place him on bedpan. He also required two person physical assist to perform personal hygiene. An interview on 01/19/17 at 8:20 AM with Resident #1 revealed CNA A had pulled out his Foley catheter during a [MEDICAL CONDITION] a few months ago. He said that the CNA was holding his Foley catheter tubing, got a weird look on her face, and fell to the floor dislodging his Foley catheter. He stated that there was significant pain and he experienced bleeding from his penis. He said that even after treatment, he continues to experience pain and leaking around the catheter. He said he still cringes thinking about it or when someone does catheter care for him. He said CNA A had always had [MEDICAL CONDITION] and has had a few in his room since the incident. He said the other day she was coming to turn off his oxygen machine and had a [MEDICAL CONDITION] in front of his bathroom. Resident #1 believes the beeping noise on the oxygen machine set off a [MEDICAL CONDITION]. He said CNA A was the only aide on his hall most of the time. He has asked not to have her work with him to the Administrator and DON, but she continues to work his hall. He said he cringes every time she comes to help him or when anyone touches his catheter and that his catheter leaks a lot more since the incident. An interview on 01/20/17 at 10:07 AM with CNA A revealed she had worked at the facility for [AGE] years as a Certified Nursing Assistant and has had [MEDICAL CONDITION] since she was [AGE] years old. She sometimes knew when a spell ([MEDICAL CONDITION]) was about to come on and sometimes she did not. She stated on the day of the catheter incident, she was providing care and she had a [MEDICAL CONDITION] and fell backwards. She woke up on the floor. She said the resident had called from his cell phone for help. LVN B was in the room when she awakened and sent the resident to the hospital. She stated prior to the incident, she was running out of medications and taking her meds sporadically and that is probably why she had a [MEDICAL CONDITION]. She stated she still has some [MEDICAL CONDITION] on the medications, but they were very rare. She stated she worked on Station 3 at nights and did not normally transfer residents. She said she will get a nurse or the other CNA to transfer anyone if they need to. She stated that she cannot drive because of her [MEDICAL CONDITION]. An interview with CNA B on 01/20/17 at 9:50 AM revealed she did not work with CNA A often, but had observed one [MEDICAL CONDITION] a few months ago as CNA A had completed her shift. She said she was aware that CNA A had [MEDICAL CONDITION]. Interview with LVN C on 01/18/17 at 12:15 PM revealed CNA A was working the night shift when she had a [MEDICAL CONDITION] and was holding Resident #1's Foley catheter line in her hands when she fell to the floor, a result of the [MEDICAL CONDITION]. When this occurred, she pulled the resident's Foley catheter out. He said CNA A was a hard worker but that she has [MEDICAL CONDITION] all the time while at work. He stated that when she smiles you know she is about to have a [MEDICAL CONDITION]. After the [MEDICAL CONDITION] she gets up and goes to do her work. She is a good CNA and a hard worker, just has [MEDICAL CONDITION]. He stated that CNA A has [MEDICAL CONDITION] no matter what area that she is working on. Interview with CNA H on 01/18/17 at 4:18 p.m. revealed she has worked with CNA A on the night shift. She stated she has seen CNA A have a few [MEDICAL CONDITION] at work in the past few months. CNA H stated when CNA A has a [MEDICAL CONDITION], she will fall to the ground for a few minutes, but will jump right back up and get back to work. Interview on 01/19/17 at 10:45 AM with RN F revealed CNA A had [MEDICAL CONDITION] frequently and she had witnesses this at times. She said when the [MEDICAL CONDITION] is over, CNA A would get up and go back to work. She said CNA A regularly worked by herself on hall 300 on the 10PM to 6AM shift. A review of CNA A's employee file revealed three different Certified Nursing Assistant job descriptions had been signed by her on 09/17/95, 12/06/96, and 09/03/05. None of these agreements mention any reasonable accommodation for her disability or any restriction on duties she could perform. No records referring to incident involving Resident #1 were found. Her date of hire was 03/03/78. Review of nurses' notes from 01/18/17 revealed Resident #1 was sent to a local hospital at 9:02 AM because Resident #1's Foley is leaking and the towel has to be changed more frequently than q1h. Resident will be sent to (local hospital) through the ED for a possible Foley catheter change. A review of Resident #1's medical records revealed no documentation for the incident on 08/21/16. Review of the Incident and Accident log revealed no documentation that this Incident had occurred. An interview with the DON on 01/18/17 at 12:00 PM revealed there was not an incident report because as it came up in conversation. She said she spoke to CNA A to encourage her to go get help. She said her only investigation of the incident was to talk to CNA A. She said she was aware that CNA A had [MEDICAL CONDITION] while working and that she sometimes calls the facility at night to inquire about CNA A and will have someone check on her. She said she knew that CNA A was running out of her meds. In interview with the Administrator on 01/19/17 at 9:00 AM revealed the facility did not investigate or report the incident to DADS involving Resident #1, but realized now it should have been reported. He said CNA A had been a very good employee for many years and no other incidents had taken place. A review of the timecard records for CNA A revealed she worked full time as a CNA from the day of the incident on 08/21/16 through 01/17/17. Facility abuse and neglect policy dated July, 2016 reflected: Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Administrator .The facility will conduct an investigation of any alleged abuse/neglect .in accordance with state law. An IJ was identified on 01/18/17 at 2:17 PM. The Administrator and DON were informed of the IJ on 01/18/17 at 2:35 PM and a Plan of Removal was requested. The facility's Plan of Removal, accepted on 01/19/17 at 10:20 AM, reflected: The PoR ' s Immediate action taken: --On January 18, 2017 CNA A was removed from the schedule for doing any direct patient care. CNA A has been notified to obtain a fitness for duty from a physician stating she is physically able to provide direct patient care without posing a risk to our residents. She will not work in the capacity of a Certified Nurses Aid or any position providing direct patient care. --CNA A will not be allowed to return to work at the facility until she receives clearance from a physician. The PoR ' s Monitoring Plan: --The facility will obtain from her physician what routine checkups will be required in order to maintain her fitness for duty and obtain those as noted. --As of 1/18/2017, CNA A has been given a 30 day window to see her physician to get a duty of release to return to work. After providing a Dr's release she will be offered a non-direct care position if available. She will not be allowed to provide direct care. --If any employee in the future has an adverse event that requires medical attention in the facility they will be required to provide a fitness for duty release from their physician prior to returning to active duty providing direct care. Review of the facility punch records revealed CNA A did not work from 01/18/17 through 01/20/17. Observation of staff on 300 hall at various times from 01/18/17 through 01/20/17 revealed CNA A did not work. Interview withe the Administrator on 01/19/17 at 10:00 AM revealed the facility waas considering buying meds and supervising their administration for CNA A, but they thought this would not be legal. On 01/19/17, the IJ was removed. On 01/19/17 at 10:20 AM, the Administrator was informed the IJ was removed. While the IJ was removed on 01/19/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the implementation of the Plan of Removal. The Resident Census and Condition of Residents, Form CMS-672, provided and signed by the DON on 01/17/17, reflected a census of 115.

Based on observation, interview and record review, the facility failed to prevent resident-to-resident mistreatment and/or abuse for five (Residents #2, #3, #4, #7, and #8) of seven residents reviewed for mistreatment by three (Residents #1, #5, and #12) residents with aggressive behaviors. 1. On 11/05/11 Resident #1 pulled Resident #2 out of her wheelchair onto the floor. Resident #1 was then taken to his room where he was left unsupervised with his dependent roommate. Resident #1 then pulled his roommate (Resident #4) out of the bed onto the floor, breaking Resident #4's finger. 2. On 10/06/11 Resident #12 punched Resident #7 in the mouth. The resident had to have a tooth pulled by the dentist. The facility failed to provide adequate supervision and interventions and on 11/02/11 Resident #12 hit Resident #9. No injuries, but Resident #12 was sent to the hospital for medication adjustment. 3. On 11/06/11 Resident #5 slapped Resident #3 about the head and face. The facility removed Resident #5 to her room, but failed to provided adequate supervision/interventions. Resident #5 promptly left her room and assaulted Resident #3 a second time. Resident #3 denied injury, but was fearful the incident would cause her to be "kicked out" of the facility. These failures resulted Resident #4's broken finger, Resident #7 having to have a tooth pulled, and Resident #3 being fearful of being displaced from her home. These failures had the potential to cause injury and harm to Resident #2 as well as the 50 mobility dependent residents in the facility. Findings included: During the entrance conference with the Administrator and DON on 11/09/11 at approximately 8:25 AM, the current facility's Abuse and Neglect policy was presented to the surveyor. The surveyor asked what guidance the facility used for Resident-to-Resident abuse. The DON revealed the facility used the Resident-to-Resident abuse "tree" provided by the state. (Reference Provider letter #06-43 - Guidelines for Reporting Incidents) 1. During an interview on 11/09/11 at approximately 8:30 AM, the Administrator revealed Resident #1 had recently assaulted Resident #2 and Resident #4. The incidents were under investigation and the State agency had been notified. Review of a facility Incident/Accident Report dated 11/05/11 revealed at 7:10 PM Resident #2 was pulled out of her wheelchair by another resident and the resident fell to the floor. The incident was witnessed by a third resident. Resident #2 was assessed and determined to be without injuries. The other residents were not identified in the report Review of a facility Incident/Accident Report dated 11/05/11 at 8:00 PM revealed Resident #1 pulled a female resident from her wheelchair onto the floor and then pulled his roommate out of bed and onto the floor. Review of a facility Incident/Accident Report dated 11/05/11 at 8:30 PM revealed Resident #4 (Resident #1's roommate) was found on the floor at his bedside. Resident #4 stated Resident #1 had pulled him to the floor by his left hand. Resident #4 was complaining of pain on his face, neck, left shoulder, arm and hand and his right hip. A. On 11/09/11 at 9:10 AM, Resident #2 was observed in her room in bed. The resident was alert and oriented. When asked if she had a recent fall, she stated she had not fallen; Resident #1 had pulled her out of her wheelchair and onto the floor. She stated Resident #1 also pulled the wheelchair over and tried to "stomp" on her. She stated she was not injured. When asked if she felt safe now, she nodded her head. Resident #2 revealed after the incident the police were called and told the staff Resident #1 did not belong at this facility. Review of Resident #2's Interdisciplinary Post Fall Review dated 11/05/11 revealed the resident was sitting in her wheelchair at the nurse's station and "Pt (patient) pushed out of w/c (wheelchair) by another resident." No injury was identified. B. On 11/09/11 at approximately 10:00 AM with LVN A, Resident #4 was observed lying in bed. He appeared to be moving in and out of sleep. He did not offer verbal communication. A splint and bandage was wrapped around the resident's middle finger on his left hand. When asked specifically what happened, the resident responded, "Bit." When asked who bit him he nodded his head towards LVN A and grinned. Resident #4 offered no more information, but LVN A revealed Resident #1 pulled him out of bed, onto the floor and the resident had suffered a broken finger. A Change of Condition report dated 11/05/11 reflected Resident #4 had [DIAGNOSES REDACTED]. The report reflected, "The patient appears to be in pain s/p (status [REDACTED]." Movement caused the pain to get worse. The pain was present in the right hip, left hand, left arm, neck and face. The report described the incident as, "This nurse found this res. (resident) on floor face down next to bed on far side. Res. States '(Resident #1) did it.' referring to his roommate. ..Res stated other res. grabbed his left hand and (L) (left) arm which are flaccid s/[MEDICAL CONDITION]." Review of Resident #4's hospital ER record dated 11/06/11 revealed the resident presented at the ER as a "Victim of physical assault" and diagnosed with [REDACTED]. Review of Resident #4's initial mobile radiology reports dated 11/05/11 revealed no fractures, but a hospital radiology report dated 11/06/11 reflected the resident had a fractured finger. C. Resident #1 was a [AGE] year-old male admitted to the facility on [DATE], per the facility sheet dated 01/12/09. The physician's History and Physical dated 01/17/11 reflected [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed [DIAGNOSES REDACTED]. The Cognitive assessment reflected impaired cognition; the resident was non-interviewable and rarely understood. The Behavior assessment reflected behaviors were not present. The Memory assessment reflected the resident knew the location of his room and staff's names and faces. The Nursing Daily Skill Summary attached to the MDS assessment reflected the resident was alert but confused and had moderate cognitive impairment. Review of Resident #1's Care Plan, last updated on 08/24/11, revealed no identification of a problem or plan for Resident #1 involving behaviors. On 11/09/11 at 9:30 AM, Resident #1 was observed in the hallway with the AD. He was stocky in build and was clean and well-dressed. He was pleasant and had a large smile on his face. During an attempt to interview Resident #1, he answered simple questions with a nod or a "yes" or "no." Any other communication from him was not understood. The AD revealed she was spending 1:1 time with him and letting him follow her around. He smiled when the topic of this arrangement was discussed. When asked if he had a crush on the AD, he reacted with excitement and stated, "Yes." When asked if he liked all the residents at the facility, he responded, "Yes." He was asked the names of his friends. His answer could not be understood, although he pointed at other residents' rooms. During an interview with the DON on 11/09/11 at approximately 11:30 AM, she revealed Resident #1 had the mental maturity of a 4-year-old. She stated he was usually very pleasant and any negative behavior would have to have been provoked. When asked if the investigation into the incident on 11/05/11 looked at the possibility of the resident being provoked, she revealed it had not, but she would investigate "that angle." On 11/09/11 at 12:50 PM, Resident #7 requested an interview. At that time, Resident #7 recalled the incident involving Resident #1 on 11/05/11 as he had heard it (hearsay). During the interview, Resident #7 revealed Resident #1 had pulled another resident (Resident #6) out of his wheelchair and broke his arm several months prior. Resident #7 complained Resident #1 wandered into his room and tried to steal his personal items and sodas that he kept at his bedside. He stated he had to keep his door shut at all times to keep Resident #1 out. Review of an Incident/Accident report dated 04/27/11 revealed Resident #1 was accused by an alert and oriented resident (Resident #6) of pushing Resident #6 out of his wheelchair onto the floor. Resident #6 suffered a broken arm. The facility investigation determined Resident #6 fell when trying to get up from the wheelchair to retaliate against Resident #1 for shaking his wheelchair. In an interview with the DON on 11/09/11 at 3:30 PM, she was queried about the incident on 04/27/11. The DON revealed she had only been at the facility since September 2011, but Resident #6 was alert and oriented and could tell what happened. During an interview on 11/10/11 at approximately 8:30 AM, the Administrator revealed the facility was investigating possible group homes where Resident #1 could be with other people more like himself. When this was discussed with the resident's family, the family became very upset. Consequently, the family decided to take Resident #1 home immediately (evening of 11/09/11). On 11/10/11 at approximately 9:30 AM, Resident #6 was interviewed and stated he easily recalled the incident where Resident #1 pulled him from his chair. He stated he was still receiving therapy for the arm that was broken during the incident. He stated Resident #1 also bit him on his right shoulder. When he reported it to the nurse, she refused to believe Resident #1 could do such a thing. He continued to report the incident to other staff, but no one believed him. When queried as to whom he reported the incident, he revealed he told everyone, but could not remember exactly who. He denied provoking any attack. He stated he and Resident #1 were roommates, but because of his continued complaint of Resident #1's behavior, the facility made him move. He stated, "I didn't think that was fair." During the above interview, Resident #9 entered the room. Resident #9 stated he was the Resident Council President and Resident #6's current roommate. He stated Resident #1's behavior and subsequent incidents were not acceptable to him and other residents. He stated the attack on Resident #2 was very similar to the incident reported by Resident #6 and residents were afraid of Resident #1. He stated he believed Resident #1 injured Resident #6 and Resident #1's behavior might be getting worse. On 11/10/11 at approximately 11:00 AM, the AD revealed she had been working at the facility since May 2011. She stated what she had been hearing about Resident #1's behavior was "unbelievable." She explained that Resident #1 was "very childlike" and "it hurts that he is gone." When asked about the incidents on 11/05/11, the AD stated she had heard about the incidents, but just did not know what to believe. When asked if these incidents could have been avoided, she stated, "If they (staff) had acted appropriately, they could have avoided the attack on (Resident #4)." On 11/10/11 at 11:30 AM, ADON B approached the surveyor. She stated other residents provoked negative behavior from Resident #1. She stated that on 11/05/11 following the incident with Resident #2, Resident #1 was slapped by Resident #10 (Resident #1's family member). Resident #1 responded to Resident #10 by attacking her and scratching her. ADON B stated Resident #1 drew blood. ADON B stated, "We (facility) know he really did it (attack Residents #2, #4 and #6) and know he will probably do it again, but he (Resident #1) is the facility's baby." She stated Resident #1 would never act maliciously but may have acted out of frustration. On 11/10/11 at 12:00 PM, LVN C revealed he worked on 11/05/11 at the time of the incidents with Resident #1. He stated he was a charge nurse on Station One. He revealed he was not aware of much until he was called to Resident #4's aid. He stated other staff were in the room, but he picked Resident #4 up from the floor and put him back in bed. After the incident with Resident #4, the DON was called and Resident #1 was placed on 1:1 supervision. He provided the 1:1 supervision for the remainder of his shift. When asked about Resident #1's demeanor, LVN C stated Resident #1 was not an aggressive person. He believed Resident #1 was playing around with the other residents. He stated Resident #1 did not act like he understood what he had done. On 11/10/11 at approximately 1:30 PM, the SW revealed she had worked at the facility for approximately one year. She described Resident #1 as "easily re-directed" and "very loving with other residents." When asked if there were any approaches that could help Resident #1 address his aggression, she stated Resident #1 needed an outlet to express himself. She revealed in the past Resident #1 had caused another resident (Resident #8) to fall. The SW revealed Resident #1 had a family member that lived on Station One. When asked about Resident #10 and Resident #1's relationship, she revealed Resident #10 liked to "keep tabs" on Resident #1, but she had never seen Resident #10 discipline Resident #1. The SW stated she and Resident #1's physician felt Resident #1's aggression was "episodic" and there was no way to predict when it would happen. On 11/10/11 at 2:20 PM, CNA D revealed she worked on Station Two and cared for Resident #2. She stated the nurse told Resident #1 to stop when he attacked Resident #2. She stated Resident #1's family member lived on Station Two and heard the commotion in the hallway. Resident #10 came and slapped Resident #1. Resident #1 retaliated and attacked Resident #10, scratching her on her arms and drawing blood. CNA D stated a CNA from Station One came and took Resident #1 back to his room. Shortly thereafter she heard a page, "(Resident #1) pulled (Resident #4) out of bed!" She went to help. When she arrived, she stated Resident #4 was not yet back in bed. She stated Resident #1 "must have grabbed him good" because Resident #4's shirt was all bunched up where he was grabbed. CNA D stated Resident #1 was still in the room and appeared very "agitated and ready to hit someone else." On 11/10/11 at 2:30 PM, CNA E revealed she worked the 2:00 PM to 10:00 PM shift on Station One. She stated she cared for Resident #1 and Resident #4. She stated it was not uncommon for Resident #1 to go to Station Two because that was where Resident #10 lived. On 11/05/11 she was called to Station Two to get Resident #1. When she arrived, Resident #1 was standing beside Resident #10. She stated she saw Resident #10 hit Resident #1 and Resident #1 retaliated by scratching Resident #10. CNA E stated she managed to get Resident #1 and take him back to his room. She realized he was incontinent of urine so she cleaned him and changed his clothes. She then heard a chair alarm and went to investigate, leaving Residents #1 and #4 alone. When queried about Resident #1's demeanor, she revealed he had been upset but settled down after she changed him. When asked if she was told to stay with Resident #1 for 1:1 supervision, she stated she was not. She stated Resident #1 was put on 1:1 monitoring with LVN C after the charge nurse called the DON. During an interview with the DON on 11/10/11 at 5:30 PM, the DON revealed she had been at the facility since September 2011. She stated she was called on 11/05/11 and informed of Resident #1's behavior. She stated she told the nurse to put Resident #1 on 1:1 monitoring. She understood that the CNA with Resident #1 heard a call light and left the resident unsupervised and Resident #1 then assaulted Resident #4. When queried about Resident #1's aggressive behaviors, she revealed she had heard of an incident involving Resident #8 but had not be able to locate the Incident/Accident Report. She stated she was not sure of when it had occurred but felt it was before she came to the facility. 2. Resident #12's face sheet dated 06/08/10 reflected he was a [AGE] year-old admitted to the facility on [DATE]. During an interview on 11/09/11 at approximately 8:30 AM, the Administrator revealed Resident #7 had complaints regarding Resident #12. Resident #12 had hit Resident #7 resulting in Resident #7 having a tooth pulled. Resident #12 was sent to the hospital for "medication adjustment." The Administrator further revealed Resident #7 had the [DIAGNOSES REDACTED]." The Administrator stated Resident #7 complained that Resident #12 hit him twice and he had to have two teeth pulled. The Administrator explained Resident #7 had dental issues other than being hit in the mouth. The dentist had pulled one tooth (hit by Resident #12) and the resident needed another tooth pulled. Review of Resident #12's Care Plan dated 03/24/11 and last reviewed on 09/07/11 revealed [DIAGNOSES REDACTED]. The approaches identified included: "1) Monitor and record any displayed behavior or mood problems... 7) Protect resident from self harm or harm to others...." There was no identification of specific behaviors or individualized approaches for the staff to use for early detection of on-coming behaviors and effective redirection techniques. Resident #12's most recent Psychiatric Evaluation/Progress Note dated 10/31/11 reflected "no change." [DIAGNOSES REDACTED]. The note referenced an incident with another resident, but the physician documented the resident was "calm" at the time of the evaluation. Review of the Incident/Accident Report dated 10/06/11 at 5:30 PM for Resident #7 revealed Resident #7 had a "physical confrontation" with an unnamed resident. Resident #7 ended up getting "punched" in the mouth. The upper premolar tooth was loose and had a small amount of bleeding. Resident #7 complained of pain. Review of another Incident/Accident Report dated 10/06/11 at 5:30 PM for Resident #12 revealed Resident #12 had an argument with an unnamed resident. In a handwritten statement signed by an LVN (signature not legible), Resident #12 "punched (Resident #7) on the mouth ...." (Note the two separate reports but only one incident.) During an interview on 11/09/11 at 12:50 PM, Resident #7 revealed Resident #12 hit him (Resident #7) on two separate occasions. He stated the dentist had to pull his tooth. Resident #7 revealed Resident #12 "attacked" another resident (Resident #8) approximately a week ago. At 3:30 PM on 11/09/11, the DON was queried regarding an incident between Resident #12 and Resident #8. She revealed Resident #8 was not injured. An Incident/Accident Report was completed and the incident resulted in Resident #12 being sent to the hospital. Review of the Incident/Accident Report dated 11/02/11 at 12:00 PM revealed Resident #12 hit Resident #8. The incident was witnessed and reported by an unnamed resident. The follow-up section of the report reflected the resident was transferred to a psychiatric hospital for evaluation. Review of a Change of Condition report dated 11/02/11 at 3:00 PM and attached to the above Incident/Accident Report revealed a resident witnessed and attempted to intervene when Resident #12 attacked Resident #8. Resident #12 became "more aggravated and was cursing. The nurse tried to separate pt (patient) in a different location for lunch for safety but pt refused. Pt was left to be calmed." In an interview with Residents #6 and #9 on 11/10/11 at approximately 9:40 AM, it was revealed that Resident #12 was not only aggressive but also inappropriate. When asked to clarify, it was revealed that Resident #12, while in the dining room, had pulled his pants down to have a bowel movement and used a tablecloth to clean himself. Review of Resident #12's Nurse's Notes dated 10/15/11 at 9:00 PM revealed the nursing documentation of the above incident. The notes reflected when staff attempted to assist the resident, he became agitated. When the staff finally got Resident #12 to his room, the resident became even more agitated and "...was quickly becoming unable to deal (with). gave [MEDICATION NAME] IM ...." On 11/10/11 at 5:30 PM, the DON revealed she had only been at the facility for approximately two months. The DON was asked for an Incident/Accident Report involving Residents #8 and #12 that occurred on 11/02/11. She stated she would "try to locate it and fax it." The DON was then asked about the incident in the dining room involving Resident #12 on 10/15/11. She stated she was unaware of the incident. The DON stated she was not aware of Resident #12 having any behaviors. The resident mostly isolated himself in his room except for meals. She stated if Resident #12 had any behaviors it should be documented on the Behavior Monitoring Form. Review of Resident #12's Behavior Monitoring Form for 10/15/11 with the DON revealed no behavior was documented. 3. During an interview on 11/09/11 at 8:25 AM, the Administrator revealed Resident #5 had recently assaulted Resident #3. The incidents were under investigation and the State agency had been notified. The Administrator described Resident #5 as having a very strong personality and stated the issue had been resolved; the resident had been moved. Review of the Incident/Accident Report dated 11/06/11 at 3:00 PM revealed an unnamed resident walked into Resident #3's room and slapped Resident #3 on the left side of her face. The unnamed resident then "pinched and twisted" Resident #3's nose. Review of the attached nurse's notes dated 11/06/11 revealed Resident #5 came out of her room "yelling and cursing and slapped (Resident #3) on the left side of her face." The note further reflected Resident #5 was taken to her room, but again came out of her room "yelling and cursing" and again pinched and twisted Resident #3's nose. Review of the Provider Investigation Report signed and dated 11/10/11 revealed Resident #5 had a history of [REDACTED]. It described her functional ability as requiring "minimal" assistance and requiring "No special supervision." Resident #5 ambulated independently, was interviewable, and had "Capacity to make informed decisions." The same report revealed Resident #3's functional ability required "minimal" assistance and requiring "No special supervision." Resident #3 ambulated independently, was not interviewable, and had did not have the "Capacity to make informed decisions." Resident #3 had a history of [REDACTED]. The investigation revealed the incident was witnessed by multiple staff. Resident #5 was moved to another hall and was placed on "15 min (minute) checks For Total 72? (hours)" beginning on 11/07/11. A psychiatric consult was ordered for both residents. A. On 11/09/11 at 9:20 AM, Resident #3 was observed sitting in the doorway of her room. She was receiving oxygen via a nasal cannula. When asked if she would talk, she invited the surveyor into her room. She was alert and oriented. Her speech was clear. She revealed there had been an altercation between her and Resident #5. She stated it had "grown out of proportion." When asked specifically what happened, she stated Resident #5 accused her of taking care of another resident (Resident #11). She added that she had never fought anyone and never would. She stated Resident #5 "slapped" her about her head and face. Resident #3 stated Resident #5 also used profanity during the altercation. When asked if she was afraid, she stated she loved it at the facility and was only afraid that she would be "kicked out" because of the incident. She revealed she knew Resident #5 was moved to another area in the facility. Resident #3's face sheet dated 04/21/09 reflected she was [AGE] years-old and admitted to the facility on [DATE]. The History and Physical dated 06/09/11 reflected [DIAGNOSES REDACTED]. The physician's progress notes dated 10/14/11 described Resident #3 as "pleasant and cooperative." B. At 9:45 AM on 11/09/11, Resident #5 was observed lying in her bed. A family member was at her bedside. Resident #5 was alert and oriented and her voice was strong and confident. When asked about Resident #3, she stated she had slapped her because she was "being mean" to Resident #11. She stated Resident #11 was helpless and unable to take care of herself. Resident #5 stated Resident #3 picked on all the residents that were not able to take care of themselves, and she was "sick of it." She revealed Resident #3 sat in the hallway and was always protecting her "territory." She stated Resident #3 "got what she deserved" and she would do it again if she had the chance. Resident #5 showed no remorse for her actions. Resident #5's face sheet dated 11/26/10 reflected an admission date of [DATE]. She was 72-years-old. [DIAGNOSES REDACTED]. Resident #5's Brief Interview for Mental Status dated 08/04/11 reflected a score of 13, representing the resident's cognition was intact. Resident #5's care plan dated 01/31/11 and last updated on 08/10/11 reflected approaches that included, "monitor and encourage appropriate behavior." The care plan did not identify any problem with behaviors or approaches to redirect or alter any behaviors. 4. The facility Abuse & Neglect Prohibition policy dated February 2011 was provided as current by the Administrator on 11/09/11 and reflected, "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property." Abuse was defined as, "...the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish...." Physical abuse was defined as, "...but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment." Neglect was defined as the "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Under the subtitle "Prevention": "...3. Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate. 4. Residents identified by staff as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate." Under the subtitle "Identification": "2. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression." Under the subtitle "Investigation": "1. The facility will conduct an investigation of any alleged abuse/neglect...in accordance with state law... 2. The facility will report such allegations to the state, as per state regulation. 3. The facility will report all investigation findings to the state as per state regulations. 4. The facility will investigate all patterns, trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property...." Under the subtitle "Protection": "1. The facility will protect residents from harm during the investigation...." Under the subtitle "Reporting and Response": 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law...." Review of the CMS 672, printed 11/18/11, but altered by the DON to reflect residents' status at the time of the survey, revealed 50 residents with mobility dependence.

Based on observation, interview and record review, the ADM and the DON failed to effectively and efficiently manage the facility's resources to attain or maintain the highest practicable physical well-being for five (Residents #2, #3, #4, #7, and #8) of seven residents, reviewed for mistreatment, who were assaulted by three (Residents #1, #5, and #12) residents with aggressive behaviors. The ADM failed to supervise and monitor the DON to ensure the DON monitored for changes in behaviors, provide adequate supervision, and provide timely, appropriate interventions to protect residents from aggressive (bullying-type) residents. The DON failed to ensure residents were monitored for changes in behaviors, provided adequate supervision, and provided timely, appropriate interventions to protect residents from aggressive (bullying-type) residents. These failures resulted Resident #4's broken finger, Resident #7 having to have a tooth pulled, and Resident #3 being fearful of being displaced from her home. These failures had the potential to cause injury and harm to Resident #2 as well as the 50 mobility dependent residents in the facility. Findings included: 1. During an interview on 11/09/11 at approximately 8:30 AM, the Administrator revealed Resident #1 had recently assaulted Resident #2 and Resident #4. The incidents were under investigation and the State agency had been notified. Review of a facility Incident/Accident Report dated 11/05/11 revealed at 7:10 PM Resident #2 was pulled out of her wheelchair by another resident and the resident fell to the floor. The incident was witnessed by a third resident. Resident #2 was assessed and determined to be without injuries. The other residents were not identified in the report Review of a facility Incident/Accident Report dated 11/05/11 at 8:00 PM revealed Resident #1 pulled a female resident from her wheelchair onto the floor and then pulled his roommate out of bed and onto the floor. Review of a facility Incident/Accident Report dated 11/05/11 at 8:30 PM revealed Resident #4 (Resident #1's roommate) was found on the floor at his bedside. Resident #4 stated Resident #1 had pulled him to the floor by his left hand. Resident #4 was complaining of pain on his face, neck, left shoulder, arm and hand and his right hip. A. On 11/09/11 at 9:10 AM, Resident #2 was observed in her room in bed. The resident was alert and oriented. When asked if she had a recent fall, she stated she had not fallen; Resident #1 had pulled her out of her wheelchair and onto the floor. She stated Resident #1 also pulled the wheelchair over and tried to "stomp" on her. She stated she was not injured. When asked if she felt safe now, she nodded her head. Resident #2 revealed after the incident the police were called and told the staff Resident #1 did not belong at this facility. Review of Resident #2's Interdisciplinary Post Fall Review dated 11/05/11 revealed the resident was sitting in her wheelchair at the nurse's station and "Pt (patient) pushed out of w/c (wheelchair) by another resident." No injury was identified. B. On 11/09/11 at approximately 10:00 AM with LVN A, Resident #4 was observed lying in bed. He appeared to be moving in and out of sleep. He did not offer verbal communication. A splint and bandage was wrapped around the resident's middle finger on his left hand. When asked specifically what happened, the resident responded, "Bit." When asked who bit him he nodded his head towards LVN A and grinned. Resident #4 offered no more information, but LVN A revealed Resident #1 pulled him out of bed, onto the floor and the resident had suffered a broken finger. A Change of Condition report dated 11/05/11 reflected Resident #4 had [DIAGNOSES REDACTED]. The report reflected, "The patient appears to be in pain s/p (status [REDACTED]." Movement caused the pain to get worse. The pain was present in the right hip, left hand, left arm, neck and face. The report described the incident as, "This nurse found this res. (resident) on floor face down next to bed on far side. Res. States '(Resident #1) did it.' referring to his roommate. ..Res stated other res. grabbed his left hand and (L) (left) arm which are flaccid s/[MEDICAL CONDITION]." Review of Resident #4's hospital ER record dated 11/06/11 revealed the resident presented at the ER as a "Victim of physical assault" and diagnosed with [REDACTED]. Review of Resident #4's initial mobile radiology reports dated 11/05/11 revealed no fractures, but a hospital radiology report dated 11/06/11 reflected the resident had a fractured finger. C. Resident #1 was a [AGE] year-old male admitted to the facility on [DATE], per the facility sheet dated 01/12/09. The physician's History and Physical dated 01/17/11 reflected [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed [DIAGNOSES REDACTED]. The Cognitive assessment reflected impaired cognition; the resident was non-interviewable and rarely understood. The Behavior assessment reflected behaviors were not present. The Memory assessment reflected the resident knew the location of his room and staff's names and faces. The Nursing Daily Skill Summary attached to the MDS assessment reflected the resident was alert but confused and had moderate cognitive impairment. Review of Resident #1's Care Plan, last updated on 08/24/11, revealed no identification of a problem or plan for Resident #1 involving behaviors. On 11/09/11 at 9:30 AM, Resident #1 was observed in the hallway with the AD. He was stocky in build and was clean and well-dressed. He was pleasant and had a large smile on his face. During an attempt to interview Resident #1, he answered simple questions with a nod or a "yes" or "no." Any other communication from him was not understood. The AD revealed she was spending 1:1 time with him and letting him follow her around. He smiled when the topic of this arrangement was discussed. When asked if he had a crush on the AD, he reacted with excitement and stated, "Yes." When asked if he liked all the residents at the facility, he responded, "Yes." He was asked the names of his friends. His answer could not be understood, although he pointed at other residents' rooms. During an interview with the DON on 11/09/11 at approximately 11:30 AM, she revealed Resident #1 had the mental maturity of a 4-year-old. She stated he was usually very pleasant and any negative behavior would have to have been provoked. When asked if the investigation into the incident on 11/05/11 looked at the possibility of the resident being provoked, she revealed it had not, but she would investigate "that angle." On 11/09/11 at 12:50 PM, Resident #7 requested an interview. At that time, Resident #7 recalled the incident involving Resident #1 on 11/05/11 as he had heard it (hearsay). During the interview, Resident #7 revealed Resident #1 had pulled another resident (Resident #6) out of his wheelchair and broke his arm several months prior. Resident #7 complained Resident #1 wandered into his room and tried to steal his personal items and sodas that he kept at his bedside. He stated he had to keep his door shut at all times to keep Resident #1 out. Review of an Incident/Accident report dated 04/27/11 revealed Resident #1 was accused by an alert and oriented resident (Resident #6) of pushing Resident #6 out of his wheelchair onto the floor. Resident #6 suffered a broken arm. The facility investigation determined Resident #6 fell when trying to get up from the wheelchair to retaliate against Resident #1 for shaking his wheelchair. In an interview with the DON on 11/09/11 at 3:30 PM, she was queried about the incident on 04/27/11. The DON revealed she had only been at the facility since September 2011, but Resident #6 was alert and oriented and could tell what happened. During an interview on 11/10/11 at approximately 8:30 AM, the Administrator revealed the facility was investigating possible group homes where Resident #1 could be with other people more like himself. When this was discussed with the resident's family, the family became very upset. Consequently, the family decided to take Resident #1 home immediately (evening of 11/09/11). On 11/10/11 at approximately 9:30 AM, Resident #6 was interviewed and stated he easily recalled the incident where Resident #1 pulled him from his chair. He stated he was still receiving therapy for the arm that was broken during the incident. He stated Resident #1 also bit him on his right shoulder. He stated when he reported it to the nurse, she refused to believe Resident #1 could do such a thing. He continued to report the incident to other staff, but no one believed him. When queried as to whom he reported the incident, he revealed he told everyone, but could not remember exactly who. He denied provoking any attack. He stated he and Resident #1 were roommates, but because of his continued complaint of Resident #1's behavior, the facility made him move. He stated, "I didn't think that was fair." During the above interview, Resident #9 entered the room. Resident #9 stated he was the Resident Council President and Resident #6's current roommate. He stated Resident #1's behavior and subsequent incidents were not acceptable to him and other residents. He stated the attack on Resident #2 was very similar to the incident reported by Resident #6 and residents were afraid of Resident #1. He stated he believed Resident #1 injured Resident #6 and that Resident #1's behavior might be getting worse. On 11/10/11 at approximately 11:00 AM, the AD revealed she had been working at the facility since May 2011. She stated what she had been hearing about Resident #1's behavior was "unbelievable." She explained that Resident #1 was "very childlike" and "it hurts that he is gone." When asked about the incidents on 11/05/11, the AD stated she had heard about the incidents, but just did not know what to believe. When asked if these incidents could have been avoided, she stated, "If they (staff) had acted appropriately, they could have avoided the attack on (Resident #4)." On 11/10/11 at 11:30 AM, ADON B approached the surveyor. She stated other residents provoked negative behavior from Resident #1. She stated that on 11/05/11 following the attack on Resident #2, Resident #1 was slapped by Resident #10 (Resident #1's family member). Resident #1 responded to Resident #10 by attacking her and scratching her. ADON B stated Resident #1 drew blood. ADON B stated, "We (facility) know he really did it (attack Residents #2, #4 and #6) and know he will probably do it again, but he (Resident #1) is the facility's baby." She stated Resident #1 would never act maliciously but may have acted out of frustration. On 11/10/11 at 12:00 PM, LVN C revealed he worked on 11/05/11 at the time of the incidents with Resident #1. He stated he was a charge nurse on Station One. He revealed he was not aware of much until he was called to Resident #4's aid. He stated other staff were in the room, but he picked Resident #4 up from the floor and put him back in bed. After the incident with Resident #4, the DON was called and Resident #1 was placed on 1:1 supervision. He provided the 1:1 supervision for the remainder of his shift. When asked about Resident #1's demeanor, LVN C stated Resident #1 was not an aggressive person. He believed Resident #1 was playing around with the other residents. He stated Resident #1 did not act like he understood what he had done. On 11/10/11 at approximately 1:30 PM, the SW revealed she had worked at the facility for approximately one year. She described Resident #1 as "easily re-directed" and "very loving with other residents." When asked if there were any approaches that could help Resident #1 address his aggression, she stated Resident #1 needed an outlet to express himself. She revealed in the past Resident #1 had caused another resident (Resident #8) to fall. The SW revealed Resident #1 had a family member that lived on Station One. When asked about Resident #10 and Resident #1's relationship, she revealed Resident #10 liked to "keep tabs" on Resident #1, but she had never seen Resident #10 discipline Resident #1. The SW stated she and Resident #1's physician felt Resident #1's aggression was "episodic" and there was no way to predict when it would happen. On 11/10/11 at 2:20 PM, CNA D revealed she worked on Station Two and cared for Resident #2. She stated the nurse told Resident #1 to stop when he attacked Resident #2. She stated Resident #1's family member lived on Station Two and heard the commotion in the hall. Resident #10 came and slapped Resident #1. Resident #1 retaliated and attacked Resident #10, scratching her on her arms. CNA D stated a CNA from Station One came and took Resident #1 back to his room. Shortly thereafter she heard a page, "(Resident #1) pulled (Resident #4) out of bed!" She went to help. When she arrived, she stated Resident #4 was not yet back in bed. She stated Resident #1 "must have grabbed him good" because Resident #4's shirt was all bunched up where he was grabbed. CNA D stated Resident #1 was still in the room and appeared very "agitated and ready to hit someone else." On 11/10/11 at 2:30 PM, CNA E revealed she worked the 2:00 PM to 10:00 PM shift on Station One. She stated she cared for Resident #1 and Resident #4. She stated it was not uncommon for Resident #1 to go to Station Two because that was where Resident #10 lived. On 11/05/11 she was called to Station Two to get Resident #1. When she arrived, Resident #1 was standing beside Resident #10. She stated she saw Resident #10 hit Resident #1 and Resident #1 retaliated by scratching Resident #10. CNA E stated she managed to get Resident #1 and take him back to his room. She realized he was incontinent of urine so she cleaned him and changed his clothes. She then heard a chair alarm and went to investigate, leaving Residents #1 and #4 alone. When queried about Resident #1's demeanor, she revealed he had been upset but settled down after she changed him. When asked if she was told to stay with Resident #1 for 1:1 supervision, she stated she was not. She stated Resident #1 was put on 1:1 monitoring with LVN C after the charge nurse called the DON. During an interview with the DON on 11/10/11 at 5:30 PM, the DON revealed she had been at the facility since September 2011. She stated she was called on 11/05/11 and informed of Resident #1's behavior. She stated she told the nurse to put Resident #1 on 1:1 monitoring. She understood that the CNA with Resident #1 heard a call light and left the resident unsupervised and Resident #1 then assaulted Resident #4. When queried about Resident #1's aggressive behaviors she revealed she had heard of an incident involving Resident #8 but had not be able to locate the Incident/Accident Report. She stated she was not sure of when it had occurred, but felt it was before she came to the facility. 2. Resident #12's face sheet dated 06/08/10 reflected he was a [AGE] year-old admitted to the facility on [DATE]. During an interview on 11/09/11 at approximately 8:30 AM, the Administrator revealed Resident #7 had complaints regarding Resident #12. Resident #12 had hit Resident #7 resulting in Resident #7 having a tooth pulled. Resident #12 was sent to the hospital for "medication adjustment." The Administrator further revealed Resident #7 had the [DIAGNOSES REDACTED]." The Administrator stated Resident #7 complained that Resident #12 hit him twice and he had to have two teeth pulled. The Administrator explained Resident #7 had dental issues other than being hit in the mouth. The dentist had pulled one tooth (hit by Resident #12) and the resident needed another tooth pulled. Review of Resident #12's Care Plan dated 03/24/11 and last reviewed on 09/07/11 revealed [DIAGNOSES REDACTED]. The approaches identified included: "1) Monitor and record any displayed behavior or mood problems... 7) Protect resident from self harm or harm to others...." There was no identification of specific behaviors or individualized approaches for the staff to use for early detection of on-coming behaviors and effective redirection techniques. Resident #12's most recent Psychiatric Evaluation/Progress Note dated 10/31/11 reflected "no change." [DIAGNOSES REDACTED]. The note referenced an incident with another resident, but the physician documented resident was "calm" at the time of the evaluation. Review of the Incident/Accident Report dated 10/06/11 at 5:30 PM for Resident #7 revealed Resident #7 had a "physical confrontation" with an unnamed resident. Resident #7 ended up getting "punched" in the mouth. The upper premolar tooth was loose and had a small amount of bleeding. Resident #7 complained of pain. Review of another Incident/Accident Report dated 10/06/11 at 5:30 PM for Resident #12 revealed Resident #12 had an argument with an unnamed resident. In a handwritten statement signed by an LVN (signature not legible), Resident #12 "punched (Resident #7) on the mouth ...." During an interview on 11/09/11 at 12:50 PM, Resident #7 revealed Resident #12 hit him (Resident #7) on two separate occasions. He stated the dentist had to pull his tooth. Resident #7 revealed Resident #12 "attacked" another resident (Resident #8) approximately a week ago. At 3:30 PM on 11/09/11, the DON was queried regarding an incident between Resident #12 and Resident #8. She revealed Resident #8 was not injured. An Incident/Accident Report was completed and the incident resulted in Resident #12 being sent to the hospital. Review of the Incident/Accident Report dated 11/02/11 at 12:00 PM revealed Resident #12 hit Resident #8. The incident was witnessed and reported by an unnamed resident. The follow-up section of the report reflected the resident was transferred to a psychiatric hospital for evaluation. Review of a Change of Condition report dated 11/02/11 at 3:00 PM and attached to the above Incident/Accident Report revealed a resident witnessed and attempted to intervene when Resident #12 attacked Resident #8. Resident #12 became "more aggravated and was cursing. The nurse tried to separate pt (patient) in a different location for lunch for safety but pt refused. Pt was left to be calmed." In an interview with Residents #6 and #9 on 11/10/11 at approximately 9:40 AM, it was revealed Resident #12 was not only aggressive but also inappropriate. When asked to clarify, it was revealed that Resident #12, while in the dining room, had pulled his pants down to have a bowel movement and used a tablecloth to clean himself. Review of Resident #12's Nurse's Notes dated 10/15/11 at 9:00 PM revealed the nursing documentation of the above incident. The notes reflected when staff attempted to assist the resident, he became agitated. When the staff finally got Resident #12 to his room, the resident became even more agitated and "...was quickly becoming unable to deal (with). gave [MEDICATION NAME] IM ...." On 11/10/11 at 5:30 PM, the DON revealed she had only been at the facility for approximately two months. The DON was asked for an Incident/Accident Report involving Residents #8 and #12 that occurred on 11/02/11. She stated she would "try to locate it and fax it." The DON was then asked about the incident in the dining room involving Resident #12 on 10/15/11. She stated she was unaware of the incident. The DON stated she was not aware of Resident #12 having any behaviors. The resident mostly isolated himself in his room except for meals. She stated if Resident #12 had any behaviors it should be documented on the Behavior Monitoring Form. Review of Resident #12's Behavior Monitoring Form for 10/15/11 with the DON revealed no behavior was documented. 3. During an interview on 11/09/11 at 8:25 AM, the Administrator revealed Resident #5 had recently assaulted Resident #3. The incidents were under investigation and the State agency had been notified. The Administrator described Resident #5 as having a very strong personality and stated the issue had been resolved; the resident had been moved. Review of the Incident/Accident Report dated 11/06/11 at 3:00 PM revealed an unnamed resident walked into Resident #3's room and slapped Resident #3 on the left side of her face. The unnamed resident then "pinched and twisted" Resident #3's nose. Review of the attached nurse's notes dated 11/06/11 revealed Resident #5 came out of her room "yelling and cursing and slapped (Resident #3) on the left side of her face." The note further reflected Resident #5 was taken to her room, but again came out of her room "yelling and cursing" and again pinched and twisted Resident #3's nose. Review of the Provider Investigation Report signed and dated 11/10/11 revealed Resident #5 had a history of [REDACTED]. It described her functional ability as requiring "minimal" assistance and requiring "No special supervision." Resident #5 ambulated independently, was interviewable, and had "Capacity to make informed decisions." The same report revealed Resident #3's functional ability required "minimal" assistance and requiring "No special supervision." Resident #3 ambulated independently, was not interviewable, and had did not have the "Capacity to make informed decisions." Resident #3 had a history of [REDACTED]. The investigation revealed the incident was witnessed by multiple staff. Resident #5 was moved to another hall and was placed on "15 min (minute) checks For Total 72? (hours)" beginning on 11/07/11. A psychiatric consult was ordered for both residents. A. On 11/09/11 at 9:20 AM, Resident #3 was observed sitting in the doorway of her room. She was receiving oxygen via a nasal cannula. When asked if she would talk, she invited the surveyor into her room. She was alert and oriented. Her speech was clear. She revealed there had been an altercation between her and Resident #5. She stated it had "grown out of proportion." When asked specifically what happened, she stated Resident #5 accused her of taking care of another resident (Resident #11). She added that she had never fought anyone and never would. She stated Resident #5 "slapped" her about her head and face. Resident #3 stated Resident #5 also used profanity during the altercation. When asked if she was afraid, she stated she loved it at the facility and was only afraid that she would be "kicked out" because of the incident. She revealed she knew Resident #5 was moved to another area. Resident #3's face sheet dated 04/21/09 reflected she was [AGE] years-old and admitted to the facility on [DATE]. The History and Physical dated 06/09/11 reflected [DIAGNOSES REDACTED]. The physician's progress notes dated 10/14/11 described Resident #3 as "pleasant and cooperative." B. At 9:45 AM on 11/09/11, Resident #5 was observed lying in her bed. A family member was at her bedside. Resident #5 was alert and oriented and her voice was strong and confident. When asked about Resident #3, she stated she had slapped her because she was being mean to Resident #11. She stated Resident #11 was helpless and unable to take care of herself. Resident #5 stated Resident #3 picked on all the residents that were not able to take care of themselves, and she was "sick of it." She revealed Resident #3 sat in the hallway and was always protecting her "territory." She stated Resident #3 "got what she deserved" and she would do it again if she had the chance. Resident #5 showed no remorse for her actions. Resident #5's face sheet dated 11/26/10 reflected an admission date of [DATE]. She was 72-years-old. [DIAGNOSES REDACTED]. Resident #5's Brief Interview for Mental Status dated 08/04/11 reflected a score of 13, representing the resident's cognition was intact. Resident #5's care plan dated 01/31/11 and last updated on 08/10/11 reflected approaches that included, "monitor and encourage appropriate behavior." The care plan did not identify any problem with behaviors or approaches to redirect or alter any behaviors. 5. During an interview with the Administrator and DON on 11/10/11 at approximately 5:00 PM, the Administrator was queried as to his knowledge of the incidents of resident-to-resident abuse. He revealed he was aware of Residents #1, #5, and #12's recent aggressive behavior; the incidents were investigated and call to the State agency. He was not aware that Resident #1 was prone to aggressive behavior prior to this incident. When asked about Resident #12, he revealed the resident was sent out of psychological evaluation and medication adjustment because of his aggressive behaviors and after the incident with Resident #8 . When asked how the care of residents were monitored, the DON revealed she made frequent rounds and watched and residents and staff interacted. She stated she attended "Action Team Meeting" and reviewed the nurse's 24-hour report book. She stated she also depended on the ADONs to keep her informed. She stated all nurses were tested on their competency when hired and annually. The DON was asked if the staff received training on Behavior Management. She stated she was sure they did. At that time she reviewed the inservices for the past several months and stated one inservices had been provided on Behaviors, but was only attended by one staff. At this time the meeting was interrupted by Resident #9, Resident Council President. He stated he was concerned about a possible upcoming altercation between Resident #13 and Resident #7. Resident #9 stated Resident #13 and other residents "can't take (Resident #7) anymore" and were tired of Resident #7 keeping things stirred up. When asked what Resident #13 might do, Resident #9 stated he did not know. At that time, the Administrator and DON agreed they would have to diffuse the situation. When asked how they would accomplish that, the Administrator stated he did not know anything to do but to transfer the resident (Resident #7) to the hospital for medication adjustment. 6. Review of the CMS 672, printed 11/18/11, but altered by the DON to reflect resident status at the time of the survey, revealed 50 resident with mobility dependence.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment and abuse for five (Residents #2, #3, #4, #7, and #8) of seven residents reviewed for mistreatment by three (Residents #1, #5, and #12) residents with aggressive behaviors. 1. On 11/05/11 Resident #1 pulled Resident #2 out of her wheelchair onto the floor. Resident #1 was then taken to his room where he was left unsupervised with his dependent roommate. Resident #1 then pulled his roommate (Resident #4) out of the bed onto the floor, breaking Resident #4's finger. 2. On 10/06/11 Resident #12 punched Resident #7 in the mouth. The resident had to have a tooth pulled by the dentist. The facility failed to provide adequate supervision and interventions and on 11/02/11 Resident #12 hit Resident #9. 3. On 11/06/11 Resident #5 slapped Resident #3 about the head and face. The facility removed Resident to her room, but failed to provided adequate supervision/interventions. Resident #5 promptly left her room and assaulted Resident #3 a second time. These failures resulted in Resident #4's broken finger, Resident #7 having to have a tooth pulled, and Resident #3 being fearful of being displaced from her home. These failures had the potential to cause injury and harm to Resident #2 as well as the 50 mobility dependent residents in the facility. Findings included: 1. During the entrance conference with the Administrator and DON on 11/09/11 at approximately 8:25 AM, the current facility's Abuse and Neglect policy was presented to the surveyor. The surveyor asked what guidance the facility used for Resident-to-Resident abuse. The DON revealed the facility used the Resident-to-Resident abuse "tree" provided by the state. (Reference Provider letter #06-43 - Guidelines for Reporting Incidents) The facility Abuse & Neglect Prohibition policy dated February 2011 and provided as current by the Administrator reflected, "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property." Abuse was defined as, "...the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish...." Physical abuse was defined as, "...but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment." Neglect was defined as the "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Under the subtitle "Prevention": "...3. Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate. 4. Residents identified by staff as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate." Under the subtitle "Identification": "2. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression." Under the subtitle "Investigation": "1. The facility will conduct an investigation of any alleged abuse/neglect...in accordance with state law... 2. The facility will report such allegations to the state, as per state regulation. 3. The facility will report all investigation findings to the state as per state regulations. 4. The facility will investigate all patterns, trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property...." Under the subtitle "Protection": "1. The facility will protect residents from harm during the investigation...." Under the subtitle "Reporting and Response": 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law...." On 11/10/11 at approximately 3:25 PM, the DON revealed if there was no harm that occurred during Resident-to-Resident altercations, it did not have to be reported. The surveyor pointed out that if a resident had the capacity to act willfully, knowingly and recklessly, the incident was to be reported (Provider Letter ##06-43 - Guidelines for Reporting Incidents). The DON was asked if Resident #5 acted willfully or knowingly. The DON stated, "Oh." The surveyor advised the DON to consider the residents and not the residents' diagnoses. 1. During an interview on 11/09/11 at approximately 8:30 AM, the Administrator revealed Resident #1 had recently assaulted Resident #2 and Resident #4. The incidents were under investigation and the State agency had been notified. Review of a facility Incident/Accident Report dated 11/05/11 revealed at 7:10 PM Resident #2 was pulled out of her wheelchair by another resident and the resident fell to the floor. The incident was witnessed by a third resident. Resident #2 was assessed and determined to be without injuries. The other residents were not identified in the report Review of a facility Incident/Accident Report dated 11/05/11 at 8:00 PM revealed Resident #1 pulled a female resident from her wheelchair onto the floor and then pulled his roommate out of bed and onto the floor. Review of a facility Incident/Accident Report dated 11/05/11 at 8:30 PM revealed Resident #4 (Resident #1's roommate) was found on the floor at his bedside. Resident #4 stated Resident #1 had pulled him to the floor by his left hand. Resident #4 was complaining of pain on his face, neck, left shoulder, arm and hand and his right hip. A. On 11/09/11 at 9:10 AM, Resident #2 was observed in her room in bed. The resident was alert and oriented. When asked if she had a recent fall, she stated she had not fallen; Resident #1 had pulled her out of her wheelchair and onto the floor. She stated Resident #1 also pulled the wheelchair over and tried to "stomp" on her. She stated she was not injured. When asked if she felt safe now, she nodded her head. Resident #2 revealed after the incident the police were called and told the staff Resident #1 did not belong at this facility. Review of Resident #2's Interdisciplinary Post Fall Review dated 11/05/11 revealed the resident was sitting in her wheelchair at the nurse's station and "Pt (patient) pushed out of w/c (wheelchair) by another resident." No injury was identified. B. On 11/09/11 at approximately 10:00 AM with LVN A, Resident #4 was observed lying in bed. He appeared to be moving in and out of sleep. He did not offer verbal communication. A splint and bandage was wrapped around the resident's middle finger on his left hand. When asked specifically what happened, the resident responded, "Bit." When asked who bit him he nodded his head towards LVN A and grinned. Resident #4 offered no more information, but LVN A revealed Resident #1 pulled him out of bed, onto the floor and the resident had suffered a broken finger. A Change of Condition report dated 11/05/11 reflected Resident #4 had [DIAGNOSES REDACTED]. The report reflected, "The patient appears to be in pain s/p (status [REDACTED]." Movement caused the pain to get worse. The pain was present in the right hip, left hand, left arm, neck and face. The report described the incident as, "This nurse found this res. (resident) on floor face down next to bed on far side. Res. States '(Resident #1) did it.' referring to his roommate. ..Res stated other res. grabbed his left hand and (L) (left) arm which are flaccid s/[MEDICAL CONDITION]." Review of Resident #4's hospital ER record dated 11/06/11 revealed the resident presented at the ER as a "Victim of physical assault" and diagnosed with [REDACTED]. Review of Resident #4's initial mobile radiology reports dated 11/05/11 revealed no fractures, but a hospital radiology report dated 11/06/11 reflected the resident had a fractured finger. C. Resident #1 was a [AGE] year-old male admitted to the facility on [DATE], per the facility sheet dated 01/12/09. The physician's History and Physical dated 01/17/11 reflected [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed [DIAGNOSES REDACTED]. The Cognitive assessment reflected impaired cognition; the resident was non-interviewable and rarely understood. The Behavior assessment reflected behaviors were not present. The Memory assessment reflected the resident knew the location of his room and staff's names and faces. The Nursing Daily Skill Summary attached to the MDS assessment reflected the resident was alert but confused and had moderate cognitive impairment. Review of Resident #1's Care Plan, last updated on 08/24/11, revealed no identification of a problem or plan for Resident #1 involving behaviors. On 11/09/11 at 9:30 AM, Resident #1 was observed in the hallway with the AD. He was stocky in build and was clean and well-dressed. He was pleasant and had a large smile on his face. During an attempt to interview Resident #1, he answered simple questions with a nod or a "yes" or "no." Any other communication from him was not understood. The AD revealed she was spending 1:1 time with him and letting him follow her around. He smiled when the topic of this arrangement was discussed. When asked if he had a crush on the AD, he reacted with excitement and stated, "Yes." When asked if he liked all the residents at the facility, he responded, "Yes." He was asked the names of his friends. His answer could not be understood, although he pointed at other residents' rooms. During an interview with the DON on 11/09/11 at approximately 11:30 AM, she revealed Resident #1 had the mental maturity of a 4-year-old. She stated he was usually very pleasant and any negative behavior would have to have been provoked. When asked if the investigation into the incident on 11/05/11 looked at the possibility of the resident being provoked, she revealed it had not, but she would investigate "that angle." On 11/09/11 at 12:50 PM, Resident #7 requested an interview. At that time, Resident #7 recalled the incident involving Resident #1 on 11/05/11 as he had heard it (hearsay). During the interview, Resident #7 revealed Resident #1 had pulled another resident (Resident #6) out of his wheelchair and broke his arm several months prior. Resident #7 complained Resident #1 wandered into his room and tried to steal his personal items and sodas that he kept at his bedside. He stated he had to keep his door shut at all times to keep Resident #1 out. Review of an Incident/Accident report dated 04/27/11 revealed Resident #1 was accused by an alert and oriented resident (Resident #6) of pushing Resident #6 out of his wheelchair onto the floor. Resident #6 suffered a broken arm. The facility investigation determined Resident #6 fell when trying to get up from the wheelchair to retaliate against Resident #1 for shaking his wheelchair. In an interview with the DON on 11/09/11 at 3:30 PM, she was queried about the incident on 04/27/11. The DON revealed she had only been at the facility since September 2011, but Resident #6 was alert and oriented and could tell what happened. During an interview on 11/10/11 at approximately 8:30 AM, the Administrator revealed the facility was investigating possible group homes where Resident #1 could be with other people more like himself. When this was discussed with the resident's family, the family became very upset. Consequently, the family decided to take Resident #1 home immediately (evening of 11/09/11). On 11/10/11 at approximately 9:30 AM, Resident #6 was interviewed and stated he easily recalled the incident where Resident #1 pulled him from his chair. He stated he was still receiving therapy for the arm that was broken during the incident. He stated that Resident #1 had also bit him on his right shoulder. He stated when he reported it to the nurse, she refused to believe Resident #1 could do such a thing. He continued to report the incident to other staff, but no one believed him. When queried as to whom he reported the incident, he revealed he told everyone, but could not remember exactly who. He denied provoking any attack. He stated he and Resident #1 were roommates, but because of his continued complaint of Resident #1's behavior, the facility made him move. He stated, "I didn't think that was fair." During the above interview, Resident #9 entered the room. Resident #9 stated he was the Resident Council President and Resident #6's current roommate. He stated Resident #1's behavior and subsequent incidents were not acceptable to him and other residents. He stated the attack on Resident #2 was very similar to the incident reported by Resident #6 and residents were afraid of Resident #1. He stated he believed Resident #1 injured Resident #6 and that Resident #1's behavior might be getting worse. On 11/10/11 at approximately 11:00 AM, the AD revealed she had been working at the facility since May 2011. She stated what she had been hearing about Resident #1's behavior was "unbelievable." She explained that Resident #1 was "very childlike" and "it hurts that he is gone." When asked about the incidents on 11/05/11, the AD stated she had heard about the incidents, but just did not know what to believe. When asked if these incidents could have been avoided, she stated, "If they (staff) had acted appropriately, they could have avoided the attack on (Resident #4)." On 11/10/11 at 11:30 AM, ADON B approached the surveyor. She stated other residents provoked negative behavior from Resident #1. She stated that on 11/05/11 following the attack on Resident #2, Resident #1 was slapped by Resident #10 (Resident #1's family member). Resident #1 responded to Resident #10 by attacking her and scratching her. ADON B stated Resident #1 drew blood. ADON B stated, "We (facility) know he really did it (attack Residents #2, #4 and #6) and know he will probably do it again, but he (Resident #1) is the facility's baby." She stated Resident #1 would never act maliciously but may have acted out of frustration. On 11/10/11 at 12:00 PM, LVN C revealed he worked on 11/05/11 at the time of the incidents with Resident #1. He stated he was a charge nurse on Station One. He revealed he was not aware of much until he was called to Resident #4's aid. He stated other staff were in the room, but he picked Resident #4 up from the floor and put him back in bed. After the incident with Resident #4, the DON was called and Resident #1 was placed on 1:1 supervision. He provided the 1:1 supervision for the remainder of his shift. When asked about Resident #1's demeanor, LVN C stated Resident #1 was not an aggressive person. He believed Resident #1 was playing around with the other residents. He stated Resident #1 did not act like he understood what he had done. On 11/10/11 at approximately 1:30 PM, the SW revealed she had worked at the facility for approximately one year. She described Resident #1 as "easily re-directed" and "very loving with other residents." When asked if there were any approaches that could help Resident #1 address his aggression, she stated Resident #1 needed an outlet to express himself. She revealed in the past Resident #1 had caused another resident (Resident #8) to fall. The SW revealed Resident #1 had a family member that lived on Station One. When asked about Resident #10 and Resident #1's relationship, she revealed Resident #10 liked to "keep tabs" on Resident #1, but she had never seen Resident #10 discipline Resident #1. The SW stated she and Resident #1's physician felt Resident #1's aggression was "episodic" and there was no way to predict when it would happen. On 11/10/11 at 2:20 PM, CNA D revealed she worked on Station Two and cared for Resident #2. She stated the nurse told Resident #1 to stop when he attacked Resident #2. She stated Resident #1's family member lived on Station Two and heard the commotion in the hallway. Resident #10 came and slapped Resident #1. Resident #1 retaliated and attacked Resident #10, scratching her on her arms. CNA D stated a CNA from Station One came and took Resident #1 back to his room. Shortly thereafter she heard a page, "(Resident #1) pulled (Resident #4) out of bed!" She went to help. When she arrived, she stated Resident #4 was not yet back in bed. She stated Resident #1 "must have grabbed him good" because Resident #4's shirt was all bunched up where he was grabbed. CNA D stated Resident #1 was still in the room and appeared very "agitated and ready to hit someone else." On 11/10/11 at 2:30 PM, CNA E revealed she worked the 2:00 PM to 10:00 PM shift on Station One. She stated she cared for Resident #1 and Resident #4. She stated it was not uncommon for Resident #1 to go to Station Two because that was where Resident #10 lived. On 11/05/11 she was called to Station Two to get Resident #1. When she arrived, Resident #1 was standing beside Resident #10. She stated she saw Resident #10 hit Resident #1 and Resident #1 retaliated by scratching Resident #10. CNA E stated she managed to get Resident #1 and take him back to his room. She realized he was incontinent of urine so she cleaned him and changed his clothes. She then heard a chair alarm and went to investigate, leaving Residents #1 and #4 alone. When queried about Resident #1's demeanor, she revealed he had been upset but settled down after she changed him. When asked if she was told to stay with Resident #1 for 1:1 supervision, she stated she was not. She stated Resident #1 was put on 1:1 monitoring with LVN C after the charge nurse called the DON. During an interview with the DON on 11/10/11 at 5:30 PM, the DON revealed she had been at the facility since September 2011. She stated she was called on 11/05/11 and informed of Resident #1's behavior. She stated she told the nurse to put Resident #1 on 1:1 monitoring. She understood that the CNA with Resident #1 heard a call light and left the resident unsupervised and Resident #1 then assaulted Resident #4. When queried about Resident #1's aggressive behaviors she revealed she had heard of an incident involving Resident #8 but had not be able to locate the Incident/Accident Report. She stated she was not sure of when it had occurred, but felt it was before she came to the facility. 2. Resident #12's face sheet dated 06/08/10 reflected he was a [AGE] year-old admitted to the facility on [DATE]. During an interview on 11/09/11 at approximately 8:30 AM, the Administrator revealed Resident #7 had complaints regarding Resident #12. Resident #12 hit Resident #7 resulting in Resident #7 having a tooth pulled. Resident #12 was sent to the hospital for "medication adjustment." The Administrator further revealed Resident #7 had the [DIAGNOSES REDACTED]." The Administrator stated Resident #7 complained that Resident #12 hit him twice and he had to have two teeth pulled. The Administrator explained Resident #7 had dental issues other than being hit in the mouth. The dentist had pulled one tooth (hit by Resident #12) and the resident needed another tooth pulled. Review of Resident #12's Care Plan dated 03/24/11 and last reviewed on 09/07/11 revealed [DIAGNOSES REDACTED]. The approaches identified included: "1) Monitor and record any displayed behavior or mood problems... 7) Protect resident from self harm or harm to others...." There was no identification of specific behaviors or individualized approaches for the staff to use for early detection of on-coming behaviors and effective redirection techniques. Resident #12's most recent Psychiatric Evaluation/Progress Note dated 10/31/11 reflected "no change." [DIAGNOSES REDACTED]. The note referenced an incident with another resident, but the physician documented the resident was "calm" at the time of the evaluation. Review of the Incident/Accident Report dated 10/06/11 at 5:30 PM for Resident #7 revealed Resident #7 had a "physical confrontation" with an unnamed resident. Resident #7 ended up getting "punched" in the mouth. The upper premolar tooth was loose and had a small amount of bleeding. Resident #7 complained of pain. Review of another Incident/Accident Report dated 10/06/11 at 5:30 PM for Resident #12 revealed Resident #12 had an argument with an unnamed resident. In a handwritten statement signed by an LVN (signature not legible), Resident #12 "punched (Resident #7) on the mouth ...." During an interview on 11/09/11 at 12:50 PM, Resident #7 revealed Resident #12 hit him (Resident #7) on two separate occasions. He stated the dentist had to pull his tooth. Resident #7 revealed Resident #12 "attacked" another resident (Resident #8) approximately a week ago. At 3:30 PM on 11/09/11, the DON was queried regarding an incident between Resident #12 and Resident #8. She revealed Resident #8 was not injured. An Incident/Accident Report was completed and the incident resulted in Resident #12 being sent to the hospital. Review of the Incident/Accident Report dated 11/02/11 at 12:00 PM revealed Resident #12 hit Resident #8. The incident was witnessed and reported by an unnamed resident. The follow-up section of the report reflected the resident was transferred to a psychiatric hospital for evaluation. Review of a Change of Condition report dated 11/02/11 at 3:00 PM and attached to the above Incident/Accident Report revealed a resident witnessed and attempted to intervene when Resident #12 attacked Resident #8. Resident #12 became "more aggravated and was cursing. The nurse tried to separate pt in a different location for lunch for safety but pt refused. Pt was left to be calmed." In an interview with Residents #6 and #9 on 11/10/11 at approximately 9:40 AM, it was revealed that Resident #12 was not only aggressive but also inappropriate. When asked to clarify, it was revealed that Resident #12, while in the dining room, had pulled his pants down to have a bowel movement and used a tablecloth to clean himself. Review of Resident #12's Nurse's Notes dated 10/15/11 at 9:00 PM revealed the nursing documentation of the above incident. The notes reflected when staff attempted to assist the resident, he became agitated. When the staff finally got Resident #12 to his room, the resident became even more agitated and "...was quickly becoming unable to deal (with). gave [MEDICATION NAME] IM ...." On 11/10/11 at 5:30 PM, the DON revealed she had only been at the facility for approximately two months. The DON was asked for an Incident/Accident Report involving Residents #8 and #12 that occurred on 11/02/11. She stated she would "try to locate it and fax it." The DON was then asked about the incident in the dining room involving Resident #12 on 10/15/11. She stated she was unaware of the incident. The DON stated she was not aware of Resident #12 having any behaviors. The resident mostly isolated himself in his room except for meals. She stated if Resident #12 had any behaviors it should be documented on the Behavior Monitoring Form. Review of Resident #12's Behavior Monitoring Form for 10/15/11 with the DON revealed no behavior was documented. 3. During an interview on 11/09/11 at 8:25 AM, the Administrator revealed Resident #5 had recently assaulted Resident #3. The incidents were under investigation and the State agency had been notified. The Administrator described Resident #5 as having a very strong personality and stated the issue had been resolved; the resident had been moved to another hall. Review of the Incident/Accident Report dated 11/06/11 at 3:00 PM revealed an unnamed resident walked into Resident #3's room and slapped Resident #3 on the left side of her face. The unnamed resident then "pinched and twisted" Resident #3's nose. Review of the attached nurse's notes dated 11/06/11 revealed Resident #5 came out of her room "yelling and cursing and slapped (Resident #3) on the left side of her face." The note further reflected Resident #5 was taken to her room, but again came out of her room "yelling and cursing" and again pinched and twisted Resident #3's nose. Review of the Provider Investigation Report signed and dated 11/10/11 revealed Resident #5 had a history of [REDACTED]. It described her functional ability as requiring "minimal" assistance and requiring "No special supervision." Resident #5 ambulated independently, was interviewable, and had "Capacity to make informed decisions." The same report revealed Resident #3's functional ability required "minimal" assistance and requiring "No special supervision." Resident #3 ambulated independently, was not interviewable, and had did not have the "Capacity to make informed decisions." Resident #3 had a history of [REDACTED]. The investigation revealed the incident was witnessed by multiple staff. Resident #5 was moved to another hall and was placed on "15 min (minute) checks For Total 72? (hours)" beginning on 11/07/11. A psychiatric consult was ordered for both residents. A. On 11/09/11 at 9:20 AM, Resident #3 was observed sitting in the doorway of her room. She was receiving oxygen via a nasal cannula. When asked if she would talk, she invited the surveyor into her room. She was alert and oriented. Her speech was clear. She revealed there had been an altercation between her and Resident #5. She stated it had "grown out of proportion." When asked specifically what happened, she stated Resident #5 accused her of taking care of another resident (Resident #11). She added that she had never fought anyone and never would. She stated Resident #5 "slapped" her about her head and face. Resident #3 stated Resident #5 also used profanity during the altercation. When asked if she was afraid, she stated she loved it at the facility and was only afraid that she would be "kicked out" because of the incident. She revealed she knew Resident #5 was moved to another area. Resident #3's face sheet dated 04/21/09 reflected she was [AGE] years-old and admitted to the facility on [DATE]. The History and Physical dated 06/09/11 reflected [DIAGNOSES REDACTED]. The physician's progress notes dated 10/14/11 described Resident #3 as "pleasant and cooperative." B. At 9:45 AM on 11/09/11, Resident #5 was observed lying in her bed. A family member was at her bedside. Resident #5 was alert and oriented and her voice was strong and confident. When asked about Resident #3, she stated she had slapped her because she was being mean to Resident #11. She stated Resident #11 was helpless and unable to take care of herself. Resident #5 stated Resident #3 picked on all the residents that were not able to take care of themselves, and she was "sick of it." She revealed Resident #3 sat in the hallway and was always protecting her "territory." She stated Resident #3 "got what she deserved" and she would do it again if she had the chance. Resident #5 showed no remorse for her actions. Resident #5's face sheet dated 11/26/10 reflected an admission date of [DATE]. She was 72-years-old. [DIAGNOSES REDACTED]. Resident #5's Brief Interview for Mental Status dated 08/04/11 reflected a score of 13, representing the resident's cognition was intact. Resident #5's care plan dated 01/31/11 and last updated on 08/10/11 reflected approached that included, "monitor and encourage appropriate behavior." The care plan did not identify any problem with behaviors or approaches to redirect or alter any behaviors. 5. Review of the CMS 672, printed 11/18/11, but altered by the DON to reflect resident status at the time of the survey, revealed 50 resident with mobility dependence.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive plan of care for one (Resident #1) of four residents reviewed. Resident #1 fell when she attempted to transfer herself to bed on 09/12/10 at 9:50 AM. The resident was assessed and found to be without injury. The physician was notified by fax at 6:25 PM on 09/12/10 (Sunday) of the resident's fall. The resident was not assessed until the next morning when the resident refused to get out of bed. When her hands were grasped, she cried out in pain. However, the resident's complaint of pain was not "specific," staff was told to monitor the resident. The resident refused to get out of bed the whole day and then requested she be sent to the hospital. At the hospital, she was diagnosed with [REDACTED]. These failures resulted in a delay in the identification and treatment of [REDACTED]. These failures could affect any of the facility's 81 residents, placing them at risk for not having injuries detected in a timely manner and provided treatment to correct the problem and ease their pain. Findings included: Resident #1 was a [AGE] year-old female resident admitted to the facility on [DATE] as reflected on the MAR for September 2010. Resident #1's History and Physical dated 04/28/10 reflected the following Diagnoses: [REDACTED]. Resident #1's physician progress notes [REDACTED]. Resident #1's MDS assessment 05/10/10 reflected cognitive skills with modified independence. Resident #1's care plan dated 05/10/10 reflected she was at risk for falls. Review of the facility's Incident/Accident Report reflected on 09/12/10 at 9:50 AM, Resident #1 was found on the floor in front of her wheelchair. The Report further reflected the resident was found lying on the floor with her body braced with her hands so not to hit the floor. The Incident/Accident Report further reflected Resident #1's physician was notified by fax at 6:25 PM of the resident's fall. The Report further reflected Resident #1's family member was left a message to return the call at 6:30 PM (eight and one-half hours later). The Report did not reflect Resident #1's family member was actually contacted in person. Review of the facility's change of condition form dated 09/12/10 revealed Resident #1 wanted to go to bed and attempted to transfer herself to bed resulting in her falling to the floor. Nurse's notes dated 09/12/10 at 9:50 AM reflected Resident #1 stated, "I want to go to bed so I jumped." The note reflected the resident was found on the floor with her arms bracing her body so as not to hit her head. The notes reflected, "No injuries noted/ pt assisted to bed, call light in reach." There was no further documentation regarding whether the resident was checked on following her fall. The next documentation in the Nurse's Notes was dated 09/13/10 at 9:05 AM, almost 24 hours later. The Nurse's Notes reflected, "follow up. pt in bed refused to be up. c/o pain in both hands but physically seen __ (no) injury or bruised. pt medication for pain as scheduled informed Dr. ____ by phone but PA in the facility to assessed (sic) pt. ...received an order to monitor pt and call if any changes occur. will continue to check on pt for safety." The next documentation in the Nurse's Notes was dated 09/13/10 at 3:00 PM. It reflected, "Assess resident in bed. laying semifowler position eyes closed, easily aroused by sound. resident complained of pain all over. when asked where in particular resident cold not pin pain. when touched on the hands resident screamed with pain. asked the medication aide to administer pain pill, to resident. Resident refused to take medicine saying she wanted to be send (sic) to the hospital. Dr. ____ paged and notified of the resident condition and also, family requested her to go out for further evaluation. Nurses notes dated 09/13/10 at 9:05 AM reflected Resident #1 was in bed, refused to get out of bed, complained of pain in both hands and received pain medication. Nurse's notes further reflected a physician was informed by phone of the resident's complaint, but a PA was in the building to assess the resident. Nurses' notes dated 09/13/10 at 3:00 PM reflected Resident #1 remained in bed and continued to complain of pain. The note reflected LVN A asked Resident #1 where her pain was and the resident could not specify the location of her pain. Nurses notes further reflected when LVN A touched the resident's hands, Resident #1 screamed with pain. Nurse's notes reflected she refused pain medication and requested to be transported to a hospital. Nurse's notes further reflected Resident #1's family member requested the resident to be transported to a hospital. Review of the hospital's Progress Note dated 09/17/10 for Resident #1 revealed Resident #1 was diagnosed with [REDACTED]. On 09/22/10 at 12:20 PM during an interview with Resident #2, who was Resident #1's roommate, she stated Resident #1 was in a wheelchair the day of the incident, and was waiting to be put to bed. Resident #2 stated she (Resident #2) turned the call light on for Resident #1. When no one responded to assist Resident #1 to bed, she attempted to transfer herself to bed. Resident #2 stated Resident #1 fell . Resident #2 stated the call light was still on and when staff walked by the room, Resident #1 was found on the floor. On 09/22/10 at 2:45 PM, LVN C was interviewed. She stated on 09/12/10 at approximately 10:00 AM, Resident #1 was wheeled from the dining room to her room and wanted to go to bed. She stated CNA D went to nurses' station to obtain a Hoyer lift and upon her return to Resident #1's room, she found the resident on the floor. On 09/22/10 at 12:40 PM, LVN B was interviewed regarding Resident #1's incident of falls and assessment. She stated the weekend nurse gave her shift report and informed her Resident #1 sustained a fall the previous day (09/12/10). LVN B stated on 09/13/10, a CNA informed her Resident #1 did not want to get out of bed. LVN B said she asked Resident #1 what was wrong and the resident told her that her hands hurt. LVN B said she medicated the resident with a pain medication and notified the PA. On 09/23/10 at 9:55 AM, Resident #1's family member/responsible party was interviewed at the facility. He/She Resident #3 had contacted him/her at approximately 9:00 PM on 09/22/10 and told him/her Resident #1 had fallen and was in pain. He/She stated he/she immediately contacted the facility and spoke to a nurse, who informed him/her Resident #1 had fallen but was in bed asleep. He/She stated the next day on 09/13/10 at about 11:00 AM, he/she called the facility to inquire how Resident #1 was. He/She stated a nurse informed him/her Resident #1 did not want to get up because he/she was in pain. He/She stated he/she instructed the nurse to send the resident to an acute care facility immediately. He/She stated at about 1:00 PM to 1:20 PM, he/she called back to the facility and wanted to speak to Resident #1, but the nurse would not allow him/her to speak to Resident #1. He/She stated at about 2:00 PM, she contacted the facility again and spoke with LVN A. He/She stated he/she asked LVN A to transport Resident #1 immediately to the ER. LVN A told him/her there was no need to send Resident #1 to the ER as she would be sent right back to the facility because of the resident's payer source (Medicaid). Resident #1's family member said he/she threatened LVN A if she did not send Resident #1 to the hospital, he/she would come to the facility and send the resident to the ER himself/herself. He/She stated 11 minutes later he/she contacted the facility and spoke with LVN A, who informed him/her that Resident #1 would be sent to ER even though there was nothing wrong with her. He/She stated when she met Resident #1 at the ER, she informed her she had called and wanted to be put to bed in order to use the bedpan. On 09/23/10 at 10:30 AM during an interview with CNA D, she stated Resident #1 was in her wheelchair in her room, and her call light was on. She stated Resident #1 informed her she wanted to go to bed, but she told her to wait, and she would be back. CNA D stated she went to another resident's room to provide care for another resident. She said while she was providing care for the resident, she heard someone yell in the hallway Resident #1 was on the floor. CNA D stated the incident occurred between 9:30 AM to 10:00 AM on 09/12/10. On 09/23/10 at 10:40 AM, Resident #3 (Resident #1's friend) was interviewed. He stated Resident #1 informed him she wanted to be put to bed in order to have a bowel movement. He stated no one would put her to bed, so she attempted to put herself to bed and fell . On 09/23/10 at 10:55 AM, the Administrator was interviewed. She stated she was informed Resident #1 pushed herself out of the wheelchair and fell . She stated a NP came and assessed the resident and instructed staff to monitor the resident. She stated when the resident continued to experience pain, she was transported to an ER. On 09/23/10 at 11:10 AM, NP E was interviewed. She stated she was called to see Resident #1 post fall on 09/13/10 at 9:00 AM. She stated she woke the resident up, who was "having pain every where and was anxious." NP E stated she spoke to the nurses regarding Resident #1 not being specific where her pain was, and she asked the nurses to monitor the resident. She stated she was not contacted after she exited the facility Resident #1's condition had changed. NP E was queried if Resident #1 would have benefited from X-Ray examination. NP E said Resident #1 was not specific about where her pain was. The surveyor and NP E reviewed Resident #1's nurses' notes dated 09/13/10 at 9:05 AM when the resident complained of pain in her hands. The facility's Resident Bed Report dated 09/22/10 reflected a facility census of 81 residents.