Every finding on record at Austin Oasis, The

Based on observations, interviews and records review, the facility failed to follow their policy for placing wet floor signs in the first-floor common area/ dining room, and the north hallway patio. This deficiency has the potential to affect 80 residents who eat their meal in the first-floor dining room, and 79 residents who utilize the north hallway smoking patio.Findings Include:On 08/18/2026 at 10:55 AM, this surveyor observed R1 sitting on her bed, she remained calm and collected. R1 did not voice any pain at this time. R1 stated she is very upset with the living conditions in the facility. R1 stated she had noticed water leaking outside another resident's room across the hall.On 08/18/2026 at 11:28 AM, this surveyor is on the first-floor common area, dining room. This surveyor observed that there is water leaking from the ceiling. There is a large trashcan stationed behind the dining table collecting the water that is leaking from the ceiling. The water seems to be leaking from multiple points in the one common area. There are no wet floor signs to alarm residents that the floor is wet, and potential risk for a slip and fall. On 08/18/2026 at 11:30 AM, V9 (Activity Aide) stated the leakage started yesterday during the morning shift, and she notified V5 (Maintenance Director). V9 stated the leaking from the ceiling looks the same as yesterday before she left the facility.On 08/18/2026 at 11:45 AM, V10 (Housekeeping) stated whenever there is a leakage, the first thing to do is to find out the source of the problem. V10 stated the spill must be cleaned from the floor, and a wet floor sign should be placed to prevent a slip and fall. V10 stated he would notify V5 as soon as possible.On 08/18/2026 at 12:05 PM, V5 stated the reason why the pipeline is dripping is due to the condensation of the pipes. V5 stated when there is humidity around the pipes, it will start sweating. V5 stated this has been an on and off situation for the last few weeks. V5 stated some of the interventions he has taken is to put a chemical around the pipe to seal and stop humidity to prevent dripping. V5 stated in the past there were some leaking concerns on the 5th floor, but that issue has already been resolved. V5 stated the issue was that there was a drain that was clogged, and water was raising up and hitting the concentrator, which penetrated a room on the 5th floor.On 08/19/2026 at 9:25 AM, this surveyor is currently on the first-floor dining/ common area. There is still a small amount of water dripping from the ceiling, but this time it is not splattered throughout the floor. The trashcan that was there yesterday is no longer there. The dining table remained near the one common leaking area; however, it is not visibly wet. The floor has a small amount of water.On 08/19/2027 at 9:39 AM, this surveyor is currently on the first floor, north hallway near the smoking patio area, there is water dripping from the ceiling pipe. There is a small puddle of water on the floor, and no signs of wet floor signage in place. This surveyor observed the floor has a water stain, indicating that the water has been dripping for some time. On 08/19/2026 at 12: 23 PM, this surveyor is currently on the first-floor common area/ dining room. There is water dripping from the ceiling, and now a smear of water on the ground. There are two residents sitting at the table while eating their meal near the affected area. There are no wet floor signs on the floor to alarm residents with potential risk for a slip and fall.On 08/19/2026 at 11:10 AM, this surveyor is currently with V5 in the north hallway smoking patio. V5 stated he had to unclog it condensation drain which stops and continues spontaneously and will continue to monitor it. V5 stated the water stain on the floor can possibly be because of the water that has been sitting for a while. V5 stated if there is a water spill on the floor it can be a hazard and cause a slip and fall to the residents walking in the hallway.On 08/20/2026 at 10:41 AM, V5 stated as a safety concern, the staff should have put up the wet floor signs and isolate the affected area to prevent slip and falls. V5 stated if the area is not secluded and residents are sitting near the affected area while eating their meals; it is a sanitation issue because water can splash in the resident food. V5 stated staff did not know the protocol as to when to remove all residents and put wet floor signs when there is a water leak. V5 stated he will ensure that all staff are reeducated on this matter.Facility policy titled housekeeping guidelines, with review date of 07/24, documents in part, I) signs will be used in designated areas to alert people to wet areas.

Based on interview, record review, and facility policy review, the facility failed to ensure that each resident was free from physical abuse for two of four residents (R5, R6) reviewed for abuse in the sample of 15. Specifically, the facility failed to protect Resident R5 from physical abuse when R4 punched R5 in the face and R7 punched R6 in the head. Based on interview, record review, and facility policy review, the facility failed to ensure that each resident was free from physical abuse for two of four residents (R5, R6) reviewed for abuse in the sample of 15. Specifically, the facility failed to protect Resident R5 from physical abuse when R4 punched R5 in the face and R7 punched R6 in the head.Findings include:8.18.2026 at 1:12 PM, R5 said, we've (R4 and R5) have never got along. The day before the incident, someone cut up my shower shoes. I figured if R4 didn't do it, he knew who did. I told R4, you better stop f*****g with my stuff. R4 punched me in my face. I went to the hospital.8.18.2026 at 1:21 PM, V8 (CNA/Certified Nursing Assistant) said, I saw R6 sitting at the nurses' station (facing south) waiting to get his medications from V7 (LPN/Licensed Practical Nurse). R7 walked towards R6, (facing north), then when R7 got up to R6, R7 began hitting R6 in the face. It happened so fast I can't say if R7 hit R6 with open hands or fists. I just know R7 made contact with F6's face. V7 (LPN/Licensed Practical Nurse) saw it happen.8.19.2026 at 10:41 AM, V6 (CNA/ Certified Nursing Assistant) said, it started with R5, when he told the nurse that someone broke his (R5's) shower shoes. R5 was upset at that. He was making accusations against R4. As R5 was going back to his room, R4 was coming out of his, R5 confronted R4, walked up to R4 and started putting his fingers in R4's face. I don't think he (R5) connected but he was very close. I went to separate them, but before I could reach them, R4 swung at R5 with his fist. I don't know if R4 connected, but I saw R5 fall backwards. I was able to catch R5.8.19.2026 at 11:26 AM, V7 (LPN/Licensed Practical Nurse) said, R6 was sitting at the nurse's station waiting on me to give him his afternoon meds. R7 walked past R6, then turned around and started hitting R6. I separated them, additional staff came to help. V11 (PRSC) was contacted and came did a 1:1 with R7. R7 was petitioned out for psych evaluation. I assessed R6. He was in no apparent distress, had no obvious injury and was not complaining of pain. Yes, this abuse.8.19.2026 at 2:21 PM, R13 a/a, n/c, propels self in wheelchair without difficulty. Said, I didn't see much, my back was soft of turned. Earlier in the day, R7 didn't look well to me, seemed agitated. R6 was sitting at the nurses' station, R7 walked by and just hit R6. I don't know why he did it.8.19.2026 at 2:25 PM, R6 a/a, n/c, propels self in wheelchair without difficulty. Said, he (R7) came and just banged on me. I was sitting in my wheelchair at the nurse's station waiting for my meds. R7 walked by, I thought he was going to say hi. He punched me in my head with his fists. He hit me multiple times.7.31.2026 final incident documents, in part: It was reported that R4 and R5 on 7.27.2026 engaged in a physical altercation on the 2nd floor hallway by room [ROOM NUMBER]. Per investigation CNA (V6) reported that (R5) approached (R4) profanely accused him of destroying his property. Per CNA (R4) responded by asking (R5) to leave his personal space. (R5) refused and continued to talk loudly in (R4's) space, then (R4) responded by physical aggression. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: Founded.7.30.2026 final incident report documents, in part: It was reported on 7/27/2026 that resident (R7) and R6 engaged in a physical altercation on the 5th floor at the nurse's station. During the interview with V7 (LPN/Licensed Practical Nurse) reported that (R6) was waiting at the nurse's station for his afternoon medication (R7) walked past (R6) then turned back and began to exhibit physical aggressive towards (R6). Interviewed (R13), she reported witnessing (R7) walk past (R6) then hearing the nurse yelling for (R7) to stop, then she witnessed staff separating residents. R4's face sheet documents R4 is a [AGE] year-old admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Cerebral Infarction, Acute Kidney Failure, and Hypertension. R4's MDS (Minimum Data Set of 7.10.2026) documents a BIMS (Brief Interview for Mental Status) as 15 or cognitively intact.R5's face sheet documents admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Cerebral Infarction, Acute Kidney Failure, and Hypertension. R5's MDS (Minimum Data Set of 8.7.2026) documents a BIMS (Brief Interview for Mental Status) as 15 or cognitively intact.R6's face sheet documents R6 is a [AGE] year-old admitted to the facility with diagnoses including but not limited to: Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Acute Kidney Failure and Arthritis Due To Other Bacteria, R Hip. R6's MDS (Minimum Data Set of 7.24.2026) documents a BIMS (Brief Interview for Mental Status) as 15 or cognitively intact.R7's face sheet documents R7 is a [AGE] year-old admitted to the facility with diagnoses including but not limited to: Hypertension, Autistic Disorder, Unspecified Psychosis Due To A Substance Or Unknown Physiological Condition and Hyperlipidemia. R7's MDS (Minimum Data Set of 7.10.2026) documents a BIMS (Brief Interview for Mental Status) as 14 or cognitively intact.Abuse Prevention and Reporting policy (undated) documents, in part: GUIDELINES: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. ln order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.DEFINlTIONS: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporaI punishment.

Based on observation, interview and record review, the facility failed to ensure residents receive nutritionally adequate meals and follow recipes. These failures have the potential to affect all 172 residents receiving food prepared in the facility's kitchen. Findings include:On 07/28/26 at 3:23 PM, R1 stated orange juice is not served every day, so the residents are not getting their Vitamin C. R1 said, Isn't that a rule or something? Don't we need a certain amount of Vit C in the day? R1 stated on the menus it is only listed as beverage so, the kitchen gives them apple juice or cranberry juice or lemonade or fruit punch. R1 asked, but that is not real juice, right? Plus, when they give us any kind of juice it is watered down with ice. R1 said, Don't get me started on the milk. R1 stated the kitchen only serves milk at breakfast and that is only when it is available. V1 stated they run out of milk a lot so sometimes they do not serve any milk at all. R1 stated when the potatoes are served for lunch or dinner they are so hard they are inedible.On 07/28/26 at 12:10 PM, during lunch tray line observations observed the staff serving residents on regular diets received tuna sandwiches with a slice of cheese, potato chips, tomato soup, and chocolate pudding. None of the residents were served creamy coleslaw. The sandwiches did not appear heated or toasted. The yellow cheese inside the sandwich was not melted.On 07/28/26 at 12:50 PM, V22 stated she pulled the tuna sandwiches out of the refrigerator, and she is the one who prepared the sandwiches today. V22 stated she added mayo, Dijon Mustard and a little relish to the drained tuna fish, then added one scoop of tuna fish to a slice of bread (not toasted), topped the tuna fish with one slice of American cheese and then put another piece of bread on top of the cheese. V22 stated she then stacked the sandwiches on a large metal tray, covered them in plastic wrap and then put the tray into the refrigerator. V22 stated none of the sandwiches were heated.On 07/30/26 at 2:45 PM, V21 (Dietary Supervisor) stated the menus list a protein side and fruit/cold side for breakfast every day and at lunch and dinner a vegetable and salad/cold side every day. V21 stated she has the option of selecting one of these categories to serve the residents for that meal, both are not being served. For example, on the summer 2026 menu cycle 1 Tuesday the menu list for the vegetable is tomato basil soup and for the salad/cold side is creamy coleslaw. V21 stated the residents prefer soup so she decided to serve the soup instead of the coleslaw. Another example is the breakfast meals. On summer 2026 menu cycle 1 Wednesday the breakfast protein side is listed as turkey bacon and the fruit/cold side is listed as applesauce. V21 stated she served the residents turkey bacon instead of applesauce. On summer 2026 cycle menu 1 Thursday the breakfast protein side is listed as a hardboiled egg, and the fruit/cold side is listed as mandarin oranges. V21 stated she decided to serve the residents the hardboiled egg instead of the mandarin oranges. V21 stated residents are not served orange juice or cereal every day, only when they are listed on the menu.On 07/30/26 at 7:24 AM, during breakfast tray line observations observed V21 serving residents on regular diets biscuit with sausage gravy, hot cereal, and hardboiled egg. None of the residents received mandarin oranges.On 07/29/26 at 2:12 PM, V29 (Certified Nursing Assistant) stated she has heard resident's complaining about the potatoes not being cooked, V29 stated the residents will say about the potatoes, it is halfway done and to hard to chew and crunchy. V29 stated this happens when baked or scalloped potatoes are served. V29 stated when she has tried to cut into the potatoes, she can tell when she is setting up the resident tray for them that the potatoes are not cooked all the way through, so she has to separate out the hard parts and only give the soft parts to the residents.On 07/31/26 at 9:15 AM, via telephone interview V33 (Registered Dietitian) stated this past Monday, 07/27/26 she received a complaint from the staff that the potatoes were hard and not fully cooked. V33 stated this would suggest the cooks in the kitchen are not following the recipe, otherwise the potatoes should be cooked properly. V33 stated the cooks should always follow the recipe to make sure the food is cooked the way it should be, so it is edible for the residents and provides them with adequate nutrition. The food items posted on the menu are what should be served to the residents. This is important because that is what the residents are expecting to receive. V33 stated if tuna melt is listed on the menu, then that is what the residents are expected to receive, not a cold tuna fish sandwich.On 07/31/26 at 9:20 AM, V33 stated all the items listed on the menu should be provided to the residents. V33 stated if the kitchen is not serving all the items on the menu to the residents, then they may not be meeting all the residents' nutritional needs. V33 stated it is important to provide all of these items to make sure the menus are nutritional complete including 6 ounces of protein/day, 5 or more servings fruits or vegetables (one of these should be a good Vit C or 2 fair Vit C sources), 6 or more servings of bread, cereal, rice, pasta, grain, and 2 dairy servings per day. V33 stated looking over the facility menus on Tuesday, cycle 1 for breakfast, the residents should have received western egg bake, wheat toast, cottage cheese, diced peaches and apple juice. V33 stated on Tuesday, cycle 1 lunch the residents on regular diets should have received tuna melt, kettle chips, tomato basil soup, creamy coleslaw and chocolate pudding. V33 stated on Wednesday, cycle 1 breakfast the residents on regular diets should have received French Toast, breakfast potatoes, turkey bacon, applesauce. V33 stated on Thursday, cycle 1 breakfast the residents on regular diets should have received sausage gravy biscuit, cream of wheat, hard-boiled egg, mandarin oranges. V33 stated V21 should be serving all the items listed, not selecting one or the other.On 07/31/26 at 9:25 AM, V33 stated juice is not listed on the menu every day. V21 tells her that they give assorted juice, but they are not giving the residents orange juice every day. V33 stated most facilities give 100% orange juice at breakfast every day as their Vitamin C source. V33 stated there is a regulation that the residents must be given a certain amount of Vitamin C a day and for the juice to count as a Vitamin C source it must be 100% juice, it cannot be a fruit punch or lemonade or orange drink. V33 stated apple juice and cranberry juice are not 100% fruit juice and cannot be counted as a Vitamin C source. V33 stated the juice should not be watered down. V33 stated there should also be milk on the menu twice a day (breakfast and dinner). V33 stated she does not see everyone receiving milk at dinner per meal round observations; therefore, the assumption is the residents are only receiving milk for breakfast. V33 stated if the residents did not want to receive milk at dinner the kitchen would have to serve yogurt, cottage cheese and cheese to meet their calcium needs but this would have to be served every night to replace the milk not being routinely served. V33 stated she does not think this is being done.On 07/31/26 at 9:30 AM, surveyor asked V33 to review the menus and add up the number of fruit/vegetables, starch and dairy serving provided in a day with the understanding that V21 is not serving both the protein and fruit side at breakfast or both the vegetable and cold side at lunch per surveyor meal round observations and V21 interview. V33 stated on Tuesday, cycle 1 for breakfast, lunch and dinner the residents are receiving four servings of fruit or vegetables, and they should be receiving five or more servings. V33 stated none of the fruits/vegetables appear to be able to count as a Vitamin C source. V33 stated there are three servings of starch (bread, cereal, pasta, grain) being served and there should have been a minimum of six servings per day. V33 stated milk is not posted on the menu but she thinks the kitchen is serving it at breakfast every day only, it should be served twice a day. V33 stated Wednesday cycle 1 for the day the residents are receiving two servings of fruit or vegetables when there should be at least five. V33 stated peppers and broccoli do provide some source of Vitamin C if they were both served but she is not sure if the portion is adequate to meet the Vit C requirement for the day. V33 stated there are six servings of starch which meet the minimum requirement. V33 stated again, even though milk is not posted on the menu she thinks the kitchen is serving it at breakfast every day but not at dinner every day because she does not see this when she does meal round observations at dinner. V33 stated Thursday cycle 1 for breakfast, lunch and dinner the residents are receiving four servings of fruits or vegetables and of these none of them appear to be able to count as a Vitamin C source. V33 stated the residents should be receiving five or more fruits/vegetables daily. V33 stated three to four serving of starch of being served when it should be at least six servings. V33 stated based on these menus and what the facility is serving to the residents the menus are not following the food code/regulations and residents are not receiving enough food. V33 stated this has the potential to cause weight loss, malnutrition and skin breakdown.R1's diagnosis includes but not limited to Nicotine Dependence, Major Depressive Disorder, Hypertension, Obesity, Gastro-Esophageal Reflux Disease Without Esophagitis, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Anemia. R1's [NAME] Data Set (MDS) dated [DATE] indicates R1's cognition is intact.Facility provided document titled, Midnight Census Report dated 07/28/26, 9:09 AM which indicates there are 173 residents in the facility. V2 (Director of Nursing) stated there is one resident who receive nothing by mouth (NPO).Facility provided document titled, Week 1 Tuesday, Wednesday, Thursday Nutrition Breakdown including Vitamin C content which assumes all the foods listed on the menu are being served to the residents.Facility provided policy titled, Cycle Menu dated 2021 which documents in part, cycle menus are planned to meet the nutritional needs of the clients in accordance with the Dietary Reference Intake of the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences and with additional guidance from My Plate for Older Adults and the USDA Dietary Guidelines for Americans Key Recommendations. Menus will be planned in accordance with the Illinois Administrative Code Section 300.2050 which documents in part, 16 ounces or more of Grade A whole or low-fat pasteurized milk where milk is used for fluid consumption. Five or more servings of fruit or vegetables with one serving of good source of Vitamin C (containing at least 60 mg of Vitamin C and six or more servings of whole grain, enriched or restored products.Kitchen Summer 2026 Menu Regular Week 1 Tuesday, documents in part, Tuna Melt, Kettle Chips, Tomato Basil Soup, Creamy Coleslaw, Chocolate Pudding.Facility policy titled, Standardized Recipes dated 2021 documents in part, standardized recipes will be available in the kitchen and will be used in food preparation. Foods will be prepared according to standardized recipes provided by the menu source.Facility provided recipe titled, Tuna Melt dated 07/09/26 for Week 1 Day 3 which document in part, ingredients to include hard cooked eggs, tuna, celery, lemon juice, minced onions, mayonnaise, toasted bread, sliced American Cheese and instructions include lay toasted bread on sheet pan, heat in 350 degrees oven until cheese melts and internal temperature reaches 165 degrees F for 15 seconds.

Based on observation, interview, and record review, the facility failed to ensure residents are receiving meals at scheduled times. These failures have the potential to affect all 172 residents receiving oral diets from the facility's kitchen. Findings include:On 07/28/26, surveyor was provided with a meal schedule which documented in part: breakfast 1st seating time 7:15-8:00 AM, 2nd seating time 8:15-9:00 AM, 2nd floor 7:35 AM, 3rd floor 7:50 AM. For lunch 1st seating time 12:00-12:45 PM, 2nd seating time 1:00-1:45 PM, 2nd floor 12:20 PM, 3rd floor 12:35 PM.On 07/28/26 at 12:33 PM, R6 stated meal delivery time in the facility is a problem. R6 stated meals are served late and it is an ongoing issue. R6 stated sometimes he has to wait for up to one hour to get his meal.On 07/28/26 at 3:18 PM, R1 stated today she received breakfast at 7:50 AM when she should have received it at 7:15 AM. R1 stated sometimes the breakfast can be up to one hour late. R1 stated when this happens no one tells the residents why it is late.On 07/29/26 at 12:06 PM, R15 stated he is the Resident Council President, and he eats all his meals in the main dining room during the first seating. R15 stated that when the meals are late it throws off the whole schedule and process. R15 stated there are two seating times in the main dining room so, when the delivery for the 1st seating is late it means he has less time to eat because the second seating group of residents are congregating in the hallways, trying to come in so he is rushed through eating. R15 stated eating should be calm and enjoyable and he should not have to rush through his meal to eat it.On 07/29/26 at 1:40 PM, V28 (Certified Nursing Assistant) stated she routinely works on the second floor unit and breakfast is usually served between 8:00-8:15 AM. V28 stated today breakfast was delivered after 8:00 AM. V28 stated she does not believe breakfast has ever been served as early as 7:35 AM on the second floor.On 07/29/26 at 2:20 PM, V29 (Certified Nursing Assistant) stated she hears residents complaining all the time that the meals are being served late. V29 stated they go down to the main dining room and then come back up complaining that they have been waiting for a while and they have not received their tray yet. V29 stated that when this happens, the residents will go wait into their room for a while and then go back downstairs to the main dining room. V29 stated the residents have a routine and they want to eat when they are hungry. V29 stated not all residents have access to snacks and it is frustrating to them when their meals are late. V29 stated this happens a lot. V29 stated the meals should be on time because it throws the residents off and makes them mad and this is when their behaviors start and then the staff have to focus on managing their behaviors which would be avoidable if their meals were delivered on time.On 07/29/26 at 2:44 PM, V30 (Certified Nursing Assistant) stated residents complain about sitting down in the main dining room for a long time and not being served their meals on time. V30 stated this makes the residents agitated. V30 stated the residents like routine and it throws them off.On 07/29/26 at 12:52 PM, V27 (Activity Director) stated she stays in the room when the Resident Council Meeting is going on and takes minutes of the meeting. V27 stated at the June Resident Council Meeting Minute there were complaints about meals not being on time. V27 stated she filled out a grievance/complaint form about the dietary concerns brought up including the late meal delivery times and gave it to V21 (Dietary Supervisor) to address. V27 stated the July Resident Council Meeting was held yesterday, 07/28/26 and one of the dietary concerns brought up again by the residents were the trays not being delivered on time. On 07/30/26 at 8:00 AM, surveyor arrived on the third-floor unit. Breakfast trays had not been delivered yet.On 07/30/26 at 8:05 AM, observed V32 (Activity Aide) waiting in the hallway on the third floor. V32 stated she has been on the unit since 7:40 AM waiting for the trays to arrive so she can pass them out to the residents. V32 stated the meals come at all different times. V32 stated it upsets the residents when the meals are late because they feel they have already gotten up early so why should they have to wait so long for their meal. V32 stated the residents need to get their medications at certain times and they do not want to be late for smoke break.On 07/30/26 at 8:15 AM, observed R16 sitting in his wheelchair in the third-floor hallway. R16 stated he has been waiting a long time for his breakfast, and he is hungry. R16 asked the surveyor, where is it? It should be here by now!On 07/30/26 at 8:28 AM, breakfast trays arrived on the third floor. The posted mealtime for the third floor is 7:50 AM.On 07/30/26 at 3:10 PM, V21 (Dietary Manager) stated mealtimes schedule should be followed because the residents are expecting to receive their meals at the posted time. V21 stated she lets the residents know if there is a delay in service and the kitchen will get the meal out as soon as possible. V21 stated the mealtime schedule for first seating time for breakfast listed as 7:15-8:00 AM which means to the kitchen that they have between those two time periods to get the breakfast meal delivered to the residents.On 07/31/26 at 9:10 AM, via telephone interview V33 (Registered Dietitian) stated the kitchen should be keeping to the posted mealtime schedule. V33 stated this is important for consistency for the residents and staff as they are expecting the food to be served at the posted times. V33 stated many of the activities in the facility are centered around the meals. For example, some medications are meal sensitive, so the staff is giving out medication expecting the meals to be served at the posted times. V33 stated some of the residents go to day programs, appointments, activity functions so they are expecting to get their meals at the posted time. V33 stated that when the residents receive their meals late, they may start to worry they will be late for their smoke break or late for pick-ups to programs and this can trigger behaviors in the residents. V33 stated based on the mealtime schedule the residents in the main dining room during the first seating are expecting to receive their breakfast at 7:15 AM. V33 thinks the kitchen thinks they have the range between 7:15-8:00 AM to serve the first seating their breakfast but the second seating in the main dining room is arriving and expecting their breakfast to be served at 8:15 AM so if breakfast is served late to the first seating, then it will push back and affect the second seating. V33 stated the first seating residents should have ample time to eat their meal and they should not be rushed to eat. V33 stated it is important for the residents to have at least 30 minutes to eat so they have time to fully complete their meals. V33 stated a 10-15-minute late grace period is acceptable but not anything later than that.R1's diagnosis includes but not limited to Nicotine Dependence, Major Depressive Disorder, Hypertension, Obesity, Gastro-Esophageal Reflux Disease Without Esophagitis, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Anemia. R1's [NAME] Data Set (MDS) dated [DATE] indicates R1's cognition is intact.R6's diagnosis includes but not limited to Unspecified Fall, Edema, Acquired Absence of Other Right Toe(s), Hypertension, Anemia, Chronic Kidney Disease, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Venous Insufficiency (Chronic) (Peripheral). R6's MDS dated [DATE] indicates R6's cognition is intact.R15's diagnosis includes but not limited to Nicotine Dependence, Chronic Venous Hypertension (Idiopathic) With Inflammation of Bilateral Lower Extremity, Chronic Kidney Disease, Stage 3, Hypertension, Hypokalemia, Alcohol Abuse, Anemia. R15's MDS dated [DATE] indicates R15 cognition is intact.R16's diagnosis includes but not limited to Acquired Absence of Right Foot, Peripheral Vascular Disease, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Depression, Hypertension, Alcohol Use, Cocaine Abuse, Major Depressive Disorder, Acquired Absence Of Other Right Toe(s), Unspecified Open Wound, Right Foot. R16's MDS dated [DATE] indicates R16 cognition is moderately impaired.Facility provided copy of Grievance/Concern Form dated 06/30/26 at 10:20 AM which documented in part, residents stated food not on time.Facility provided copy of document labeled Resident Council Meeting July 28th, 2026, which documented in part, Dietary - Residents stated trays be late.Facility provided document titled, Midnight Census Report dated 07/28/26, 9:09 AM which indicates there are 173 residents in the facility. V2 (Director of Nursing) stated there is one resident who receive nothing by mouth (NPO).Facility provided kitchen policy titled Frequency of Meals dated 2018 which documents in part, meals will be served at regular times and at times that are comparable to typical mealtimes for the areas in which the healthcare community is located.

Based on observations, interviews, and record reviews, the facility failed to sanitize kitchen equipment based on facility policy. These failures have the potential to affect all 172 residents receiving food prepared in the facility's kitchen. Findings include:On 07/28/26 at 1:05 PM, R1 brought cup of juice to surveyor and stated, there is a roach in my cup and gave surveyor her cup. Surveyor observed tiny oval bodied insect light tan in color floating on top of the liquid inside R1's plastic cup. The insect was not moving.On 07/28/26 at 1:07 PM, V24 (PM Cook) looked into R1's cup and said, that is a roach! V24 looked at it again and said, that is definitely a roach and that should absolutely not be in a resident's cup.On 07/28/26 at1:09 PM, V21 (Dietary Supervisor) looked into R1's cup and said, it looks like it could be a roach or a gnat. V21 stated the cups and juice dispensers are washed after every meal using the dishwashing machine which cleans and disinfects the cups. V21 stated she does not know how the roach got in there, but it should not be there.On 07/28/26 at 1:29 PM, observed V26 (Dietary Aide) working by the dishwasher feeding a rack of dirty plastic cups into the dish machine. V26 stated if the cups do not look clean then they are sent through the dish machine again.On 07/28/26 at 1:38 PM, surveyor requested for the dish machine be tested. V21 stated she thinks the dish machine is a low temperature machine.On 07/28/26 at 1:42 PM, observe V21 remove a white test paper strip from a circular container labeled as (Chlorine Test Paper) and on the side of the bottle there was a chart to indicate the parts per million of sanitizer detected when tested.On 07/28/26 at 1:45 PM, V21 tested the dish machine water while running the machine and the test paper remained white. There was no change to indicate there was any sanitizing solution in the dish machine. Observed large plastic barrel near the dishwasher that appeared empty except for a very small amount of blackish colored liquid barely covering the bottom.On 07/28/26 at 1:59 PM, V21 stated the color on the test strip did not change because there was no chemical sanitizer in the barrel. V21 stated whatever liquid was in the sanitizer barrel was too low so none was going into the machine which is why when V21 checked the sanitizer concentration level earlier it did not change. V21 stated when she noticed the large plastic barrel container with chemical sanitizer so low she asked one of the Dietary Aides to put in a new barrel of sanitizing solution. V21 stated she does not know how long the dish machine was without sanitizer, but the staff is supposed to check it before every meal, so she thinks the sanitizer just ran out now.On 07/31/26, 2:03 PM, observed V25 (Dietary Aide) remove emptied plastic barrel container and hook up a new plastic container of labeled as Chorine Additive for Dishwashing to the dish machine. Surveyor observed the new plastic barrel container which contained a pale-yellow liquid inside. Surveyor requested for V21 to recheck the concentration to make sure the sanitizer was feeding into the machine, V21 stated she would like to run the dishwasher a couple of times now that the new bottle of sanitation solution was added.On 07/28/26 between 2:03 - 2:07 PM, observed V21 run the dishwasher through three to four cycles.On 07/28/26 at 2:08 PM, V21 tested the water in the dish machine, and the color of test strip did not change at all, it remained white. V21 stated it may need more time to warm up. V21 continued to run the dish machine.On 07/28/26 at 2:10 PM, V21 tested the water in the dish machine again while the dish machine was running and again there was no change in color on the test strip; it remained white. V21 stated she does not see a change in the color and the concern is that the items being put into the dish machine are not getting sanitized which is a problem for the safety of the residents. V21 stated she will call the service company to come fix the dish machine and they will use paper plates and plastic silverware until the dish machine is operating properly.On 07/29/26 at 8:45 AM, Surveyor observed that technician arrived to fix the dish washer machine after it was observed not cleaning dishes properly.On 07/29/26 at 11:45 AM, R15 stated lately the plastic cups are not clean. R15 stated can see a film which looks like a cloudy residue around the top of the cups. R15 stated when he sees a dirty cup it makes him wonder if they are being cleaned properly and worries that could make him sick. R15 asked, Who wants to drink out of a dirty cup? It is not sanitary. R15 stated if he was at home he would only drink out of a clean cup and since this is his home now, he expects to be given clean cups to drink out of.On 07/29/26 at 1:37 PM, V28 (Certified Nursing Assistant) stated the plastic cups often look dirty, she can see food particles or residue on the inside and/or outside of the cup. V28 stated she saw a live roach inside one of the cups last week. V28 stated she does not know if the roaches are attracted to the water or food residue in the cups. V28 estimated that when the cups are sent up on the beverage cart at mealtime 10 or more cups are not usable because they are dirty.On 07/29/26 at 2:10 PM, V29 (Certified Nursing Assistant) stated she has received complaints from residents living on the second floor about the cups not being dirty. V29 stated the cups are cloudy; it seems like they have not been properly cleaned or sanitized based on the look of the cups. V29 stated this is a routine problem on the second floor and that sometimes as much as 10-20 cups or all of them are dirty and not usable. On 07/29/26 at 2:40 PM, V30 (Certified Nursing Assistant) stated she routinely hears residents complain that the drink cups are dirty and not cleaned properly.On 07/31/26 at 8:56 AM, via telephone interview V33 (Registered Dietitian) stated the facility has a low temperature dish machine which means any items put inside get cleaned using a chemical which is a sanitation solution. V33 stated the sanitation solution is needed to clean the items being washed and to kill off bacteria to prevent cross contamination and infections. V33 stated if there is not any sanitation solution in the dish machine then nothing being put into the dishwasher is getting cleaned and this could make the residents sick; it is not sanitary.R1's diagnosis includes but not limited to Nicotine Dependence, Major Depressive Disorder, Hypertension, Obesity, Gastro-Esophageal Reflux Disease Without Esophagitis, Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Anemia. R1's Minimum Data Set (MDS) dated [DATE] indicates R1's cognition is intact.R15's diagnosis includes but not limited to Nicotine Dependence, Chronic Venous Hypertension (Idiopathic) With Inflammation of Bilateral Lower Extremity, Chronic Kidney Disease, Stage 3, Hypertension, Hypokalemia, Alcohol Abuse, Anemia. R15's MDS dated [DATE] indicates R15 cognition is intact.Facility provided document titled, Midnight Census Report dated 07/28/26, 9:09 AM which indicates there are 173 residents in the facility. V2 (Director of Nursing) stated there is one resident who receive nothing by mouth (NPO).Facility provided kitchen policy titled, Machine Washing and Sanitizing (Low Temperature Dishwashing Machine) dated 2017 which documents in part, dishwashing machine may be used for cleaning and sanitizing tableware, utensils, equipment, pots and pans. Dishwashing machine using chemicals (typically chlorine) for sanitizing and the final rinse will be 50 part per million (PPM) hypochlorite (chlorine) on dish surface.

Based on observation, interview and record review the facility failed to store and distribute food in accordance with professional standards for food service safety. This failure affected one resident (R5) and has the potential to affect all 182 residents that reside in the facility receiving oral diets.Findings include:On 06/30/26 at approximately 10:00am R5 entered room with surveyor stating that R5 was served spoiled milk for breakfast. R5 stated that the milk carton that R5 was given that morning was expanded and the milk was warm and had a bad taste. R5 stated that she informed a staff member that was in the dining area, and the staff member removed the milk and gave R5 a new carton of milk.On 06/30/26 at 11:00am observed facility's walk-in refrigerator with water and ice covering the entire floor of the refrigerator. The water observed on the floor approximately over 1 inch in height. Walk in refrigerator's thermometer observed at 66 degrees Fahrenheit. Observed 8 boxes of milk stored in walk in refrigerator. Observed V23 (Dietary Director) check temperature of one carton of milk which tempted at 50 degrees Fahrenheit.On 06/30/26 at 11:01 V23 (Dietary Director) stated that the water and ice observed on the walk-in refrigerator's floor is not safe or sanitary. V23 stated that the refrigerator's temperature is not within normal range. V23 stated that she was made aware of the refrigerator not working properly that morning and did not serve the residents the milk that was previously stored in the refrigerator. V23 stated that the milk currently observed was from the shipment that just came in. V23 stated that the milk's temperature is not within normal range and would need to be discarded. V23 stated that serving the milk that is not at a safe range could make the residents sick.On 06/30/26 at 11:08am V24 (Cook) stated that she first observed the walk-in refrigerator not working properly the day before. V24 stated that she informed the dietary director the day before that the refrigerator wasn't working properly. V24 stated that water was dripping in the refrigerator and food boxes were getting wet.On 06/30/26 at 11:20am V25 (Dietary Aide) stated that the milk that was stored in the walk-in refrigerator was given out first to the residents and when that milk was all gone, they served the milk that was delivered that day.On 06/30/26 at 2:34pm V7 (Certified Nursing Assistant/CNA) stated that R5 complained to her that R5's milk was spoiled. V7 stated that she replaced R5's milk with new milk and discarded the old milk. V7 stated that the milk carton felt soft. V7 stated that she reported R5's concerns to V23 (Dietary Manager). V7 stated that V23 came out and replaced all the milk at that time with new milk.Facility's policy titled Storage of Refrigerated Foods revised 2017 documents in part, Policy: Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Procedure: Refrigerated foods are stored at 41 degrees F (Fahrenheit) or below.Facility's policy titled Time/Temperature Control for Safety Food revised 2017 documents in part, Policy: Foods that require time and temperature control to prevent the growth of microorganisms (bacteria) which cause foodborne illness are known as TCS (temperature control safety) foods. TCS foods may also be referred to as potentially hazardous food (PHF). Some foods are more likely than others to be TCS foods. They include: Milk and Dairy Products. Procedure: Special attention is paid to foods that are Time/Temperature Controlled for Safety (TCS).

Based on interview and record review the facility failed to ensure that one resident (R1) was discharged to a safe place back to the community. This failure affected 1 of 3 residents reviewed for discharges.Findings include:R1's medical diagnoses include but are not limited to bipolar disorder, schizoaffective disorder, pneumonia, type 2 diabetes, asthma.R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R1's cognition is intact.R1's progress note entered by V11 (Registered Nurse/RN) dated 03/31/26 documents in part, Patient was d/c (discharged ) today all belongings and medications was sent with patient no issues was noted.R1's document titled Discharge Instructions Plan of Care dated 02/11/26 documents in part, 1. General Information: This section is to be completed by Nursing. 1a. discharge date [DATE]. 1b. 8:00am. 1c. Who is accompanying resident? Son V27. 1d. How is resident being transported? Car. 1e. Schizoaffective Disorder, Bipolar type. 1f. Person Completing this section V10 (Psychiatric Rehab Service Coordinator/PRSC).On 06/29/26 at 9:58am V27 (R1's family member) stated that he was not aware that R1 was discharged from the facility. V27 stated that no one from the facility discussed R1's discharge with him. V27 stated that he found out that R1 was discharged from the facility when R1's brother arrived at the facility to bring R1 some food and R1 was no longer there. V27 stated that R1 was not allowed to live with V27 due to R1's mental instability. V27 stated that R1 was found homeless and living on the train. V27 stated that the paperwork found on R1 showed that it was documented that V27 picked R1 up from the facility in a car. V27 stated that he did not pick R1 up from the facility. V27 stated that he does not own a car and has not owned a car in a couple of years.On 06/29/26 at 2:14pm V9 (Psychiatric Rehab Service Coordinator/PRSC) stated that R1 informed her that he resided at the facility because R1 was kicked out of the house by R1's son. V9 stated that she was assisting R1 with applying for subsidized housing and the plan was for R1 to discharge back to the community when his subsidized housing was approved.On 06/29/26 at 2:40pm V10 (Psychiatric Rehab Service Coordinator/PRSC) stated that a safe discharge consists of a resident leaving the facility with someone. V10 stated that the facility doesn't allow a resident to leave the facility by themselves unless the resident is leaving AMA (Against Medical Advice). V10 stated that R1's discharge was a safe discharge which required R1 to be picked up by someone. V10 stated that the facility is supposed to confirm who would be picking the resident up at the time of discharge. V10 stated that she thinks that she is the one who spoke to R1's son about discharge. V10 stated that R1's son came to pick R1 up from the facility in a car. V10 then stated that she can't confirm or deny if R1's son came to pick R1 up from the facility. V10 stated that she can't confirm that she seen R1's son when R1 left the facility. V10 stated that R1's discharge instructions is dated 02/11/26 because R1 was supposed to initially discharge with a girlfriend but R1 was not able to live with that friend and the date was never changed.On 06/29/26 at 3:25pm V12 (Receptionist) stated that she observed R1 leaving the facility at the time R1 was discharged . V12 stated that social service walked R1 to the door and R1 left the building. V12 stated that R1 did not get in a car and that R1 left the facility by himself walking.On 06/29/26 at 3:11pm V11 (RN) stated that she was informed by R1 and social service that R1 was being discharged . V11 stated that she believes that she got a discharge order from V16 (Nurse Practitioner/NP). V11 stated that if she got the discharge order then it would be in R1's records. V11 stated that she does not know how R1 left the facility and who R1 left the facility with.On 07/01/26 at 2:20pm V2 (Director of Nursing) stated that the facility doesn't allow the residents to discharge without a place to go. V2 stated that the facility has whoever the resident is going to live with come to pick the resident up from the facility. V2 stated that the facility does not allow residents to discharge and get on the bus. V2 stated that social service is supposed to verify where the resident is discharging to. V2 stated that the nurse should call the physician for a discharge order. V2 stated that if R1's chart indicates that R1 left the facility with R1's son then that should have been what happened.Review of R1's physician's orders does not show that R1 had a discharge order entered.On 06/30/26 at 12:53pm V15 (Certified Nursing Assistant/CNA) stated that she was R1's CNA at the time R1 was discharged . V15 stated that she is unsure of what time R1 left the facility. V15 stated that after R1 was discharged , V15 saw R1 standing at the bus stop outside of the facility with a backpack.On 06/30/26 at 3:31pm V16 (NP) stated that she did not know that R1 was discharged from the facility. V16 stated that she does not recall giving the nurse a discharge order for R1. V16 stated that even if the nurses get a verbal order, the nurse should enter the order into the record. Facility's policy titled Discharge/Transfer of Resident dated 11/2025 documents in part, Purpose: To provide safe departure from the facility. To provide for continuity of care and treatment. Procedure: 1. Explain discharge procedure to resident and family. Provide additional health education or medication instruction information for resident or family as indicated in lay terms. 2. An attending physician order is required to discharge/transfer.

Based on observation, interview, and record review the facility failed to maintain Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food at above 135 degrees F (for hot foods) on the steam table in accordance with professional standards for food service safety. This failure has the potential to affect all residents that eat food from the kitchen.Findings include:On 4/29/2026 at 12:15 PM, this surveyor observed the steam table during the tray line, there was steam coming from the food. V15 (Dietary Cook) checked the temperature of the polish sausage with the facilities thermometer, and V15 stated that it read 140-degrees Fahrenheit, mashed potatoes were at 165-degrees Fahrenheit, pureed meal was at 180 degrees Fahrenheit, mechanical soft polish was at 130 degrees Fahrenheit.On 4/29/2026 at 12:20 PM, this surveyor observed tray line begin. The first tray on the tray line was placed on the bussing cart. Staff did not check the food temperature for the first bussing cart.On 4/29/2026 at 12:30 PM, this surveyor asked V15 to recheck the first tray on the first-floor bussing cart. V15 checked the temperature of the polish sausage with the facilities thermometer, and V15 stated that it read 100-degress Fahrenheit. Surveyor asked V15 if the meal tray is at a safe serving temperature. V15 stated the tray will be replaced with another one because the temperature is in the danger zone.On 4/29/2026 at 12:45 PM, surveyor asked V15 when food temperature should be checked. V15 stated food temperatures should be checked as we go to avoid the food from being sent to the resident's cold.On 04/29/2026 at 1:15 PM, surveyor asked V15 to recheck the temperature on the first tray for the 3rd floor bussing cart. V15 checked the temperature of the polish sausage with the facilities thermometer, and V15 stated that it read 115-degrees Fahrenheit. Surveyor asked V15 if the meal tray is at a safe serving temperature. V15 stated the tray will be replaced with another one because the temperature is in the danger zone.On 04/29/2026 at 1:45 PM, this surveyor asked V15 to recheck the temperature on the last tray for the 4th and 5th floor bussing cart. V15 checked the temperature of the polish sausage with the facilities thermometer, and V15 stated that it read 145- degrees Fahrenheit.On 04/29/2026 at 2:00 PM, this surveyor asked V16 (Dietary Director) to recheck the temperature for R187's meal tray, which was the last tray on the tray line. V16 checked the temperature of the polish sausage with the facilities thermometer, and V16 stated that it read 120- degrees Fahrenheit. V16 stated she will take the meal tray back to the kitchen and ensure that R187 receives a new tray one because the temperature is in the danger zone.On 04/28/2026 at 11:36 AM, R61 stated he is concerned about the food always being cold. He stated the food is either burned or undercooked.Facility policy titled Food Serving Temperatures with review date of 06/2025 documents in part, To ensure food is served at temperatures which prevent spoiling and are palatable. Prior to meal services, temperatures of both hot and cold foods are to be taken and recorded. Appropriate measures will be taken by the Supervisor in Charge to ensure food is served at the proper temperature. Measures may include additional heating, re-heating or additional cool, or if the integrity of the food is in question, discarding the item and replacing.Facility's menu for 04/29/2026 documents in part sausage polish, onion and green pepper sliced, mixed vegetables, mashed potatoes,State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. Under section S483.60 Food and Nutrition Services documents in part Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation).

Based on interview and record review, the facility failed to ensure a resident received a blood pressure medication. The failure affects one (R1) of three residents reviewed for medication in a total sample of four residents.Findings include: R1 is a [AGE] year-old female. R1's diagnoses are but not limited to chronic obstructive pulmonary disorder, bipolar disorder, hypertension, major depressive disorder, and reflux. R1's BIMS (Brief Interview for Mental Status) notes R1 is alert.R1's POS (Physician Order Statement) dated 1/13/2026, notes R1 is supposed to take one Amlodipine Besylate Oral Tablet, 5 mg by mouth in the morning for hypertension. On 11/09/2025, R1 started Lisinopril Oral Tablet, 5 mg, one tablet, in the morning for hypertension.On 2/20/2026, at 5:29 PM, R1 stated, I have two blood pressure medications that I am on. On 2/16/2026, the facility did not have my blood pressure medication, so I did not get it. The nurse was V4 (Nurse). On 2/20/2026, at 6:33 PM, V4 stated, one of her blood pressure medications was not available. I reordered it for R1. On the February MAR (Medication Administration Record) I must have documented that I gave it by error. I did not contact the physician. I instructed R1 to stay hydrated and to not do too much to elevate her blood pressure. Honestly, I did not check the convenience box. I was not informed of the procedure on what to do when medication is out. I just knew how to reorder it. I was passing out medications all day and I could not follow up, to be honest. It was just one of them, not both and I cannot remember which one.On 2/20/2026, at 6:45 PM, V2 (DON-Director of Nursing) stated, if the medication is out, the nurse needs to go to the electronic medicine machine or the emergency medication cart and retrieve the medication from there. The nurse should also call the physician and tell them that the resident did not receive the medication. I was not aware of any incident where a resident did not get their blood pressure medication. There is an in-service sheet on medication administration.On 2/20/2026, R1's MAR (Medication Administrator Record) from February 2026 was reviewed on 2/16/2026. V4 marked that R1 had received the medication.On 2/20/2026, the facility provided medication administration in-services. V4's name was listed on the in-service form. V4 was in-serviced on medication administration.Facility policy titled, Medication Administration Policy, undated, notes medications should always be prepared, administered, and recorded by the same licensed nurse. Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.If a medication and/or treatment error occurs, the licensed nurse will: a. Immediately notify the attending physician, b. Describe the error and the resident's response in the Nurse's notes, c. Complete an Incident Report, d. Identify the error on the 24-Hour Report, and e. Monitor the residents' status.

Based on observation, interview, and record review, the facility failed to ensure food items were 6 inches above the floor in an effort to prevent foodborne illness. This failure has the potential to affect all 179 residents taking oral nutrition at the facility. The (01/14/2026) facility census was 180.The undated list of residents on NPO (nothing per mouth) include 1 resident.On 01/15/2026 at 10:28am with V6 (Dietary Manager) inside the Kitchen's walk-in refrigerator, there were stacks of boxes of food items with a box labeled pork/cerdo on the floor. V6 stated boxes of food items should be 6 inches above the floor to prevent food contamination.On 01/15/2026 at 1:24pm V6 stated all food items should be 6 inches above the floor to prevent food contamination and to prevent potential food borne illness. The (Revised 2017) Sanitation and Food Safety Storage of Refrigerated Foods documented, in part Policy: Refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Procedure: Food is stored six inches above the floor.

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff. This failure affected 1 (R2) resident reviewed for abuse and has the potential to affect all 34 residents on the 5th floor who smoke.The (undated) Patio/Smoking Schedule documented that there were 34 residents who smoke on the fifth floor.R2's (12/10/2025) Final Incident Investigation Report documented, in part (R2) alleged that a facility member called him a profane name. Calling residents kids when overseeing the cigarette line. Resident (R3) was interviewed him being there at the time of the incident. (R3) stated (V4-Former PRSC Psychiatric Rehabilitation Services Coordinator) was verbally aggressive towards residents. (R4) stated (V4) was rude and did not know how to talk to people. The facility was able to substantiate the allegation due to witness testimony. (R3)'s statement (V4) use derogatory language towards everyone in line, including (R2). Called the wrong floor to smoke, 5th floor came to smoke. (V4) got upset and started cursing. (V4) said she was sick of this S***. When (R2) came around the corner she (V4) really got upset and was calling people F***** kids. On 01/14/2026 at 2:35pm, R3 stated the receptionist called for 5th floor residents to go down to smoke. When they got on line to the smoking area, she (V4) said 'what are you doing mother f***r and also said they were acting like kids. He (R2) and (V4) were talking back and forth.On 01/14/2026 at 3:25pm, R2 stated there was a miscommunication between the front desk and (V4). The front desk called (overhead paged) for one floor to smoke, and she (V4) called for another floor to smoke. R2 stated he went down to the first floor and got in line, was talking to other residents about energy and people's character and just out of the blue she (V4) told him (R2) Little boy, watch the F*** you are saying. R2 stated it just escalated from there. R2 stated he felt disrespected by (V4).On 01/20/2026 at 2:33pm, V3 (Social Services Director/Administrator-in-Training) stated staff are not supposed to tell residents they are like children because it is demeaning and that is a dignity issue. On 01/15/2026 at 2:49pm, V1 (Administrator) stated they (R2, R3, R4) were in the smoking line and she (V4) was cursing telling them to get in line, you are all acting like F****kids. He (R2) took offense and told her, who are you talking to, don't talk to me like that. and she (V4) went to him aggressively basically saying 'if you don't like it here, be somewhere else. V1 stated he was taking all stories including (R3) and he (R3) said she was verbally aggressive. He intervened and escorted him (R2) away. V1 stated he asked (R4) and he said she (V4) talked crazy all the time. V1 stated with these testimonies, he substantiated the allegation, and she was terminated. Her last day was on 12/09/2025. It is not expected of staff to verbally abuse residents, and her aggressive behavior affected him (R2) and could potentially affect all the smokers on the 5th floor. R2's admission Record documented that R2's diagnoses (include but not limited to) alcohol abuse, asthma, and Type 2 Diabetes Mellitus.R2's (12/03/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R2's mental status as cognitively intact. R3's admission Record documented that R3's diagnoses (include but not limited to) disorder of kidney and ureter, hypertension, and nicotine dependence.R3's (10/15/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R3's mental status as cognitively intact.R4's admission Record documented that R4's diagnoses (include but not limited to) major depressive disorder, bipolar disorder, and alcohol abuse.R4's (11/11/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R4's mental status as severely impaired.V4's (11/2025 - 01/20260 Timecard (Terminated Employees) documented that V4's last day of work was on 12/09/2025.The (undated) Resident Rights documented, in part Policy: employees shall treat all residents with respect, kindness, and dignity. To provide an environment of care that supports a positive self-image. Policy Interpretation and Implementation: 1. Federal and State Laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: ee. The right to an environment that preserves the dignity and contributes to a positive self-image. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interviews, and record review, the facility failed to ensure a resident was administered a medication with a correct dosage. This failure affected 1 (R6) resident reviewed for medication administration in the total sample of 8 resident.On 01/15/2026 at 9:53am, during the medication administration observation with V11 (Licensed Practice Nurse), V11 dispensed R6's medications including Metoprolol 25mg/tab x 1 tablet. R6's container of Metoprolol has instruction written Metoprolol Tartrate 25mg. Take 0.75 tablet (18.75mg) by mouth every 12 hours.On 01/15/2026 at 9:56am, V11 administered R6 medications.ON 01/15/2026 at 10:01am, V11 stated she dispensed and gave Metoprolol 1 tablet to R6. V11 checked the container of R6's Metoprolol and stated he (R6) is supposed to get 18.75mg and she gave Metoprolol 25mg. V11 stated she did not follow the doctor's order.On 01/15/2026 at 10:07am, V12 (Licensed Practice Nurse) stated she works regularly on the second floor and whenever she is assigned to him (R6) she dispensed the medication from the container and gives one whole tablet. V12 stated the whole tablet is already 18.75mg. V12 checked the container of R6's Metoprolol Tartrate and stated she has been giving him (R6) 25mg and she did not follow the order to give Metoprolol 18.75mg.On 01/20/2026 at 11:00am, V2 (Director of Nursing) stated according to the order, he (R6) should get 1/2 tablet and 1/4 tablet of the Metoprolol 25mg, so he would get a total of 18.75mg. The nurse who gave the whole table of Metoprolol 25 mgs did not follow the doctor's order. The expectation is to follow the doctor's order, and if they are giving him the whole tablet, they are not following the doctor's order. Metoprolol is for hypertension and the resident could potentially become hypotensive if given a higher dose.R6's admission Record documented that R6's diagnoses (include but not limited to) hypertension, tachycardia, and dependence on oxygen.R6's (11/19/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 5. Indicating R6's mental status as severely impaired. Section I. Active Diagnoses. I0700. Hypertension.R6's (Active Order as Of: 01/15/2026) Order Summary Report documented, in part Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 18.75 mg by mouth two times a day for HTN (hypertension). Active 09/17/2025. R6's (01/2026) Medication Administration Record documented, in part Metoprolol Tartrate Oral Tablet 25 MG, (Metoprolol Tartrate) Give 18.75 mg by mouth two times a day for HTN (hypertension). Start Date: 09/18/2025 0900. D/C (discontinuation) Date: 01/15/2026.The (undated) Registered Nurse Job Description documented, in part Job Summary: The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day to day nursing activities performed by the nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility to ensure the highest degree of quality care. Essential Duties and Responsibilities: 16. Prepare and administer medications and treatments as ordered by Physician. The (undated) LPN Job Description documented, in part Job Summary: The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility to ensure the highest degree of quality care. Essential Duties and Responsibilities: 16. Prepare and administer medications and treatments as ordered by Physician.The (undated) MEDICATION ADMINISTRATION POLICY documented, in part II. ADMINISTRATION OF MEDICATIONS. Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time.

Based on interview and record review, the facility failed to ensure a resident's environment was free from hazardous material (razor). This failure affected 1 (R5) resident reviewed for supervision and hazard in the total sample of 8 residents. R5 sustained a wide linear abrasion on the left forearm beginning at the base of left thumb and extending to the mid forearm on radial side. The abrasion is approximately 1.5inch in width. R5's admission Record documented that R5's diagnoses (include but not limited to) cannabis dependence, alcohol dependence, alcoholic cirrhosis, and depression. R5's (01/03/20260 Petition for Involuntary/Judicial admission documented, in part a person subject to involuntary in-patient admission to a facility by reason of emergency inpatient admission by certificate. A person with mental illness who because of his or her illness is reasonably expected, unless treated on an inpatient basis to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed. In need of immediate hospitalization for the prevention of such harm. Exhibiting suicidal ideation with attempt to cut/slit her wrist. R5's (01/03/2026) Wound Paired Inspection Form documented, in part Abnormal findings: Small cut wound at the left wrist/abrasion on the left wrist. R5's (01/03/2026) Hospital Record documented, in part history of present illness: she became frustrated and today superficially cut her left wrist. Review of system. Skin: there is a wide linear abrasion on the left forearm beginning at the base of left thumb and extending to the mid forearm on radial side. The abrasion is approx.(approximately) 1.5inch in width. This was done with a razor blade. V1 (Administrator)'s (01/05/2026) email correspondence with V14 (Nurse Practitioner-Psychiatrist) documented, in part This email is sent to inform you that a resident on your caseload named (R5) has been given an emergency IVD for bringing razors into the facility and harming herself. V1's (01/05/2026) email correspondence with V29 (Ombudsman) documented, in part Resident brought razors into the facility and harmed herself. On 01/22/2026 at 8:01am, V27 (Certified Nursing Assistant) stated she worked the 11pm-7am shift, she was doing her rounds, checking her residents. When she got to her (R5) room, she saw her scraping her arm with a razor. She asked her why she was scraping her arm and she (R5) stated she wanted to go to the hospital to be with her boyfriend, (R8). V27 stated she called (V19 - Nurse Supervisor) and he (V10) asked her where she got the razor, and she said she brought it with her to the facility when she went out on pass. V27 stated the razor did not look like the one they used at the facility. That is why she believed her that she got it while she was out on pass. V27 stated that her forearm had a long scratch; there was blood, but it was not gushing. On 01/20/2026 at 3:19pm, V10 (Nurse Supervisor) stated he worked 3-11 and 11-7pm. V10 stated she (V27) was doing her round, went to her room, and she (V27) saw the wound on her (R5) left forearm, as if she ran the razor on her forearm 2x. She (R5) said she got the razor outside. She came back from the community pass with a razor. V10 showed a picture of the blue razor, the handle was straight with label (Brand of Razor). V10 stated the facility is both psych and skilled facility. A resident should have not access to a razor because it is not safe for them, the resident could hurt themselves and other residents and staff. The resident should be safe at the facility at all times, and she was able to hurt herself with a razor.On 01/21/2026 at 2:36pm, V23 (Medical Records/Central Supply) stated she has been the central supply person for 6-7years and the razor she purchased have been the same, curved and not branded because it is cheaper than the branded razor. This surveyor showed the razor used by R5 and stated it was not the razor she purchased for the facility. V23 showed to this surveyor the razor she purchased for the facility. The razor's handle was curved and has no label (brand name).R5's census list documented that R5 was on Therapeutic Leave on 12/24/2025 and Returned to the facility on [DATE].R5's (12/24/2025) untitled record documented, in part Time 5:11 (pm). Date return: 12/26/2025. On 01/22/2026 at 3:09pm, V24 (Psychosocial Aide - PSA) stated he worked when she (R5) returned from community pass on 12/26/2025 but he did not do the search on her. V24 stated if she has diagnoses of Cannabis and Alcohol Dependence, she should be searched. V24 stated he never documents the search is completed if there were no contraband. V24 stated he understands if the search was not documented, it means it is not done. V24 stated he was never informed to do extra documentation if they did the search with no findings.On 01/21/2026 at 3:44pm, V26 (PSA) stated he worked on 12/26/2025 and he did not do the search for (R5). V26 stated when the search is completed and there is no findings, he lets the resident go back to the room. V26 stated he never documents the search is completed if there is no findings.On 01/20/2026 at 3:55pm, V3 (Social Services Director/Administrator-In-Training) stated if a resident is on the BMOD (Behavior Modification Program) they have to be searched when they go back from the community to ensure they did not bring drugs, alcohol or any sharp objects like a razor. She (R5) was on a Behavior Modification program because she has diagnoses of cannabis dependence and alcohol dependence and she has to be searched when she returned from a community pass because it is part of her contract. On 01/22/2026 at 5:20pm, V1 (Administrator) stated the Drug Parameter is part of the Behavior Modification (BMOD) Program. V1 stated she did not have Drug Parameter contract nor the BMOD contract signed. She could have been educated about the program. If she (V3) said she (R5) was on the list for BMOD, she should be searched when she returned from the community to ensure she was not bringing contraband in the building. If the search was not documented, then it cannot be confirmed if the search was done. V1 stated the facility should provide the resident with a safe environment. The (undated) Behavior Modification Program Resident Addiction Program Parameters documented, in part Any resident admitting to the facility with a recent drug history (use within 1 year) or a current resident that has violated the facility drugs policy/procedures must follow these guidelines: Parameters for new/admitting residents: Must sign or accept the education of the Drug Parameter Agreement prior to being admitted to the facility.

Based on interviews and record review, the facility failed to prevent one resident (R4) from being physically attacked in an elevator. This failure has resulted in R4 sustaining a closed head injury, becoming emotional and stating that she is no longer comfortable in the facility. This failure has affected one (R4) of four residents reviewed for abuse. Findings include:R4 is a [AGE] year-old with diagnosis including but not limited to: epilepsy, cerebral infarction, transient cerebral ischemic attack, headache and benign neoplasm of cerebral meninges.R4 has a BIMS (Brief Interview of Mental Status) score of a 12, which indicates moderately impaired.R7 is [AGE] year-old with diagnosis including but not limited to: Unspecified behavioral and emotional disorders, unspecified intellectual disabilities, bipolar disorder, oppositional defiant disorder and morbid/ severe obesity.R7 has a BIMS score of 0 indicates severe cognitive impairment.On 12/08/25 at 12:10 pm, R4 stated the following as she started to cry, It's horrible here, I'm miserable! Just a couple of weeks ago, I was attacked on the elevator by a male resident who is about six feet tall and weighs over 300 pounds. He (R7) punched me all in my head and my face. I couldn't do nothing but scream out for help and no one could help me because the elevator was so crowded. That's why I have anxiety riding the elevator now. My friend (R5) rides the elevator with me now because I asked to have my meals on the unit and was told that I can't eat on the unit even though a few other residents are allowed to receive their meal trays on the unit. After R7 attacked me, they (facility) sent him (R7) out for a psychiatric evaluation but he returned right back after a week. The only reason that he (R7) is not here now is because he left AMA (Against Medical Advice) on his own. I'm afraid and traumatized since the attack and I feel targeted. I have been threatened by a couple other male residents since the attack because everyone knows what happened. This place is filled with mental patients and I don't feel safe here.On 12/10/25 at 2:15 pm, V8 (Nurse Practitioner) stated the following, It is never ok for a resident to be attacked by another resident. If a person is hit in the head, we send them out for further evaluation and a CT scan because you never know what is going on underneath. Many things such as headaches, seizures, visual problems may occur when a person is hit in the head and it could lead to more serious outcomes.R4's Care Plan documents, the resident's (R4's) comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase her susceptibility of abuse. Neglect.Preliminary Incident Investigation Report dated 11/15/25 documents the following, Residents involved: R4 and R7. It was reported that R4 and R7 were involved in an altercation on the elevator. R4 was noted to have a scratch on the right side of her head in relation to the incident.Incident Investigation Form dated 11/15/25 and documents the following: V15 (PRSC/ Psychiatric Rehabilitation Services Coordinator) stated, R4 and R7 were coming upstairs after eating lunch in the elevator R7 and R4 got into it with one another, then R7 started hitting her (R4) from behind.Statement of Witness dated 11/15/25 documents the following by V14 (Housekeeper), when I came off of lunch break, I was standing at the elevator. R7 was making verbal threats to R4 after R4 told R7 to move from in front of the elevator because she (R4) could not get on. R7 told R4 that he would get another resident to fight R4. Once inside the elevator, R4 and R7 keep making verbal threats and then R7 hit R4 in her head (right side) twice with his cane.Police Report dated 12/11/25 documents R4 as the victim in a simple battery incident.R4's Progress Note dated 11/15/25 documents R4 was sent out to hospital due to having headache and sensitivity to light. R4's family, Medical Doctor and Director of Nursing made aware; R4 returned to the facility with Minor Closed Head Injury.Hospital Record indicates R4 was transmitted to the hospital Emergency Department via ambulance on 11/15/25 at 1935 (7:35 PM); R4 seen in the hospital for headache and a diagnosis of minor closed head injury.Petition for Involuntary admission dated 12/15/25 at 12:30 pm documents, R7 in need of immediate hospitalization for the prevention of harm; R7 presenting with verbal and physical aggression, continuing to escalate despite attempts to de-escalate; R7 having bizarre delusions about other residents; R7 is presenting with labile mood.AMA (Against Medical Advice) Form dated 11/15/25 documents, R7 signing himself out AMA.R7's Nursing Progress Note dated 11/21/25 documents, R7 returned from the hospital; R7 left AMA.Abuse Prevention Program Policy documents, this facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on observation, interviews and record review, the facility failed to ensure adequate running water and failed to provide adequate hot water. This failure has affected four residents (R1, R3, R9 and R10) and has the potential to affect all 181 residents that reside in the facility. Findings include:R1 is [AGE] year-old with diagnosis including but not limited to: Type 2 diabetes mellitus, unspecified asthma, essential hypertension, insomnia and gastro-esophageal reflux disease without esophagitis.R1 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. R3 is [AGE] year-old with diagnosis including but not limited to: Chronic obstructive pulmonary disease with acute exacerbation, type 2 diabetes mellitus without complications, epilepsy, acute kidney failure and essential hypertension.R3 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.R9 is [AGE] year-old with diagnosis including but not limited to: Other specified disorders of kidney and ureter, essential hypertension, chronic kidney disease, hypokalemia and anemia.R3 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.R10 is [AGE] year-old with diagnosis including but not limited to: Unspecified asthma, otalgia, type 2 diabetes Mellitus and gastro-esophageal reflux disease.R10 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.On 12/08/25 at 11:15 am, V1 (Administrator) stated the following, We have an issue with water pressure, valves, and ball joints. The water is running, but at a very low pressure. 4th and 5th floors have more of an issue with pressure.On 12/08/25 at 11:50 am, V5 (Project Manager) stated the following, We have been having issues with the water pressure. The City wants us to change our water meters, but we've had to change two water valves beforehand. We were able to change one valve but had issues with the other valve. The Plumbers could not cut the water supply off from the City in order to change the other valve. The City came out and closed the valve but when they tried to reopen, it did not open all the way. This is why the water pressure has been low. I've been in contact with the City and the plumber in order to finally take care of the water issues. They are both scheduled to come out this Saturday to make the repairs.On 12/08/25 at 1:56 pm, R1 turned on his hot water and Surveyor noted cold water running from the faucet.At that time R1 stated the following, I understand that the building is old, but we should have hot water. The water in the shower is ice cold. I need a shower bad. I have to clean myself the best way that I can. When I get up at around 2 am, I check my water, and it is a little warm then. The last time I was able to take a shower here was last month sometime. My toilet doesn't even flush at times, and we (residents) were told that it was due to the low water pressure here on the fifth floor.On 12/08/25 at 1:57 pm, R1 attempted to flush his toilet but it would not flush.On 12/08/25 at 2:18 pm, R3 stated the following, About two months ago is when the water issue first started. The water had gone out completely in my room and since then, it's hit or miss. Sometimes it runs ok, sometimes is runs very slow and sometimes it don't run at all. That's why I keep a jug of water in my bathroom to at least wash my face or take a sponge bath in my bathroom. My last shower was about four days ago. I don't know why we have the worst water issues here on the 5th floor. If my toilet doesn't flush, I have to pour water into the toilet so that the urine or feces will go down. I know that this is an old building an I heard that they have been working to fix the issue, but I feel like two months is enough time to fix it. At that time, R3 turned on her hot water valve. Surveyor noted a small stream of cold water flowing from R3's faucet and R3's toilet did not flush.A gallon of water was also noted in R3's bathroom.On 12/10/25 at 10:36 am R10 stated the following, the water works off and on. Sometimes the toilet won't flush because of the low pressure. Right now, the water doesn't get hot. I have to wake up at 4am in order to get lukewarm water from my faucet to clean myself.At that time, R10 turned the hot water valve on.On 12/10/25 at 10:36 am Surveyor touched the water running from R10's bathroom sink and it was cold.On 12/10/25 at 11:15 am, V10 (Maintenance worker) went with Surveyor to test the water temperature in the 2nd floor shower room. At that time, the water measured 60 degrees F (Fahrenheit) and was cool to touch.On 12/10/25 at 11:23 am, V10 went with Surveyor to test the water temperature in the 3rd floor shower room. At that time, the water measured 62 degrees F (Fahrenheit) and was cool to touch.On 12/15/25 at 12:53 pm, V11 CNA (Certified Nurse Assistant) went with Surveyor to test the water temperature in the 4th floor shower room. At that time, the water measured 58 degrees F (Fahrenheit) and was cool to touch.On 12/15/25 at 1:30 pm, V10 (Maintenance) went with Surveyor to test the temperature of the water in the 5th floor shower room. At that time, the water measured 61 degrees F (Fahrenheit) and was cool to touch.On 12/17/25 at 11:12 am, R9 stated the following, I can only wash up in the bathroom. The shower water trickles down and it's cold. The last time I had a good shower was probably in October.On 12/17/25 3:20 pm, V3 (Director of Nursing) stated the following, The residents should have hot running water. Hot or warm water works better to remove germs during showers. They (residents) are not expected to take cold showers.On 12/17/25 at 3:37 pm, V12 (CNA) stated the following, somedays we have hot water and some days the water is cold. When I give a resident a bed bath, I try to warm the towels by holding it in my hand after lathering the towel. I let my residents know that the shower water is cold and give them the option to shower or not. Some days the water is not as cold, but when it is cold I encourage the residents to just wash up in their bathroom sinks instead of taking a cold shower.On 12/17/25 at 3:50 pm, V13 (CNA) stated the following, I am not able to give my assigned showers because we cannot put the patients in cold water. Some residents refuse the shower just because the water is cold. I wouldn't want to get in a cold water. Even if I offer a bed bath, some people still refuse the bed bath because the water is too cold. When it is cold outside, the water is ice cold.On 12/15/25 at 11:40 am V9 (Dietary Manager) measured the temperature of the hot water running from the main kitchen faucet.At that time, the water temperature was measured at 60 degrees Fahrenheit.Facility Census Report dated 12/07/25 documents 181 active residents in the facility.Facility Maintenance Log document the following maintenance requests for the second floor: 11/13/25- water hasn't been hot in four days; 12/3/25 and 12/8/25- toilet not flushing.Facility Maintenance Log document the following maintenance requests for the third floor: 11/4/25- shower room water is ice cold; 11/5/25- toilet not flushing; 11/11/25- no acceptable water pressure and water temperature no good; 11/22/25- no water from sink, water pressure low; 11/24/25- no water; 12/6/25- water not warm in shower room; 12/17/25- no hot water.Facility Maintenance Log document the following maintenance requests for the fourth floor: 11/6/25- shower room water not working.Facility Maintenance Log document the following maintenance requests for the fifth floor: 11/10/25- water from sink not working and toilet not flushing; 11/21/25- toilet wont flush; 12/4/25- low water pressure.Plumbing Company Estimate dated 3/13/25 documents a total repair cost of $3,250.Facility email between V5 (Project Manager) and V1 (Administrator) dated 8/14/25 documents, Plumbing company will be out on Tuesday (8/19/25) to replace valves on both sides of the water meter.Facility email between V4 (Maintenance Director) and V5 dated 12/2/25 documents, low water pressure/ fire pump not operable.Maintenance Director Job Description documents the following as part of the essential duties: maintain the building in good repair and free of hazards such as those caused by electrical, plumbing, heating and cooling systems, life safety, etc.

Based on observations, record review and interviews, the facility failed to ensure that the kitchen was free from pests. The facility also failed to ensure that the kitchen oven was clean and free from debris. This failure has the potential to affect 181 residents that reside in the facility.Findings include:On 12/15/25 at 11:40 am Surveyor noted a brown bug crawling on the sink across from the oven. The oven was also noted to have brown dried substance on the doors and inside of the oven with black particles in the oven as well.At that time, V9 (Dietary Manager) stated the following, It looks like a roach crawling. I think the oven was last cleaned on our deep cleaning day, last Wednesday. We usually clean and sanitize everything after each use to contribute to pest control.On 12/17/25 at 3:21 pm, V3 (Director of Nursing) stated the following, I would hope to not see pest in the kitchen because that where the food is prepared. They can harbor germs and bacteria.Facility Census Report dated 12/07/25 documents 181 active residents.Dietary Services Policy documents, to store prepare and distribute food under sanitary conditions and prevent foodborne illnesses.Pest Control Policy documents, to prevent or control insects and rodents from spreading disease.

Based on interview and record review, the facility failed to ensure that residents are free from abuse for two of four residents (R2, R4) reviewed for abuse in the sample of eight. This failure resulted in R2 requiring antibiotics for treatment of a bite to R2's hand.Findings include:R2's face sheet documents R2 is a [AGE] year-old admitted to the facility on 10.31.2024, with diagnoses including but not limited to: Unspecified psychosis, Hallucinations, Parkinsonism, and Anxiety disorder. R2's MDS (Minimum Data Set of 8.13.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R2 is cognitively intact.R4's face sheet documents R4 is a 55 -year-old admitted to the facility on 7.2.2025, with diagnoses including but not limited to: Type 2 diabetes Mellitus, Cerebral infarction, Acute kidney failure, and Opioid use. R4's MDS (Minimum Data Set of 9.18.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R4 is cognitively intact.Final Incident Investigation Report (10.24.2025) documents in in part: On 10.18.2025, the facility administration was notified by facility nurse that residents (R2) and (R4) were involved in an altercation in the elevator that verbally challenged her reasoning. Both residents had minor injuries in reference to the altercation. (R4) was interviewed and stated that (R2) refused to allow another resident on the elevator. (R4) stated that (R2) became angry and attacked him. (R4) stated that he only fought back to defend himself. (R2) was interviewed and stated that after she told a waiting resident to wait until the next elevator, (R4) hit her. (R7) was in the elevator at the time of the incident and corroborated (R2's) account of the incident. (R6) was also in the elevator at the time of the incident and corroborated (R4's) account of the incident. On 10.25.2025, at 11:45 AM, R4 said R2 told another resident that they could not get on the elevator. I told R2, you can't do that, then (R2) hit me and I retaliated.On 10.25.2025, at 2:14 PM, R7 said R2 told another resident they couldn't get on the elevator. R4 told R2,you can't do that. R7 then hit and choked R2. On 10.25.2025, at 3:30 PM, V7 (RN-Registered Nurse) said Social Service told me R2 is fighting with a man. I got between them (R2 and R4). R4 said R2 wouldn't let anyone on the elevator. I don't' recall what R2 said. I assessed them both. R2 looked like she had a bite mark on her hand, the skin was broken. I don't recall which hand. I called the on-call NP (Nurse Practitioner) and received an order for an antibiotic for R2. On 10.27.2025, at 11:08 AM, via telephone, V8 (NP) said I was told that R2 was bit by another resident and was refusing to take the antibiotic that was ordered by another provider. We all have bacteria in our mouths, any break in the skin can increase the risk for infection. The antibiotic was to prevent an infection. I gave an order for a topical antibiotic ointment.R2 was not in the facility during the investigation.On 10.18.2025, at 11:28 PM, Nursing Progress Note documents in part, Resident stated that she was involved in an altercation on the elevator with another resident. The residents were separated and the peer was moved to another floor. On 10.22.2025, at 6:16 PM, Nursing Progress Note documents in part, Resident seen this evening by infection control NP (V8). NP notified of resident's refusal to take Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (milligrams). New order for Triple Antibiotic External Ointment to be applied topically to right hand and leave out to air BID (twice daily) x 5 days, order carried out as ordered. Abuse Prevention Program Facility Policy (undated) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interviews and record reviews, the facility failed to protect one (R40) resident's right to be free from physical abuse out of one sampled resident. R132 slapped R40 on the face that resulted in R40's falling on her back and sustained left elbow, back, and neck pain. R40 felt scared and shaken. Findings Include: The facility's incident investigation report dated 3/3/25 documents in part: On 3/3/25 [V1 Administrator] was notified by [R40] that [R132] pushed [R40] down. Both residents' representatives and the police were notified. R40's Minimum Data Set (MDS) dated [DATE] shows R40 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15 and requires supervision with walking. R40's functional assessment dated [DATE] shows R40 had no limitation with range of motion to upper extremities. R40's progress notes dated 3/3/25 at 4:39 PM documented by V10 (Psychiatric Rehabilitation Services Coordinator) reads in part: Resident had an altercation with another resident this morning. Resident was redirected and was checked by nurse. The writer will continue to assist resident's needs. R132's MDS dated [DATE] shows R132 is cognitively intact with BIMS of 15 and independent with walking. R132's progress notes dated 3/3/25 at 10:30 AM documented by V13 (Registered Nurse/RN) reads in part: Patient came to the medication cart where other patients was standing in line for their medication and stated I want my medication now, I am not waiting. [R132] started yelling and became aggressive with another resident slapped her [R40] in her face and pushed her to the floor. On 3/4/25 at 10:55 AM, R40 stated on 3/3/25 at around 10:00 AM, R40 was in line to get medications from V13 (Registered Nurse). R40 stated, [R132] came up real fast next to [V13] and said [R132] needs her medication. [R132] was loud and angry. [V13] tried to tell [R132] that [V13] will finish giving my meds. [R132] was so angry and demanding her meds. I said please have some respect the nurse was telling you something. Then [R132] took her hand, slapped me on my face, and pushed me real hard and knocked me out on my butt. I fell on the ground. I fell on my butt and back and left shoulder. I had a replacement surgery there it's very very painful. Now the pain level is 8. I landed on my left side. Now my left side of my neck, my left side of my mid to lower back and my left elbow is hurting. I was so scared, and I was shaken. [R132] was twice as big as me. [R132] was double the frame of me. I'm only 124.8 pounds. I screamed for pain. [V13] the nurse and another staff helped me up. I stood for a while. I slowly walked to my room and laid down. I didn't want to go to the hospital. I told [V13] I was having pain. [V13] gave me Hydrocodone. I already have chronic pain on my left arm but it got worse because of the incident. My elbow, my neck, my back are hurting more. R40 stated the pain medications help control the pain. R40 stated [V13] sent [R132] to the hospital. Surveyor asked R40 to lift R40's left arm and noted R40 with limitation on range of motion. On 3/5/25 at 9:34 AM, interviewed V10 (Psychiatric Rehabilitation Services Coordinator/PRSC) about the incident that happened on 3/3/25 between R40 and R132. V10 stated, It was around 10:15 to 10:30 in the morning it happened at the nurses' station on the 5th floor. Front desk paged social service to go to the fifth floor. When I came up there they had the residents [R40, R132] separated already. [V13] and the [Certified Nursing Assistant] CNA (does not know her name) were there they witnessed the incident. [R40] was a little shaky she told me that [R132] pushed [R40]. [R132] was being disrespectful to [V13] and [R40] told [R132] to be more respectful and then [R132] got angry at [R40] and proceeded to pushing [R40] on the face. [R40] told me she fell and hurt her left shoulder and left elbow. [R132] was already in the room and [R40] was in the hallway sitting on the chair with [V13]. The nurse was assessing [R40]. [R40] said that she was okay but [R40] said she was hurting on her left shoulder and left elbow. [R40] did not want to go to the hospital. We kept them separated. After that I started the petition for [R132]. We removed [R132's] roommate from the room because [R132] was still agitated. V10 stated that physical abuse is when someone put their hands on somebody attempting to hurt them in a malicious way. V10 stated that what [R132] did to [R40] is a type of physical abuse. A follow up interview was conducted with V10 on 3/6/25 at 9:55 AM and stated that R132 had history of aggressive behavior prior to the incident with [R40]. On 3/6/25 at 9:29 AM, a phone interview was conducted with V13 (RN) about R40 and R132's incident on 3/3/25. V13 stated, It happened in the morning time. I was passing medication when it happened. [R132] came up to me and wanted me to stop to give her medications. I told [R132] that there is a line and people are in line waiting. [R132] started saying she will punch me on my face. [R40] tried to stop [R132] and told [R132], Oh no you can't talk to the nurse like that. Then [R132] slapped [R40] on the face and pushed her. [R40] fell on her back, I think on her left side. V13 stated she assessed [R40] with no injuries and did not complain of pain. V13 stated R40's doctor was notified but R40 did not want to go to the hospital. V13 stated R132 was sent to the hospital for psychotic behaviors. The facility's Abuse Prevention Program Facility Policy (no date) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental mends and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on observations, interviews, and record reviews, the facility failed to ensure a.) kitchen staff wearing appropriate hair covering, b.) hand washing was being done in between handling dirty and clean dishes/equipment, c.) food items were properly labeled and dated. These failures have the potential to affect all 175 residents receiving food prepared in the facility's kitchen. Findings include: On 03/04/25 at 9:10 AM, upon entering the kitchen to conduct initial kitchen tour observed V18 (Dietary Aide) working in the dish machine area by himself. A hairnet was covering his head however V18 had a full mustache that was not covered. V18's mustache was extending over his top lip. On 03/04/25 at 9:15 AM, V17 (Dietary Director) stated everyone who enters the kitchen must wear a hairnet to cover their hair on their head. V17 stated beard/mustache coverings do not need to be worn in the kitchen and that facial hair does not need to be covered, only the hair on someone's head needs to be covered. V17 stated the purpose of wearing a hairnet is to prevent hair from falling into the prepared food and served to the residents. On 03/04/25 at 12:00 PM, observed V18 working on the lunch tray line. V18 was still not wearing any hair protector to cover V18's mustache. On 03/04/25 at 12:10 PM, observed V21 (Dietary Aide) walking around the kitchen filling up water pitcher with ice from the ice machine only wearing a hairnet on his head. V21 had a mustache and beard which were not covered with a hair restraint. V21 stated he was never told or asked to cover his beard or mustache before. On 03/04/25 at 12:45 PM, observed V18 and V21 walking around the kitchen wearing face masks. On 03/04/25 at 01:10 PM, V17 stated when she pulled the policy on hair restraints it said that facial hair should be covered so she told the male staff to cover their beards/mustaches with a face mask until she can order beard protectors for them to wear. On 03/04/25 at 9:10 AM, observed V18 feeding dirty trays into the dish machine and then pulling the cleaned trays out of the dish machine without performing any hand hygiene in between handling the dirty and cleaned items. On 03/04/25 at 9:17 AM, observed V18 putting dirty plates into the dish machine and then removing the cleaned plates from the dish machine and stacking the plates in a pile. No hand hygiene was performed in between handling the dirty and cleaned items. On 03/04/25 at 9:20 AM, V17 stated the dish machine area typically has two people working in there with one staff scraping and feeding the dirty items into the dish machine and the other staff pulling out the cleaned items from the machine once they are cleaned. V17 observed V18 working in the dish room putting soiled items into the dish machine and pulling the cleaned items out of the dish machine without performing any hand hygiene. V17 stated after V18 feeds the dirty items into the dish machine he should be changing his gloves, washing his hands, and putting on new gloves before pulling the cleaned items out of the dish machine. V17 stated this is important because she does not want V18 transferring bacteria and other pathogens from his dirty gloves or hands to the cleaned items. V17 stated this could potentially make the residents sick and proper hand hygiene is important for infection control to minimize potential illness which could spread throughout the facility. On 03/04/25 at 9:25 AM, V17 stated any prepared or opened food should be wrapped in plastic and a sticker should be added which has the prepared/opened date and use by date/expiration date of the product and stored in the refrigerator. V17 stated prepared items should be used within three days; all other items used within seven days except for condiment items which are good for 30 days. V17 stated it is important to label and date the items with open and use by dates so that the staff knows if an item(s) is safe to use. V17 stated if the item is opened but not labeled with an open/use by date then the staff would not be able to know who long the item has been in the refrigerator. On 03/04/25 at 9:27 AM, in Prep Refrigerator observed the following: 1.) Opened one-gallon Italian Dressing delivered 02/01/25. There was no open or use by date on the product. 2.) Opened 46-ounce container of Thickened Apple Juice from Concentrated Moderately Thick with no opened or use by date on it. On 03/04/25 at 9:32 AM, in Walk-In Refrigerator observed the following: 1.) Opened plastic bag of Shredded Cheddar and Monterey [NAME] Cheese wrapped in plastic. Not labeled with an open or use by date. 2.) Opened five-pound Sliced American Yellow Cheese wrapped in plastic. Not labeled with an open or use by date. 3.) Container of prepared chili like material covered in tin foil. Not labeled with an open or use by date. 4.) Container of diced tomatoes with a label documenting a preparation date 02/03/25 and a use by date 02/10/25. On 03/04/25, facility provided list of diet orders for all residents in the facility. The diet order list indicates there are not any residents nothing by mouth (NPO). Facility provide policy titled, Hair Restraints/Jewelry/Nail Polish/False Eyelashes dated 2017 documents in part, food and nutrition service employees shall wear hair restraints and beard guards and hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated. Facility provided policy titled, Dish Room Safe Food Handling dated 2017 documents in part, potential for cross-contamination is prevented in the Dish Room and the task of loading the dirty dishes and utensils into the dishwashing machine is handled by one person. The task of removing the clean dishes and utensils from the dishwashing machine is handled by a different person. If there is only one person working in the dish room, the person will remove their gloves, wash their hands and put on fresh gloves whenever they cross over to the clean side of the dishwashing machine to unload the sanitized dishes and utensils. Facility provide policy titled Labeling and Dating Food documents in part, foods prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality of product for the residents and minimize waste and foods prepared on the premises to be held cold will be labeled with the date of preparation and this food will also be labeled with the date to discard or use by date. The discard/use by date will be a maximum of 6 days after preparation.

Based on observation, interview and record review, the facility failed to follow their linen handling policy and procedure to ensure soiled linens are properly placed inside closed plastic bags with no loose items. This failure has the potential to affect all 175 residents residing in the facility reviewed for infection control. Findings Include: On 3/5/25 at 1:46 PM, Surveyor inspected the facility's laundry chute with V30 (Laundry Aide). When V30 opened the laundry chute, loose soiled and dirty incontinence pads, towels, and bed sheets were found that were not inside a plastic bag. V30 stated that staff should be bagging dirty soiled linens and clothing before dropping them in the laundry chute. V30 stated it's not sanitary to drop them in the chute without properly bagging them. On 3/5/25 at 1:54 PM, V2 (Director of Nursing/Infection Preventionist) stated that staff should properly place dirty and soiled linens inside a plastic bag and make sure the bag is securely closed before dropping them in the laundry chute to keep from spreading bacteria. V2 stated that if soiled dirty linens are not properly bagged, biohazard materials could get on things that it should not get on. It could contaminate other things that would negatively affect the staff and residents. The facility's LINEN AND LAUNDRY HANDLING FOR LAUNDRY DEPT policy dated 10/14 documents in part: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganisms. Every effort will be made to ensure that soiled articles do not come into contact with the floor, uniforms, furniture, or other areas deemed clean. Soiled linens shall be placed in plastic bags by nursing personnel. The facility's residents' roster printed on 3/4/25 shows a total of 175 residents residing in the facility.

Based on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of 4 residents reviewed for physical abuse. This failure resulted in R2 physically attacking R1, resulting in R1 bleeding from an abrasion R1 sustained under the left eye and R1 being transferred to the hospital for evaluation and treatment. Findings include: Facility's Final Investigation Report (dated 02/03/2025) documents in part: On 01/27/2025, the facility administrator was notified by a facility nurse that resident R2 was physically aggressive towards resident R1. R1 was noted to have an abrasion under her left eye for which care was provided by her assigned nurse. Both residents' representatives were notified of the reported incident along with the resident's physician and the police. R2 refused to be interviewed and left the facility against medical advice. R1 was interviewed and stated that R2 has become verbally and physically aggressive towards her for no reason. R1 stated that R2 struck and grabbed her prior to pushing her out of their shared room. R1 was sent to the hospital for safety precautions. Abuse Prevention Program Facility Policy (dated 2011) documents in part. The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property corporal punishment and involuntary seclusion. This will be done by identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identifying reports of possible abuse. R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic obstructive pulmonary disease with (acute) exacerbation, heart failure, hypotension, insomnia, shortness of breath, abdominal distension (gaseous). Minimum Data Set Section (MDS) section C (dated Jan. 1, 2025) documents that R1 has a Interview for Mental Status (BIMS) score of 14, indicating that R1's cognition is intact. Care plan (dated 12/18/2024) documents that R1 is at risk for alteration in comfort related to advanced disease process, chronic physical disability. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: schizoaffective disorder, bipolar type, unspecified psychosis not due to a substance or known physiological condition, anemia, bipolar disorder, altered mental status. Minimum Data Set Section C (dated Dec. 12, 2024) documents that R2's Brief Interview for Mental Status (BIMS) score is 14, indicating that R2's cognition is intact. Care plan (dated 01/14/2025) documents that R2 displays behavioral symptoms related to: Severe mental illness, poor and/or ineffective coping skills. These behavioral symptoms are manifested by verbal abuse/aggression, and disturbed sense of entitlement. On 02/06/2025, at 10:13 AM, V1 (administrator) stated, On 01/27/2025, it was reported to me that there was a loud commotion coming from R1 and R2's room. R1 and R2 were roommates at the time. V3 (registered nurse) went down the hallway to see what was going on. He explained to me that he saw R2 throw/push R1 from their bedroom into the hallway. V3 immediately intervened and escorted R1 to the nurse's station. V3 called the nursing supervisor and the nursing supervisor called me. We called the family; the physician and we called the police. The nursing supervisor went to speak to R2. R2 was informed that the police were called. R2 was notified that she would be petitioned and sent out to the hospital. R2 said that she refused to be sent to the hospital. R2 signed herself out against medical advice and left the facility. R1 said that R2 attacked R1 for no reason. V3 said that it appeared like R2 was going through some psychosis issues because R2 was acting bizarre and making weird statements that did not make sense. This could be the possible reason why she attacked R1. R1 had an abrasion under her eye. R1 said that R2 hit her, grabbed her and pushed her out of the room. R1 was kept safe away from R2. R1 was sent out to the hospital because she had an abrasion under her eye, and we were not sure if R2 hit R1 on the head. R1 is frail and R2 was of bigger frame, so that was an advantage over R1. On 02/06/2025, at 11:31 AM, during an interview with R1, surveyor observed an abrasion under R1's left eye, which appeared to be healing. R1 stated, On 01/27/2025, R2 was my roommate at the time. I was sitting on my bed, watching tv and doing puzzles. R2 said to me, B**** it's my room get out. Then R2 started attacking me. R2 started hitting me on my face and on my head and pulled my hair. R2 was beating me, and I fell to the floor. Then R2 grabbed me by my hair and called me names. R2 pulled me into the hallway by my hair. R2 went back into the room and slammed the door. The nurse came and asked me what happened. The nurse went into the room to talk to R2. The nurse gave me gauze to wipe my face and the nurse took me to the nursing station and called the social worker. My family, the physician and the police were notified. I was sent to the hospital because I was bleeding. I had a cut under my eye. I was examined in the hospital, and I received a tetanus shot just in case due to the scratches. R2 attacked me for absolutely no reason. I never provoked R2 in any way. R2 and I never had any issues in the past prior to the physical attack. I want to press charges against R2 but she left before the police came and now they cannot find her. On 02/06/2025, at 2:39 PM, V3 (registered nurse) stated, On 01/27/2025, R2 came and told me that she wanted to change rooms because she did not like her roommate. When I asked R2 what her issue was with her roommate, R2 said that she did not have to explain herself to me. I told her that social services handled room changes and since it was still relatively early, she can still talk to social services. R2 did not want to do that and said to me, What if I go in there and beat the woman up. I told her that she should not do that because then I would have to call the police. She left to go to her room, and she came back a short while later and called her mom. R2 started to complain to her mom that she was mad at her roommate and that she was going to do something to her roommate. R2 slammed the phone and went to her room and started knocking things down to the floor on her way to her room. I figured that she was going to do something to her roommate because R2 was upset. I got on the phone with social services to let them know that there is an incident possibly brewing and that the social worker needed to come up. In the middle of that phone call, I heard yelling and commotion in R1 and R2's room. I went to the room, and I saw R2 tossing R1 out of the room. R2 tossed R1 into the hallway with a lot of force, holding R1 by her pants. I separated R1 and R2 by getting in between them. Social services came up also and I took R1 by the nursing station. I tended to R1's laceration under her left eye because it was bleeding. R2 left against medical advice from the facility before the police got there. R1 was sent to the hospital for evaluation for the laceration under her eye. R1's Progress Note (dated 01/27/2025) documents, While on the phone with social services at start of this incident. Writer heard yelling coming from the residents' room. Writer went to the room and saw R1's roommate holding her by her hair and back of her pants tossing her out into the hallway. Writer stood between the two residents to prevent further assault until social services arrived. Residents separated; vitals taken. R1 stated she did not hit her head. A small 1 centimeter laceration was noted under the left eye. Writer dressed the wound with gauze. There was minor bleeding. R1 was medicated with Tylenol for pain. R1's Progress Note (dated 01/28/2025) documents, Received report from nurse at community hospital. CT scan done, no fracture. Laceration treated. Awaiting to transport resident back to facility. R1's Progress Note (dated 01/28/2025) documents, Resident has a laceration to left eyebrow, resident will receive wound care. Physician notified; new orders carried out. R2's Progress Note (dated 01/27/2025) documents, R2 came to nursing station complaining that she wanted a new room because she did not like her roommate. Writer informed her that social services handled all room changes and she could consult with them as they had not left for the day. She got increasingly upset and wanted something done now. Writer asked the resident what the issue was. R2 stated I don't have to explain anything to you. Writer informed her again that social services can help her. She then stated; What if I just go beat her a**. Writer informed the resident that would be a bad idea because of the possibility of police involvement and expulsion from the facility. R2 came back to nursing station and called her mother telling her that she was going to attack her roommate. She began pushing items off the counter and knocking CNA's (Certiified Nursing Assistant) belongings on the floor on her way back to her room. Writer called social services to inform them of the situation and impending issue. While on the phone with social services, writer heard yelling and items falling coming from residents' room. Writer went to room and saw R2 holding her roommate by her hair and back of her pants tossing her out into the hallway. Writer stood between the two residents to prevent further assault until social services arrived. The residents were then separated. R2 was in the care of social services. R2 chose to sign out AMA (Against Medical Advice). Family stated to call her when R2 returns. Received police report number. Resident gone when Chicago Police Department & EMS Arrived. R1's emergency room Patient Discharge Summary (dated 01/28/2025) documents in part: Chief complaint/diagnosis: Assault. Discharge diagnoses: Acute head trauma/ Acute knee pain.

Based on interview and record review, the facility failed to protect one resident (R1) out of 9 from physical abuse. This failure affected R1 who was pushed in the elevator by R8. As a result, R1 had an unwitnessed fall, R1 was sent to a local hospital. R1 sustained a left lateral tibial plateau fracture approximately 1mm (One millimeter) depression and small joint effusion. Findings include: R1's medical record Admission record showed documentation that R1 was originally admitted to the facility on [DATE] with latest recorded admitted [DATE]. Listed diagnosis includes but not limited to Displaced fracture of lateral condyle of the left tibia, subsequent encounter to closed fracture with routine healing, type 2 diabetes mellitus without complications, muscle weakness (Generalized), paranoid schizophrenia, depression, unspecified fracture of shaft of left fibula initial encounter for closed fracture. R8's medical record Admission Record showed that R8 original admitted as 08/22/2023 and latest admitted [DATE] with diagnosis list that includes but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. Aphasia, weakness, unspecified abnormal of gait and mobility, furuncle of neck, restlessness, and agitation. On 12/16/24 at 11:45am R1 noted on the 1st floor of the facility ambulating around with a sit to stand roller walker. R1 was able to communicate in English as a second language. R1 was able to remember about what happened on 09/30/24 stating that one man pushed R1. R1 stated that I was next to the wall in the elevator (indicating that there was no other space to move in the elevator). R1 stated the man pushed R1 to the floor (Fall to the floor) and broke R1 leg. According to the facility Preliminary Incident Investigation Report dated 09/30/24. V1 (Administrator) documented that he (V1) was notified by a facility nurse that (R8) was physically aggressive towards (R1) in the elevator on the 4th floor. Both residents were checked for injuries. R1 was noted to have pain in the left knee. R1 was sent to the (hospital) for evaluation. V1 documented that R8 forcefully rolled into the elevator hitting R1 in the legs causing R1 to fall. R8 was interviewed and R8 stated that R1 would not let (R8) into the elevator and hit (R8). R8 stated R1 fell on (R1)'s own. V1 documented that (V10 Nurse) was interviewed and stated she did not see the altercation but heard yelling. V10 walked to the elevator and saw R1 on the ground complaining of knee pain. V1 documented that both resident (R1 and R8) files (medical Record) were reviewed. R1 was noted to have history of verbal aggression and R8 was noted to have history of verbal and physical aggressiveness. The report documentation showed that the local law enforcement (police) and both residents' physician was notified. Recording the incident as a simple battery. R1's hospital record dated 09/30/24 documented that R1's reason for visit patient (R1) here for L (left) knee pain s/p (status post) fall from wheelchair in the elevator 2 hrs PTA (Prior to Arrival) per patient (R1). R1's hospital record presented showed documentation that CT (Computer Tomography) left knee without contrast showed that R1 had lateral tibial plateau fracture approximately 1mm (One millimeter) depression and small joint effusion. On 12/17/24 at 10:00 am, when the surveyor asked about the conclusion of the incident of the incident of 09/30/24 and if this incident can be a form of abuse. V1 (Administrator) stated that yes, it is an abuse, I will consider that to be abuse. V1 stated that due to R8's history of being verbally and physically aggressive towards peers R8 was sent to the hospital for psych-eval and has not returned to the facility. On 12/17/24 at 10:08 am V2 DON (Director of Nurse's) who was present at this time stated it is a form of abuse because R8 pushed R1. On 12/17/24 at 12:38 pm, V10 (Licensed Practical Nurse) who identified self as the nurse in charge on the 4th floor at the time of incident on 09/30/24. V10 stated that Yes, I was passing meds (Medicines) on the 4th floor when I heard some noise between residents on the 4th floor elevator. I (V10) went to see what was happening. I (V10) saw (R1) on the floor in the elevator lying down on the floor inside the elevator. (R8) was in-between the entrance of the elevator, the elevator could not close. I (V10) asked what happened and R1 said R8 pushed her. So, I called the front desk (receptionist) to call social services and V1 (Administrator). After that I (V10) assessed R1 who was having lots of pain to the legs. I (V10) could not remember which leg, but I think is the left leg, I called 911 (emergency number). I (V10) called the guardian and R1 was sent to the hospital, R8 was also sent to the (local hospital) for psych-evaluation. The surveyor asked V10 in your professional opinion can this incident on 09/30/24 be considered a form of abuse, V10 stated Yes. On 12/18/24 at 12:07pm, V3 NP (Nurse Practitioner) stated that R1 had a fracture of the tibia. V3 stated in part that after the unwitnessed fall (R1) was complaining of left knee pain, so V3 sent R1 out (to the hospital). When asked whether in V3 medical professional opinion if R1's fracture occur due to the fall. V3 stated I do believe so. R1's falls/accident care plan initiated on 10/13/2028 and revision date 07/12/2022 showed that R1 is at high risk for fall. Goal documented that R1 will not sustain injury throughout the review date. Initiated date 10/13/2018, revision date 11/21/2024 and target date 02/05/2025. R1's MDS (Minimum Data Set) dated 11/07/2024 showed that R1 has a BIMS (Brief Interview for Mental Status) Score of 04. R8's plan of care initiated 03/26/2024 with revision date 04/01/2024 showed a focus documentation that R8 has history of being physically aggressive toward others when angry and due to poor impulse control. Goal is that R8 will not harm self or others through the review date initiated 04/01/2024, revised date 06/20/2024 and target date 12/29/24. The interventions listed includes but not limited to assisting verbalization of source of agitation and seeking out of staff member when agitated. R8's MDS (Minimum Data Set) dated 09/23/2024 showed that R8 has a BIMS (Brief Interview for Mental Status) Score of 11. The facility Abuse Prevention Program policy presented documented in part that the facility affirms the right of our residents to be free from abuse. this facility therefore prohibits mistreatment, neglect, or abuse of its residents. The facility is committed to protecting our residents from abuse by anyone including, but not limited to another resident. The policy documented in part that abuse means/ includes any physical injury or mental injury. Abuse is willful infliction of injury. Physical abuse is infliction of injury on a resident that occurs other than by accidental means.

Based on interview and record review, the facility failed to ensure that a resident was free from physical abuse. This failure affected R3 who was physically punched and pushed by R8, causing R3 to fall and sustained a left hip fracture and right finger fracture that required emergency transfer to the trauma hospital with surgical repair of the left hip fracture and right finger fracture when reviewed for physical abuse in the sample of 4 residents (R3, R6, R7 and R9). Findings include: On 4/16/24 at 11:22 am, R3 stated that a while back, R3 broke R3's hip and that it was hurt real bad. When asked about the hip fracture, R3 stated that R3 was hit by R8 when R8 knocked the h*** out of R3. R3 confirmed with this surveyor that this occurred on 4/10/2020. R3 stated that it was on R3 and R8's floor, down the hallway by the entryway to the stairs, and that R3 was not bothering anyone. R3 stated that R8 punched R3 first and that R3 then tried to stop R8 from hitting R3 again when R3 fell to the floor, saying down I (R3) went. R3 stated that staff came to break it up and that R3 had immediate pain on R3's left hip and right hand. R3 stated that R3 went to the hospital and had surgery on R3's left hip. R3's Admission Record, documents, in part, diagnoses of seizures, mild protein-calorie malnutrition, schizoaffective disorder, major depressive disorder, dysphagia, pain in right hip, hypokalemia, fracture of part of left femur neck, displaced fracture of base of 5th metacarpal bone of R hand and paranoid schizophrenia. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 11 which indicates that R3 has moderate cognitive impairment. R3's MDS, dated [DATE], documents, in part, a BIMS score of 12 which indicates that R3 has moderate cognitive impairment. On 4/17/24 at 2:42 pm, V20 (Former Employee, Licensed Practical Nurse, LPN) stated that V20 worked in facility through 2021 and does remember R3 and R8's physical altercation on 4/10/2020. V20 stated that V20 was at the nurse's station which was at the other end of the hallway, and V20 responded immediately to R3 and R8's altercation and observed R3 on the floor. V20 stated that R3 was trying to get up from the floor but could not move due to the pain. V20 stated that other staff, including V19 (Certified Nursing Assistant, CNA) were present separating R8 from R3. V20 stated that R3 was complaining of pain to R3' left hip and right hand. V20 performed assessment, vital signs and that V20 called 911 for R3's emergent transfer to the hospital. V20 stated that V20 assessed R8 too, and R8 informed V20 that there was another resident, R13, who R3 was talking to in the hallway, and that R8 punched (R3) and knocked (R3) down to the ground. V20 stated that both R3 and R8 were both liking (R13). In R3's Progress Note, dated 4/10/2020 at 2:44 pm, V20 (LPN) documents, in part, that R3 and R8 were involved in a physical altercation in the hallway, and that V20 assessed (R3), laying on the floor, complaining of right hand and left hip pain with physician orders to send R3 via 911 to the hospital. In R3's Progress Note, dated 4/10/2020 at 3:09 pm, V20 (LPN) documents, in part, that V20 was informed by hospital staff that R3 was being transferred to a trauma hospital due to R3's left hip fracture and right pinky fracture. R3's trauma hospital records, document, in part, that on 4/14/2020, R3 has surgical repair of R3's left hip fracture (hemiarthroplasty pinning surgery) and R3's right 5th metacarpal fracture (closed reduction and external fixation pinning surgery). Hospital records document, in part, that R3's fractures are result of a physical altercation with R3 being assaulted in the facility by another resident (R8), and that R3 stated that R8 started the physical altercation. R8's Admission Record, documents, in part, diagnoses paranoid schizophrenia, hyperlipidemia, dysarthria, hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, osteoarthritis, insomnia, bipolar disorder, abnormal posture, obstructive and reflux uropathy, chronic obstructive pulmonary disease, acute sinusitis, drug induced subacute dyskinesia, and flaccid neuropathic bladder. R8's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R8 is cognitively intact. R8's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors, dated 3/9/2020, documents, in part that R8 has a history of presence of dysfunctional behavior (e.g. {for example} provoking, aggressive, manipulative, derogatory, disrespectful, obnoxious, abhorrent, insensitive, attention-seeking, and/or otherwise abrasive/inappropriate behavior) including roaming/wandering into peer's room/personal space. R8's Census documents, in part, that R8 was discharged from the facility on 11/7/2022 and was not able to be interviewed. In R8's Progress Note, dated 4/10/2020 at 2:35 pm, V20 (LPN) documented, in part, that (R8) was in a physical altercation with peer (R3) in the hallways, (R8) stated 'peer (R3) was talking to R8's lady (R13) friend'. On 4/17/24 at 11:04 am, V19 (CNA) stated that V19 was routinely working on R3 and R8's floor in 2020 and does remember a physical altercation between R3 and R8 with V20 being the nurse on 4/10/2020. V19 stated that R8 used to walk around the floor, was difficult to redirect and didn't want to take no for an answer. V19 stated that on 4/10/2020, V19 responded to R3 and R8's physical altercation at the end of the hallway (by the stairwell) with R3 on the floor. V19 stated that V19 was unsure if R3 lost R3's balance, and that V19 broke it up between R3 and R8. V19 stated that R8 did have a friend (R13) that R8 was always around and R13's room location was in the hallway area where R3 and R8 had a physical altercation. Facility roster, dated 4/10/2020, and R3 and R8's Census reports document that R3, R8 and R13 were all residing on the same floor on 4/10/2020. R13's Admission Record documents, in part, that R13 was discharged from the facility on 10/22/2020. On 4/17/24 at 2:42 pm, V20 (Former Employee, LPN) stated that V20 worked in facility through 2021, and that V20 does recall R3 and R8's physical altercation on 4/10/2020. V20 stated that V20 was at the nurse's station at the other end of the hallway. V20 stated that V20 responded immediately and observed R3 on the floor and was trying to get up from the floor but could not due to pain. V20 stated that other staff were present separating R8 from R3. V20 stated that R3 was complaining of pain to left hip and right hand. V20 performed assessment, vital signs and that V20 called 911 for R3's transfer to the hospital. V20 stated that R8 informed V20 that there was another resident, R13 (whose room was the first room down that hallway, next to R8's room), who R3 was talking to in the hallway, and that R8 punched (R3) and knocked (R3) down to the ground. V20 stated that both R3 and R8 were both liking (R13). On 4/18/24 at 11:07 am, when asked if a resident has the right to be free from physical abuse, V2 (Director of Nursing, DON) stated, Absolutely. V2 stated that facility staff prevent physical abuse from happening by monitoring residents and intervening and separating when residents before it escalates into a physical altercation. On 4/18/24 at 1:14 pm, V1 (Administrator) stated that V1 is the abuse coordinator for the facility. When asked about residents admitted to and residing in the facility, how are staff ensuring that residents are not being abused, and V1 stated, It's harm and safety. We make sure that residents are safe. That their rights are not violated. That they are not harmed. That they are getting care. And not getting beat up. In R3/R8's physical abuse report to the state agency, dated 4/10/2020, V16 (Former Administrator) documents, in part, that V20 reported that (R8) allegedly punched and pushed (R3) down to the floor while passing in the hallway with resident injuries or complaints of injury as (R3) complains of right hand pain and left hip pain. Facility policy, date 2011 and titled Abuse Prevention Program Facility Policy, documents, in part, Policy: This facility affirms the right of our residents to be free from abuse . This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment . The facility is committed to protecting our residents from abuse by anyone including, but not limited to, . other residents . Definitions: . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention . Physical abuse includes hitting, slapping, pinching, kicking.

Based on observation, interview, and record review the facility failed to ensure that adequate supervision was provided for five of five residents (R15, R16, R17, R18, and R19) reviewed for supervision in the sample. This failure affected R15 who had a fall with injury laceration to the right side of the head and was sent to hospital emergency room where R15 received seven staples for laceration closure. This also affected R16 who was noted in the shower room without any supervision and R17, R18 and R19 who were observed in the dining room during lunch time without supervision. This has potential to affect all the resident on the 2nd and 4th floor of the facility. Findings include: On 02/15/24 at 10:05am, R15 was observed in bed with 7 (Seven) staples noted on the right side of the head. When the surveyor asked R15 what happen to R15's head. R15 stated that I (R15) fell in the shower, and I went to the hospital. R15 stated I was in pain, and it hurts bad. R15 stated on a scale of one to ten the pain was at 10. R15 stated they give me (R15) something for pain. R15 stated it still hurts now. R15 stated that there was no one (Referring to staff) to help me, R15 stated I was shouting for help, but no one came. R15's medical record Admission Record showed that R15 was admitted to the facility on [DATE] with listed diagnosis that includes Schizophrenia, Unspecified, Acute Kidney Failure, Adjustment disorder with mixed anxiety and depressed mood, Bradycardia, and Vitamin D deficiency. On 02/09/24 had unwitnessed fall and was sent to the medical center. R15's MDS (Minimum Data Set) facility assessment tool used in assessing facility resident showed R15 a score of 09 indicating that R15 is moderately cognitively impaired. According to facility investigation report, V24 CNA (Certified Nurse's Aide) statement dated 02/09/24 documented that I (V24) took (R15) in the shower room and told him to wait until I come back. I told the other CNA identified by V2 DON (Director of Nurses) as V26 that R15 was in the shower room. V24 stated that when she came back R15 told her that R15 had a fall. On 02/15/24 at 10:15am, V7 (MDS / Care plan coordinator) who identified self as the 4th floor supervisor stated that there are call light in the rooms and she will have to refer to V1 (Administrator) to share whether the shower room call light should be functional (In working condition). V5 LPN (Licensed Practical Nurse) stated that call light should be always placed within resident reach when in the room. V7 also stated that a staff member should be present when resident is in the shower room to monitor and supervise for safety reasons. On 02/15/24 at 1:00pm, R17, R18 and R19 were observed in on the 2nd floor dining room eating with no staff supervision. R18 was observed trying to move the food plate so R18 can reach it. When this observation was brought to V18 CNA's attention and was asked about the facility protocol /policy on dining supervision. V18 who came into the dining area stated there should be a CNA assigned to monitor the dining room. V18 stated that R17 and R18 looking on their tray are on puree diet and should be monitored because they (referring to R17 and R18) can shock, they have problem in swallowing. At 1:12pm, V27 RN (Registered Nurse) stated that the dining room should be monitored by the staff they are not supposed to be left by them self while eating, R17 and R18 are on puree diet and should be monitored by the (CNAs) because they are at high risk for aspiration. At 1:41pm, V2 DON (Director of Nurses) stated whenever the resident is still eating in the dining room they should be monitored by staff and any staff can monitored. When asked specifically about monitoring or supervising for resident on mechanical diet puree diet. V2 stated the nursing staff should monitor. R17's medical record admission record listed diagnosis includes but not limited to Anemia unspecified, Dysphagia, oropharyngeal phase, abnormal posture, weakness, and Extrapyramidal movement disorder. R18's medical record admission record listed diagnosis that includes but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, moderate protein-calorie malnutrition, chronic obstruction pulmonary disease unspecified, Type 2 diabetes mellitus without complications, acute respiratory failure with hypoxia, dysphagia following cerebral infarction, gastrostomy status and bell's palsy. R19 medical record admission record listed diagnosis that includes but not limited to Epilepsy, abnormal reflex, obesity, major depressive disorder, schizophrenia, hypothyroidism, unspecified psychosis not due to substance or known physiological condition and other intervertebral disc displacement lumbar region. On 02/15/24 at 10:10am, V8 (Housekeeping) staff who was cleaning the opposite room to the shower room was asked to observe with the surveyor the functionality of the call light system in the shower room. R16 was noted in the shower room without any staff monitoring or supervising the shower area or the room. V8 stated the CNAs are the staff who monitors during shower. At 10:14am, V22 (CNA) who identified self as CNA who was supposed to monitor the residents during shower was made aware of the observation and was asked about the facility policy on supervision during shower stated that the residents are to be monitored closely so the no one (referring to staff or other resident) can go in the shower room for safety of the resident because we don't know what can happen (referring to fall incident or abuse). V22 stated in part that she is the only one on the floor and was checking on other resident's needs. R15's fall care plan focus initiated 05/02/23 with revision date of 05/11/2023 documented that R15 is at risk for fall / accidents related to medical complexities, psychotropic medications. Goal indicated that (R15) will not sustain serious injury throughout the review date. Interventions listed includes but not limited to be sure that the resident (R15) call light is within reach. R15's actual fall plan of care with revision date 02/08/24, listed interventions include resident (R15) instructed to use call light when feeling dizzy. Added intervention dated 02/09/24 documented that R15 instructed on importance of not trying to shower without assistance. On 02/20/24 at 12:25pm, V26 confirmed that V24 made her aware that R15 was in the shower room but was sitting in the middle of the hallway documenting and was not aware that R15 fell . V26 stated she did not hear any sound to indicate that R15 had a fall until few minutes later when V24 called her to inform her that R15 fell and was bleeding. When asked about the facility protocol on monitoring or supervision when in the shower room. V26 stated that she was busy doing her own work documenting. Showing that R15 was not monitored or supervised before V24 returned to the shower room. V26 stated R15 was noted bleeding from the side of the head. On 02/20/24 at 1:45pm, V25 NP (Nurse Practitioner) stated in part that she was paged to the 4th floor after the incident, and she examined R15. V25 stated R15 had approximately three (3) inches of laceration to the right side of the head and because R15 stated that (R15) hit the head on the floor and there was a laceration she ordered for R15 to be sent to the hospital for further examination because there is a possibility of other things going on. V25 stated that there was no loss of consciousness reported to her. V25 stated that on 02/11/24 at around 1pm she examined R15 upon return to the facility and there was 7staples applied for closure of the laceration. V25 stated the site is being monitored for swelling, redness and there is no special treatment dressing. V25 stated the staples will be removed in 7 to 14 days. The facility policy on Supervision and Safety dated 3/15 documented in part that the policy strives to make environment as free from hazards as possible, resident safety and supervision are facility-wide priorities. Resident supervision is a core component to resident safety. Staff to decrease safety risk factors as much as possible. The facility Job Description for Maintenance director presented documented in part that the maintenance director is responsible for the day-to -day activities maintenance department in accordance with current Federal, stated, and local standards guidelines and regulations governing the facility and maintained a clean, safe, and comfortable manner. Essential duties listed includes but not limited to maintains the building in good repair, maintain the building and grounds in compliance with federal, state, local, and joint commissions laws and standards. The facility LPN (Licensed Practical Nurses) Job Description presented documented in part that the primary purpose of the job is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the nursing assistants in accordance with current federal, state, and local standards.

Based on interview and record review, the facility failed to prevent resident to resident abuse and resident to employee. This failure affected two (R2, R1) residents in a sample of three residents reviewed for abuse. This failure resulted in (R4) with known aggressions striking (R2) in the face causing inury. This failure resulted in R1 being verbally and mentally abused by V3(former cook). Findings include: 1. R2 and R4 are no longer in the facility and were reviewed as closed records. R2's electronic medical record documents that R2 was discharged to the hospital on 10/05/2023 and has not returned back to the facility. R4's electronic medical record documents that R4 was discharged from the facility on 10/02/2023 and has not returned back to the facility. On 10/24/2023 at 12:57PM, V4 (Registered Nurse) stated she started her shift at 11pm on 09/27/2023, the date of the incident between R2 and R4. V4 stated another resident wandered into R4's room and R4 was upset about that. V4 stated that R2 informed her that R2 wanted some water from the dispenser in the hallway on the 4th floor, which was close to R4's room at the time. V4 stated that R2 usually spills water everywhere when R2 tries to get water by himself so V4 went to assist R2. V4 stated that she and R2 were located at the water dispenser and R4 came out of his room and reached over V4 and punched R2 in the face. V4 stated that R4 did not say any words and believed that R4 was responding to internal stimuli. V4 separated R2 and R4 and another staff member assisted R4 to his room. V4 stated she gave R2 first aid for a nose bleed and there was a small amount of blood and took 5 minutes to stop the bleeding. V4 stated that upon her assessment, R2 did not have any nasal swelling and R2's nose did not appear broken. V4 stated she called her supervisor and called 911 to make a report. V4 stated the police came to the facility in less than 10 minutes. The ambulance also arrived and R2 went out to the local hospital to be evaluated and R2 returned to the facility later that night. V4 stated R4 also went out to the hospital. V4 stated she also called the medical director and got the order to send R4 out to the hospital to have a psychiatric evaluation. V4 stated that R4 has a history of being physically aggressive. On 10/26/2023 at 9:27am, V1 (Administrator) stated he is the abuse coordinator, and a staff member called him and informed him that R4 was aggressive towards R2. V1 stated he informed the staff member to separate R2 and R4 and call the doctor to petition to get R4 out to have a psychiatric evaluation. V1 stated R2 was also sent to the local hospital to be medically evaluated. V1 stated R4 has a history of violence towards peers and staff. V1 stated that it was a danger to residents for R4 to continue to be in the facility due to R4's history of physically aggression. V1 stated he witnessed via video the physical abuse that took place between R2 and R4. V1 stated that upon viewing the video himself, he saw that R4 hit R2, unprovoked. R2s' Facesheet documents that R2 has diagnoses not limited to: Schizoaffective disorder, hypothyroidism, epilepsy, alcohol abuse, depression, insomnia, borderline personality disorder, and anxiety disorder. R2's Minimum Data Set/MDS dated [DATE], R2 has a BIMS/Brief Interview for Mental Status of 05, indicating that R2 is cognitively impaired. R2 requires independence with ADL/Activities of Daily Living care. R2 is continent of bowel and bladder, and ambulates via walking. Care plan dated 10/12/2023 documents that R2 is care planned for psychotropic medication, alterations in comfort, risk for metabolic dysfunction, risk for injury, self-care deficit, risk for abuse, mood and anxiety disorder. R2s' care plan states R2 will be treated with respect, dignity, and reside in the facility free of mistreatment (i.e., abuse/neglect) (on-going). R4s' Facesheet documents that R4 has diagnoses not limited to: cognitive communication deficit, schizoaffective disorder, mood disorder with depressive features, paranoid schizophrenia, unspecified psychosis, insomnia, violent behavior, and epilepsy. R4's MDS dated [DATE] documents that R4 has a BIMS of 06, indicating that R4 is cognitively impaired. R4 requires supervision and set-up and one-person physical assist with ADL care. R4 ambulates via walker and is continent of bowel and has an indwelling urinary catheter for bladder incontinence. R4s' care plan dated 07/26/2023 documents that R4 is care planned for physical aggression, risk for injury, risk for altered cardiac function, psychotropic medications, risk for falls, threatening and violent behaviors, severe mental illness, and risk for abuse. R4s' progress notes dated 09/27/2023 reviewed and documents that R4 was physically aggressive towards his peer (identified as R2) and R4 was transferred to a hospital for psychiatric evaluation. Progress notes written by V4 (RN) on 09/27/2023 documents in part, At 01:25, R4 was agitated and became physically aggressive towards peer (R2) punching R2 in the face while R2 was getting water from the water dispenser. Residents were separated. MD, police and administrator notified. Order given to send R4 out to hospital for psychiatric evaluation. ETA for ambulance is between 7-8am. Police report received from Officers, Beat 1522, RD#JG440-661. R4s' care plan states R4 has a history of displaying physical aggression towards his peers. The history includes: threatening behavior, verbal or physical aggression. R4 has been given an IVD (involuntary discharge) due to R4's recent aggressive behavior towards a peer. Facility Reported Incident dated 09/27/2023 documents in part that V4 (RN) witnessed R4 walk up to R2 and hit R2 in the face for no known reason. R2 sustained a bloody nose as a result of R4 hitting R2 in the face. Police report dated 09/27/2023 documents an incident of battery with report # JG440-661. Facility policy, dated 2011, titled Abuse Prevention Program Facility Policy documents in part, This facility affirms the right of our residents to be free from abuse .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 45111 2. On 10/24/2023 at 1:47pm, R1 said on that day (09/18/2023) during dinner, she did not get her dinner tray and she informed staff (No name provided) about it. R1 said and she was told it wase better for her to go to the kitchen to get her food, so that she can tell the kitchen staff what she wanted. R1 said she went and got V9(Psychiatric Rehabilitation Services Coordinator -PRSC) to take her to the kitchen. R1 said they found V3(Former Cook) in the kitchen and V9 asked her for R1's dinner tray. R1 stated V3 said she would not get R1 any food tray, and if it was up to V3, she would feed R1 cat food than give R1 a sandwich R1. R1 said V9 asked V3 what she (V3) had said, and V3 repeated that she would feed R1 cat food if it was up to her, then give R1 a sandwich. R1 said she and V9 left the kitchen without saying anything, and R1 said she felt hurt, disrespected, and she felt like a nobody, and felt like she was being treated like a child. R1 said she would not eat anything from the kitchen if V3 was still in the kitchen because she was scared V3 might feed her some bad food. R1 said she did not eat that night because she feared something bad might be put in her food. R1 said went and got a bag of potatoes to eat for dinner. R1 said she slept very upset, and she was hungry. On 10/25/2023 at 10:53am V9(Psychiatric Rehabilitation Services Coordinator -PRSC) said stated 09/18/2023, she took R1 to the kitchen to get a sandwich after R1 said she was brought the wrong food than what she had ordered. V9 said V3(Former cook) gave R1 a regular sandwich, but R1 said she wanted a sub sandwich. V9 said V3 got irritated by R1 and instead of V3 deescalating the issue, she escalated the situation by telling R1 that she, V3 would rather feed R1 cat food than give R1 a sub sandwich. V9 said at that point, she asked R1 to go back to the unit and escorted R1 back to the floor to prevent further escalation of the situation. V9 said she went back to the kitchen to speak to V3, and informed V3 that she(V9) was going to call V1(administrator) to inform his about the verbal exchange directed to R1 by V3. V9 said what V3 told R1 is a form of abuse (Verbal& mental) and staff should not tell residents such statements and should be deescalating the situation instead if escalating it. On 10/24/2023 at 1:10pm, (Director of Nursing-DON), said she was the DON when R1 was verbally abused by V3. V2 said V3 telling R1 that she(V3) would rather serve R1 cat food than make her a sandwich is definitely verbal and emotional abuse, and it could have had so many ramifications for R1, such as R1 refusing/stopping to eat from the kitchen for fear of being served cat food. On 10/26/2023 at 11:48am V15(Social Services Director) said R1 come to her office on 09/19/2023 and told V15 that the evening before, V3 had spoken to her(R1) inappropriately. V15 said V9(PRSD) told her that she had witnessed the verbal abuse by V3 towards R1. V15 said what V3 told R1 was verbal abuse and mental and can affect a resident's dignity, and staff should never engage with a resident inappropriately, and staff should deescalate the situation if a resident is agitated. On 10/24/2023 at 1:22 V1(Administrator)said more than likely the verbal abuse happened because a staff member (V9- Psychiatric Rehabilitation Services Coordinator-PRSC), was present when the abuse happened, and V9 said she heard V3 say to R1 that V3 told her she would rather serve her(R1) cat food than make her sandwich. V1 said after the allegation happened, R1 come to V1's office the following day and told V1 him it. Social Service Note dated 9/19/2023 10:46 Documents: -R1 met with V5 and reported she was verbally threatened by V3 on 9/18/2023 around 6pm. Review of V3's HR record with V8 document: -12/08/22- V3 was suspended pending investigation for verbal and emotional abuse to residents (No name/s of the residents) - 9/19/2023, V3 was suspended pending investigation of alleged abuse to R1 Facility Reported Incident Report (FRI) dated 9/19/2023 documents: - R1 told V3 that her food order was wrong, and V3 told R1 that she(V3) would rather serve R1 cat food than make R1 a sandwich. -Facility has evidence to support allegation made by R1. Abuse Prevention Program, Facility Policy Dated 2011 documents: -This facility affirms the right of our residents to be free from abuse, neglect. -The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of the mistreatment, neglect, or abuse of our residents. -Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents of families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but not limited to, threats of harm, saying things to frighten a resident. -Mental abuse includes but not limited to, humiliation, harassment, threats of punishment or deprivation.

Based upon observation, interview and record review the facility failed to ensure accuracy of assessment (re: risk for pressure ulcer) and failed to provide timely incontinence care for one of three residents (R1) in the sample. These failures resulted in R1 sustaining MASD (Moisture Associated Skin Damage), linear raw bleeding areas on medial thighs and pain. Findings include: R1's diagnoses include morbid obesity, weakness, hemiplegia and hemiparesis. R1's (2/4/23) POS (Physician Order Sheets) include moisture barrier cream to buttocks and groin areas as needed. R1's (2/7/23) progress notes state resident skin assessed no open area noted. R1's (12/15/22) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). R1's (12/15/22) functional status affirms (2 person) physical assist is required for toilet use and personal hygiene. On 2/9/23 at 10:55am, R1 stated, I've had a problem with V7 (CNA/Certified Nursing Assistant) changing me. She's (V7) on evenings. When I ask her to change me, she takes her time to do it. Surveyor inquired when R1's incontinence brief was last changed. R1 stated, 5:30 this morning (over 5 hours ago), I actually just asked the CNA to change me and she's helping somebody else right now. On 2/9/23 at 2:07pm, surveyor inquired when R1 was last changed. V5 replied, I changed her (R1) when I got here and again around 9:00am (over 5 hours ago). R1 was transferred from the wheelchair to bed her pants and wheelchair cushion were notably wet. R1 was barely able to stand, pivot, and/or reposition in the bed (due to weakness morbid obesity, hemiplegia and hemiparesis) staff assistance was required. V5 subsequently removed R1's incontinence brief (as requested) which was completely saturated with urine, bright red blood was also noted near the edges of the diaper. R1 stated, My skin, it hurts really bad. MASD (Moisture Associated Skin Damage) and raw linear bleeding areas were observed on R1's medial thighs. Surveyor inquired again when R1's brief was last changed R1 affirmed 5:30 this morning. R1's (2/4/23) assessment for predicting pressure ulcer risk determined a score of 21 (indicating not at risk). Moisture: rarely moist, skin is usually dry. Sensory perception: no impairment. Activity: walks frequently. Mobility: no limitation. R1's (2/9/23) initial skin alteration assessment (documented after surveyor inquiry) includes bilateral inner thigh partial thickness MASD (Moisture Associated Skin Damage) and Serosanguenous (clear-bloody) drainage. On 2/14/23 at 10:01am, surveyor inquired about R1's (2/9/23) skin assessment. V9 (Wound Nurse) stated It's a moisture associated skin damage. The moisture just keeps the skin irritated, it damaged the skin to inner thighs. It could be from the sweating of her thighs or her urine, now it's open. I (V9) saw it (skin damage) this morning (5 days after initial assessment) its open on her (R1) inner thighs and the posterior right thigh. Surveyor inquired if R1's inner thighs were bleeding today. V9 responded, No but on Thursday (2/9/23) it was raw. Surveyor inquired about the requirement for changing incontinent residents. V9 replied, It's before meals, after meals, or when they use the bathroom. Surveyor inquired if R1 Walks frequently (per 2/4/23 assessment). V9 stated, No. She walks but not frequently with assistant. Surveyor inquired if R1 was Rarely moist (per 2/4/23 assessment). V9 responded, I can't speak for what she (staff) put on there (referring to the assessment). Surveyor inquired if incontinent residents are rarely moist. V9 replied No. Surveyor inquired if residents diagnosed with hemiplegia/hemiparesis have sensory perception problems. V9 stated, Yes they do. On 2/14/23 at 12:13pm, surveyor inquired about potential harm to a resident if incontinence briefs are not changed timely. V10 (Medical Director) stated, Potentially they can get urinary tract infection and they can get wounds. The (9/16) pressure injury and skin condition assessment policy states each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the Charge Nurse who will perform the initial assessment. If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock area and groin.

Based on interview and record review, failed to follow their policy to be free from physical abuse by providing necessary care in services thus resulting in a male resident (R2) physically assaulting another male resident (R1) for two (R1 and R2) out of three residents reviewed for physical abuse. Findings include: On 02/07/23 at 10:40 AM, surveyor observed R1 laying on his bed in his room. R1 was not in any pain or discomfort. On 02/07/23 at 10:40 AM, R1 stated that R2 hit him (R1) on the head, and he (R1) started bleeding. He (R1) stated R2 hit him (R1) on the head with his (R2) cane. R1 stated that he (R1) was sent out to the hospital, and he (R1) needed staples on his (R1) head. On 02/07/23 at 11:00 AM, R2 stated that he (R2) did hit R1 on the head. On 02/07/2023 at 12:11 PM, V2 (Assistant/Interim Administrator) stated that if they have a care plan in place for that particular behavior, we don't update the care plan if we see that behavior. We just follow the interventions. Intervention for R2's behavior was to evaluate, work on improving listening skills, He refuses to take medications, so medication is not an appropriate intervention. If I have a resident is agitated, then I (V2) would reach out to psychiatrist and see what could be changed in his (R2) medications but he (R2) refuses all his medications so that is not an appropriate intervention. R2's current interventions are on-going interventions, to prevent him from being aggressive to anyone. After any incident we don't usually update care plans. V2 stated that R2 acts like he is the boss on his floor. He (R2) tells people what to do. On 02/07/2023 at 12:53 PM, V12 (Registered Nurse) stated that R1 is a resident that eats out of the garbage. So, we have to redirect him (R1) from going through garbage cans. I (V12) was at the nurse's station and there was a garbage can near the nurse's station. I (V12) saw him (R1) go to the garbage can. He (R1) GRABBED a piece of garbage and was about to eat it. He (R1) was determined to eat what he (R1) grabbed. I (V12) took the bag behind the nurse's station and R1 followed me (V12) behind the nurse's station to grab the bag. He (R1) was not trying to attack me. He (R1) was just trying to reach for the bag. R2 saw that and started swearing. R2 then left and then came back and had what looked like in his hands a cane. R2 was yelling at R1 and swearing at him (R1). R2 then swung with the cane and made contact with R1's head. I (V12) then heard a crack. I then saw blood running down R1's neck. I ran into the bathroom and got paper towels to press on his (R1) open wound. I (V12) tried to apply pressure and call a code yellow because I (V12) needed help. The other staff came. We wrapped his (R1) head, called 911 and sent him (R1) out to the hospital and sent R2 out for psych evaluation. V12 stated that R2 is loud and more verbal. I (V12) didn't know that he (R2) had a stick in his (R2) room. They call him (R2) a general and he (R2) thinks he (R2) runs the floor. He (R2) thinks he (R2) is the boss of the floor. If someone gets out of hand, he (R2) usually intervenes and yells at them and they listen. R2's Facesheet documents in part: Diagnosis: Violent Behavior. Facility's Final Abuse Incident Investigation Report (1/12/2023) documents in part: It was reported that R2 hit R1 on the head in an attempt to stop him (R1) from going through the garbage. R1 noted with laceration to his (R1) head. First aid provided, sent to ER for evaluation. R2 and R1 were immediately separated. MD notified and new orders noted and carried out. R1 returned from the ER with 2 staples to his (R1) posterior head. Site being monitored for signs and symptoms of infection. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation, abuse; is substantiated. Facility reported incident investigation report witness statement by V12 documents in part: I saw R1 come out of his room and go to the garbage can in the hallway on the 4th floor. He (R1) grabbed a bag of garbage and I (V12) took it from him (R1). He (R1) followed me (V12) into the nurse's station and another resident (R2) walked up behind him with a long cane and hit R1 on the back of his (R1) head, causing him (R1) to bleed and receive a head injury. He (R1) received two staples to the back of his (R1) head. Facility's abuse policy documents in part: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical, mental or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury with resulting by physical harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury upon a resident that occurs by hitting slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to ensure that residents are free from abuse for two of 8 residents (R1 and R2) in the sample of 8 reviewed for abuse. This failure resulted in R1 being verbally abused by staff using curse words and R2 physically abused by staff, by physically hitting, and punching R2 on the back of the head. Findings include: R1's medical record showed that R1 was last admitted to the facility on [DATE] with diagnosis that includes but not limited to Chronic obstructive pulmonary disease unspecified, unspecified Asthma uncomplicated, Essential (primary) Hypertension, chronic kidney disease, Heart failure, Unspecified Dementia, Unspecified severity, with other behavioral disturbances, Schizophrenia Covid-19, contact with and (suspected) exposure to other communicable disease, underweight, and hemiplegia unspecified affecting right Dominant side. R2's admission record documented that R2 was last admitted to the facility on [DATE] with diagnosis that includes but not limited to Catatonic Schizophrenia, Paranoid Schizophrenia, Abnormal Posture, Unspecified Dementia, unspecified severity, with other Behavioral Disturbances, Adult to thrive and Strange and inexplicable behavior. On 01/17/2023 at 12:13pm, interview conducted with R1 regarding the incident of 01/01/2023, R1 was unable to express how (R1) felt but stated that (V15) used bad words when talking to (R1). According to the facility Final Incident Investigation Report documentation of the incident of 01/01/2023 at 7:45pm, it showed the incident was reported by another resident identified as R5. R5 reported that V15 LPN (Licensed Practical Nurse) cursed out R1 and it was also witnessed by V17 CNA (Certified Nurse's Aide) and another resident. The facility's presented witness report dated 1/4/23 documented that V17 gave a statement that (R1) kept asking for tubing (referring to the Oxygen tubing). V17 stated that she (V17) heard V15 using a cursed word when talking to R1. V17 stated she (V17) was sitting in the Hallway with another resident identified as (R5), V17 stated that R1 asked about 3 times, and the nurse (referring to V15) kept telling (R1) to wait. Facility investigation concluded that the allegation was substantiated and V15 contract was terminated. Review of abuse book from October 2022 to January 2023 showed that R2 was physically abused by another staff identified as V16 LPN (Licensed Practical Nurse). According to the facility investigation this incident was substantiated, V18 CNA (Certified Nurses Aide) reported to V12 (LPN) that she (V18) witnessed V16 (CNA) physically punching and hitting R2 at the back of the head stating that R2 stole her (V16) money. Facility statement of witness presented and dated 1/9/23 documented V16's statement that she (V16) left her (V16) bag and coat in R2's room. Upon V16 returning to R2's room the bag was opened, and the food was gone. V16 admitted that she (V16) physically touched R2's neck asking why R2 went in her (V16) bag. The final investigation report showed that this incident was substantiated and V16 was terminated. On 01/17/23 at 1:00pm, R2 was unable to recollect the incident and not willing to talk with the surveyor. On 01/18/2023 at 10:45am, interview conducted with V1 (Administrator) regarding the facility policy on abuse. When the surveyor asked whether it is appropriate for V16 to physically hit R2, V1 stated that Absolutely not, completely not tolerated which is why she (V16) was terminated. The surveyor then asked whether this a form of abuse. V1 stated Yes, it is, and she (V16) has been terminated, V16 has been previously educated on form of abuse. Regarding V15 verbally abusing R1, V1 stated that She (V15) should not have (referring to verbally abuse of R1). And it is considered a form of abuse. She (V15) was also terminated. On 01/19/2023 at 9:29am, interview with V1 (Administrator) regarding V16 termination, V1 stated that V16 had a 13 (thirteen) weeks contract with the facility to work 40 hours per week so the contracted was terminated, V16 cannot come back to work in the facility. On 01/30/23 at 10:00am, interview with V12 LPN (Licensed Practical Nurse) regarding the incident of 01/09/23, V12 stated that she was the charge nurse at the time and that one of the CNA's (identified as V18) reported the incident stating that another staff (V16) was being a little not nice and a little bit inappropriate with (R2). V12 stated that during her (V12) investigation, V16 stated that R2 was going through V16's personal belongings. V12 added R2 tends to do that. V12 stated that the incident was reported immediately to V1 and V16 was asked to go down to V2 DON (Director of Nurses) office. V12 acknowledged that hitting any resident by staff is a form of abuse and should be reported immediately to V1. V12 stated that full body assessment was done with no injury noted on R2. On 01/30/23 at 10:16am, interview conducted with R5 regarding the incident of 01/01/23. R5 stated I (R5) was sitting not far from the nurse's station. I (R1) asked the Nurse identified as (V15) for (R1) 's breathing treatment. V15 slammed her (V15) hand on the desk told (R1) not to (foul language) ask for any thing (referring to oxygen tubing). On 01/30/23 at 10:27am, interview conducted with V18 CNA (Certified Nurse's Aide) regarding the incident of 01/09/2023 involving R2 and V13 (CNA). V18 stated in part that I (V18) was in the dining area with V13, when I turned around V13 was standing over (R2) who was sitting by the table. V13 was punching and slapping R2 and speaking in another language that is not English, all I (V18) could understand was where is it?. V13 continued to slap and punch R2 on the back of the head. V18 stated that I (V18) told V13 not to hit R2 like that. V18 stated that she then reported it to the Nurse identified as V12 (LPN). When the surveyor asked about R2's reaction to V13 physically abusing R2. V18 replied R2 is non-coherent confused and not fully alert. V18 stated R2 cannot hold conversation but can make needs known. V18 acknowledged that physically hitting any resident by either the staff, family or another resident is a form of abuse, and it should be reported immediately. On 01/30/23 at 10:56am during interview with V19 (LPN) and MDS Coordinator, regarding whether hitting resident is an abuse. V19 stated that hitting a resident by staff is a form of abuse and should be reported immediately to V1 (Administrator). On 01/30/23 at 11:08am, interview with V1 (Administrator), V1 acknowledged that it is not appropriate for staff to keep their personal belongings in the resident rooms. That there is a facility locker room downstairs in the facility provided for staff or the staff should not bring their belongings into the facility. R5's facility assessment tool used in assessing all resident MDS (Minimum Data Set) dated December 31, 2022, showed that R5 has a BIMs (Brief Interview for Mental Status) summary score of 15. R2's facility assessment tool used in assessing all resident MDS (Minimum Data Set) dated December 21, 2022, showed that R2 has no score recorded for BIMs (Brief Interview for Mental Status). On 01/30/23 at 10:56am, interview with V19 MDS Coordinator regarding R2's BIMS score why there was no numerical score entered. V19 stated in part that when a resident is unable to be assessed for cognitive functioning or was uncooperative then there will be no score entered or 99 will be documented in the BIMS score box. The facility Abuse Prevention Policy presented with effective date November 22, 2017, documented that residents have the right to be free from abuse) An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. (Section 2-107 of the Act). Under abuse definitions the policy documented in part that abuse is willful, and it includes but not limited to verbal abuse and physical abuse. Physical abuse includes but not limited to hitting and verbal abuse includes that willfully includes use of oral disparaging and derogatory terms to residents or within their hearing distance.

Based upon observation, interview and record review the facility failed to provide supervision, failed to review/revise fall prevention interventions (post fall) and failed to implement fall prevention interventions for two of three residents (R1, R3) reviewed for falls. These failures resulted in R1's (8/18/22) laceration requiring suture repair and R3's (9/9/22) left eye swelling/bruise. Findings include: R1's (7/20/22) BIMS (Brief Interview Mental Status) determined a score of 11 (moderately impaired). R1's (7/20/22) functional assessment affirms supervision is required for transfers and walking. R1's (7/16/22) fall risk assessment determined high risk for falls. R1's (8/18/22) initial facility reported incident states resident was observed by activity aid on floor of dayroom, noted blood on his face. Witnessed? No. R1's (8/18/22) final investigation states resident was sent to the hospital for evaluation and repair of laceration to chin (5 sutures). R1's care plan states resident is at risk for falls related to impaired mobility with an unsteady gait, incontinence, psychoactive medication use, and history of falling however the interventions were last reviewed/revised on 6/14/22 (2 months prior to falling) and staff supervision in the dayroom is excluded. On 9/14/22 at 11:02am, surveyor inquired about R1's cognitive status. V3 (Licensed Practical Nurse) stated, he's alert and oriented maybe like 2-3. Surveyor inquired about R1's fall prevention interventions. V3 responded, Using the call light before he gets up to ambulate or if he needs toileted, bed in low position and floor mats in place overnight. On 9/14/22 at 11:07am, R1 was observed in the dayroom (with seven other residents) however, the dayroom was not supervised by staff and a call light was not present. Surveyor inquired about R1's recent fall R1 proceeded to write symbols on a paper and did not respond. On 9/14/22 at 11:10am, surveyor inquired if the dayroom is supposed to be supervised by staff. V3 stated, Usually we have activities in there. She (Activities Staff) may have stepped out for a second. On 9/14/22 at 11:15am, surveyor inquired about staff supervision in the dayroom. V4 (CNA/Certified Nursing Assistant) stated, It was activities in there and they (Activities Staff) let no one know that they were leaving. __ R3's (8/23/22) cognitive assessment affirms daily decision making is severely impaired. R3's (8/23/22) functional assessment affirms extensive assistance is required for bed mobility and toilet use. R3's (8/20/22) fall risk assessment determined high risk for falls. R3's (9/9/22) incident report states resident experienced an unwitnessed fall (in the bedroom). Noted with bruise and swelling to left eye. Predisposing factors confused, impulsive, gait imbalance and decreased strength/endurance. R3's (11/22/19) care plan states resident is at risk for falls related to cognitive/communication deficits. R3's interventions include be sure the resident's call light is within reach however, the interventions were last reviewed/revised on 4/16/22 (roughly 5 months prior to falling). On 9/14/22 at 11:19am, surveyor inquired about R3's fall prevention interventions. V5 (CNA) stated, They (Staff) use the floor mats for him (R3) and keep the bed kinda low. R3 was lying in bed (in low position) and floor mats were adjacent the bed however the call light was out of reach and on the floor. Surveyor inquired about the location of R3's call light. V5 responded, They (Staff) need to keep it on the bed. On 9/14/22 at 12:51pm, V2 (Director of Nursing) stated, If we have residents in the dayroom we're supposed to have somebody supervising the dayroom. Surveyor inquired about R1's (8/18/22) fall. V2 responded, He (R1) was walking in the hallway, he (R1) lost his balance, he (R1) slipped and fell . He (R1) hit his chin which caused a laceration. Surveyor advised that R1's (8/18/22) fall occurred in the dayroom (not the hallway as stated) and inquired about R1's preventive interventions post fall. V2 replied, We try to have staff make sure that they (staff) are staying in the dayroom with the residents. Surveyor inquired who supervises the dayroom. V2 stated, We have our shift staff that would help out in the dayroom, activity staff, ancillary staff or anybody we assign there. Surveyor inquired if there's a schedule for staff assigned to the dayroom. V2 responded, We have an assignment sheet but I'm not sure if there's an assignment for the dayroom, I would have to look. Surveyor inquired about R3's (9/9/22) fall V2 replied It was an unwitnessed fall they (Staff) were able to get him (R3) back up and get him back into bed. At the time, bed was in the lowest position. He (R3) had some bruising around his nose and forehead. Surveyor relayed concerns regarding R3's call light observed on the floor (while lying in bed). V2 stated, The call lights are supposed to be in reach that is for sure. The (2/28/14) fall prevention program states safety interventions will be implemented for each resident identified at risk using a standard protocol. Accident/Incident reports involving falls will be reviewed by the Director of Nursing and the IDT (Interdisciplinary Team) to ensure appropriate care and services were provided and determine possible safety interventions. Care plan interventions are changed with each fall as appropriate. Call lights are kept in reach. The resident will be checked approximately every two hours, or as or as according to the care plan to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on observation, interview and record review the facility failed to ensure that the Low Air Mattress was set at the recommended settings; failed to ensure the Low Air mattress were not layered with multiple linens and padding; failed to identify a pressure ulcer on a resident who was assessed and coded at high risk for pressure ulcer. This failure affected two of three residents (R1 and R3) reviewed for pressure ulcer care and prevention in the sample. As a result, R3 developed a new facility acquired pressure ulcer that went unidentified and treated until it was unstageable. Findings include: 1. On 06/29/22 at 2:00pm, during incontinent care with V12 and V25 CNA (Certified Nurse's Aides), R3 was noted in bed on an air loss mattress with a disposable incontinent pad, a facility clothes incontinent pad and a draw sheet linen in the bed. When the survey asked V12 CNA (Certified Nurse's Aide) about how the bed should be made with a resident using an air loss mattress. V12 became upset telling the surveyor that, the surveyor is making her nervous. V12 did not answer the surveyor. At 2:56pm, during R3's wound care observation with V2 DON (Director of Nurse's) and V8 (RN), R3 was noted with a new skin alteration to the right feet and toes with blackish color that measured 4cm by 2cm (centimeter) and unstageable. Both V2 and V8 could not explain or present any documentation showing where this has been addressed. V8 told the surveyor to wait for V7 (wound care Nurse) explanation on the wound site. V2 stated V7 was in another facility to assist in performing the wound care. V2 stated (V7) works in two of their facility as a wound care nurse. V2 stated the licensed nurses on the floor after their medication pass will have to assist in wound care. R3's medical record treatment order documented use of Santyl ointment 250 unit/Gm ([MEDICATION(S)]) apply to right hip topically every-day shift for wound healing cleanse with NS (Normal saline). Apply Santyl to wound bed, cover with gauze and xeroform. V8 searched for the Santyl Ointment, and it was unavailable. V2 stated that the treatment medication should not finish before it was re-ordered. On 7/1/22 at 10:34am, interview with V16 (Wound Care Physician), regarding R3's pressure ulcer. V16 stated in part that he was at the facility on 06/27/22 and gave treatment orders for the left heel pressure ulcer not the right heel. V16 stated no pressure ulcer was on the right heel during the visit. When asked about the use of Low Air Mattress and the significant of setting the mattress right. V16 stated the Low Air mattress is a mattress used to help relieve pressure on multiple sites and to relieve pressure on sites to prevent pressure wounds. V16 stated in part that we (referring to the facility) make sure the mattress is functioning to make sure that the resident is not having pressure ulcer. V16 stated it is important to inflate to relief pressure, V16 stated he cannot explain that, just make sure the mattress was inflated. On 07/06/22 at 2:50pm, interview conducted with V7 regarding the right heel and toes ulcer, V7 stated that they were new openings. V7 stated the first pressure ulcer on the heel healed 5/30/22 as documented. V7 stated that she was not aware of the new opening on the right heel. When the surveyor asked V7 about making of the Low Air mattress bed regarding the layers on the bed. V7 stated the bed should have only one incontinent cloth layer or a disposable adult incontinent (brief) and a draw sheet. V7 stated the purpose of the mattress can be defeated if not properly made. 2. On 06/22/22 at 11:13am, R1 was observed in bed on a low air mattress the bed setting was set at 8 = 800 LBS (Pounds). At 11:17am, when this observation was shown to V8 RN (Registered Nurse) in charge of R1's care and was asked whether R1's setting should be that high. V8 replied that to her knowledge the bed setting should not be that high. At 11:20am, V4 (Maintenance Director) walked into R1 's room and stated (V4) was the one that set the mattress at Eight because he does not want the pressure to be too low. When the surveyor asked V4 about the reasons for the use of the low air mattress. V4 stated R1's weight was 135lbs and the air mattress should be set using the weight. At 11:36am, V8 stated the low air mattress is used to prevent development of pressure ulcer and the sitting should be based on total overall health assuming the weight, height and overall physical health because of the pressure wound. On 06/22/22 at 12:18am, during R1's wound care observation with V7 LPN (Licensed Practical Nurse) identified as the facility wound care nurse. R1's right hip was noted without any treatment dressing over the wound. V7 stated that R1's right hip pressure ulcer should have a treatment dressing covering as ordered at all times to prevent any infection and promote healing unless there is an ordered to keep the site open to air without any dressing. On 06/22/22 at 12:34pm, V7 was interviewed regarding the use of air loss mattress setting and the rationale for use. V7 stated the bed should not be set higher than the resident weight, the weight should be considered in setting of the low air mattress. V7 explain that if the pressure is not set wright, it will defeat the purpose of the use in preventing development of a new pressure ulcer and maintenance of the developed ulcer for healing. V2 DON (Director of Nurse's) was also interviewed, V2 stated the information about the resident should be written on the feeding bottle. Regarding the open wound pressure ulcer site should have a dressing on the site. When asked about the low air mattress setting, V2 stated I'm not sure about the setting of the low air mattress but let me get the information and I (V2) will let you know (referring to the surveyor). V2 then added I know it is for pressure ulcer and prevention.

Based on interview and record review, the facility failed to ensure that residents' medications are administered as ordered by the physician. This failure affected two residents (R2 and R3) out of three residents reviewed for quality of care and administration of prescribed medications. In addition to other medications of R2 that were missed, R2's [CONDITION(S)] medication ([MEDICATION(S)]) was also missed. As a result, R2's aggressive behavior escalated and R2 physically attacked another resident (R1). R1 sustained a [MEDICATION(S)] head trauma, fractured nose, and eyebrow laceration and was sent to the hospital. According to R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/3/22 at 12:15 PM, V1(Administrator) presented R2's MAR (Medication Administration Records) and POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's POS dated 4/23/2020 states: [MEDICATION(S)] [MEDICATION(S)] Tablet 100 mg Give 1 tablet by mouth every 12 hours related to [CONDITION(S)] Disorder, [CONDITION(S)] Type. There were missing entries for Nurses' signatures on the MAR for February 2022, March 2022 and April 2022 at 9 PM for [MEDICATION(S)] [MEDICATION(S)] Tablet 100 mg(milligrams) Give 1 tablet by mouth every 12 hours: On February 16th, March 3rd, March 22nd, March 29th, and April 5th. R2's POS dated 4/23/2020 states: [MEDICATION(S)] capsules 250 mg, Give 500 mg by mouth every 12 hours. R2's [MEDICATION(S)] Capsules administration records had missing entries for nurses' signatures on 2/16/22 at 9 PM, 3/3/22 at 9 PM, 3/22/22 at 9 PM, 3/29/22 at 9 PM, 4/5/22 at 9 PM, 4/16/22 at 9 PM, 4/25/22 at 9 PM, and 4/26/22 at both 9 am and 9 PM. R2's care plan dated 4/18/2020 states that R2 is receiving [CONDITION(S)] medications to help manage/alleviate symptoms of Dementia with Behavior Disturbances. Intervention states in part to Administer medications as ordered. R2's care plan dated 2/10/2022 states that R2 has a history of aggressive, inappropriate, attention-seeking and maladaptive behavior. Intervention states in part to give psycho-active medications as ordered. R2's MDS(Minimum Data Set) dated 4/12/2022, Section E(Behavior Section) shows the following: R2 has Delusions as a potential indicator of [CONDITION(S)]; Behavioral Symptom Presence and Frequency scored 2, which implies that Physical Behavioral Symptoms directed toward others(like hitting, kicking, pushing, scratching, grabbing) occurred 4-6 days but less than daily. On 5/3/22 at 2.00 PM, V2(Director of Nursing) was interviewed regarding the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated Nurses are supposed to sign when they give medications to residents, and if they didn't give it, there is a chart code to put in, and they should also document in the resident's progress notes why the medication was not given. It is not acceptable to leave the MAR blank. If you didn't chart it, you didn't do it. On 5/3/22 at 1:48 PM, V19(R2's Attending Physician) was interviewed regarding R2's missed medications. V19 stated that if a resident does not take his [CONDITION(S)] medications, they will start to have [CONDITION(S)], delusional thoughts, physical and verbal aggression. V19 added that residents have a right to refuse their medications but that right ends when the resident becomes aggressive and hits another resident or a staff. V19 explained that the natural consequence or sequence of events is that when they don't take their medications, their judgement is impaired, and they become aggressive and may physically attack someone else. On 5/2/22 at 2:09 PM V10(QA Nurse/Fall Nurse) presented R3's MAR (Medication Administration Record) and POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] February 13th at 9 PM- [MEDICATION(S)] Tablet 10 mg Give 1 tablet by mouth two times a day February 16th at 9 PM-[MEDICATION(S)] Tablet 10 mg Give 1 tablet by mouth two times a day February 23rd at 9 am- [MEDICATION(S)] Tablet 10 mg Give 1 tablet by mouth two times a day. R3's POS dated 5/4/22 states: [MEDICATION(S)] Tablet 10 mg Give 1 tablet by mouth two times a day for [CONDITION(S)] until 3/5/22. On 5/3/22 at 2:00 PM V2(DON/Director of Nursing) was interviewed regarding R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated The nurses are supposed to sign out on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 12 PM V1(Administrator) presented the policy Physician Orders. This undated policy states in part: These guidelines are to ensure that: #1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record. #2 Any orders given by Physician are carried out. On 5/4/22 at 1:30 PM, V1 (Administrator) presented the facility's Medication Administration Policy. This undated policy states, under Administration of medications: [MEDICAL RECORD OR PHYSICIAN ORDER] ., the right resident, right medication, right dosage, right route, and right time.

Based on observation, interview and record review the facility failed to follow its abuse policy and failed to protect a resident from potential further sexual abuse after R4 touched R1's breast and allowed R4 to continue residing on R1's floor after the incident. This affects one (R1) of 6 (R1, R2, R3, R4, R5 and R6) residents reviewed for abuse. These failures resulted in R1 experiencing increased anxiety, behavioral aggression and verbalizing expressions of self-harm. Findings include: The Facility's Abuse Prevention Program states under Purpose: The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property and exploitation. Section V. Protection of Residents states: The facility will take steps to prevent mistreatment while the investigation is under way. Residents who allegedly mistreated another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. Section VII. External Reporting of Potential Abuse states: 2. Five-day Final abuse Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The Public Health requirements for a final investigation report are detailed in paragraph five of the Internal Investigations section of this procedure. R1 is a [AGE] year old female with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Brief Interview of Mental Status (BIMS) score dated 9/2/21 was 13, indicating intact cognition. On 10/10/21 V10 (Wound Care Nurse/Floor Nurse) documented on R4's Progress Note that it was communicated to her (V10) that resident (R4) was witnessed exiting from peer's (R1's) room, peer (R1) states: He touched my breast. Staff redirected resident (R4) to his room, social service communicated to resident (R4) not to enter peer's room, education, and therapeutic communication was offered to resident. Final Report dated 10/15/21 documented: As per charge nurse (V9), R1 reported to her that R4 touched her breast. Charge nurse interviewed R1 to ascertain her level of comfortability. R1 stated that she is OK and that she feels safe in the facility, R4 did it one time. On 10/15/21 V8 (Psychiatric Rehab Services Coordinator) documented on R1's Progress Notes that she (V8) was informed about the allegation by R1 that she (R1) was touched inappropriately by another peer. R4's Progress Notes with the same date reads that she (V8) educated R4 on expressing his feeling and using his coping skills when he feels anxious and increased sexual excitement. Per facility census and R1's notes, R1 stayed in the same room on the same floor as R4 from 10/10/21 to 10/15/21. R1 was moved to a different floor on 10/15/21. On 10/27/21 V11 (Psychiatric Rehab Services Coordinator) documented on R1's Progress Notes that R1 expressed that she (R1) was having thoughts of self-harm and that R1 appeared in a high state of anxiety. On 10/31/21 V5 (LPN) documented that R1 came out of R1's room yelling He found me, he found me. V5 stated, That's why I moved R1 off that floor. On 11/23/21 at 11:20 AM R1 was observed alert and able to express her thoughts well. R1 stated that many people came inside her room and touched her inappropriately. When asked if R1 could remember who came inside her room, R1 stated that R4 came to her room and showed her his penis. R1 said it happened in the past but cannot remember exact dates. R1 then said that R4 was staying on (X) floor. R1 stated R1 wants to leave the facility because R1 does not feel safe. During interview V5 (LPN) stated that on 10/31/21 she was the nurse taking care of R1. V5 stated that day R1 came out of her room yelling, He found me and raped me! He raped me! I (V5) called the social worker, who was V7 (Social Service Director). V7 came and spoke with R1. I called the Administrator (V6/Past Administrator) immediately and V6 said that R1 needed to be transferred to the hospital. After that, R1 called 911 and the police came and spoke with R1. V5 further said, This was the first time I encountered R1 having this behavior and I worked regularly with R1. At 11:54 AM V7 (Social Service Director) stated that R1 was transferred to the hospital via Petition for Involuntary/Judicial Admission. At 12:17 PM V9 (Regional Consultant/Acting Administrator) stated that this happened during V6's (Past Administrator) time so he has limited information. (V9) stated V9 was not aware that V5 (LPN) stated on 10/31/21 R1 said, He found me and raped me! He raped me! V9 was asked about facility report to State Agency on the incident that happened on 10/31/21. V9 stated that there is no record of report dated 10/15/21 and 10/31/21. V9 stated the only incident that was reported to State Agency was on 10/10/21. V9 then provided a Final Report dated 10/15/21 but not the Preliminary Report that it was sent to State Agency. According to V9 the facility cannot find the preliminary report with the date sent to the State Agency. Request for Preliminary Report and details of the investigation was requested on 11/23/21 at 12:17 PM, 11/24/21 9:36 AM and 11:05 AM. V9 stated the only document they can find was the Final Report dated 10/15/21 without details of the investigation. On 11/24/21 at 9:57 AM. V8 (Psychiatric Rehab Services Coordinator) stated that R1 has mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 stated V8 was aware of the incident of 10/10/21 regarding R4 touching R1's breast. V8 stated that as a Social Worker, V8 felt it was natural for R1 to be uncomfortable and afraid because of the incident that happened on 10/10/21. V8 stated, Yes, I agree that R1 would want to feel safe after the incident that happened between R1 and R4. I don't know what took them so long time to transfer R1 to another floor. But I agree she should have been transferred immediately. I do not know why R4 was not transferred to another floor. Any female person would feel uncomfortable, afraid and would want to feel safe if someone touched her without her consent. V8 further stated that she was aware that R1 verbalized expressions of self-harm and R1's increased anxiety and behavioral aggression manifested after the 10/10/21 incident. On 11/24/21 at 11:05 AM. V9 (Regional Consultant/Acting Administrator) stated that upon further inquiry it was found out that R1 and R4 resided on the same floor from the time of the incident 10/10/21 until 10/15/21. Although R4 went to the hospital on 10/11/21, R4 came back the same day. V9 stated except on the hours R4 went to the hospital, R1 and R4 were on the same floor. V9 also stated that he understands that any female resident would feel afraid and anxious if touched by a male resident without consent. V9 stated, I understand the concerns related to abuse, reporting and investigation abuse. See what I inherited {this situation}? R1's Petition for Involuntary/Judicial admitted d 10/31/21 documents: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has shown an increase in anxiousness and believing everyone wants to harm her. Currently not responding to staff directives or as needed medication. R1 is currently pacing the unit. R1 is in need of hospitalization . R1's care plan documents that R1 is at risk for abuse and neglect based on her diagnoses. The goal for R1 is to be treated with respect, dignity and reside in the facility free of mistreatment. Facility intervention is to assure that R1 is in a safe and secure environment. R4 is a [AGE] year old male with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's BIMS score date 11/26/21 is 13 which indicates intact cognition. On 11/23/21 at 11:15 AM R4 was observed in his room sitting on a chair. R4 was alert but was signaled that he cannot hear. Surveyor wrote R4's name on a piece of paper, which R4 acknowledged. Surveyor wrote R1's name; R4 did not respond. Surveyor wrote R1's floor number on the paper; R4 did not respond. Surveyor wrote the words, KNOW HER? on the piece of paper. R4 continued to not respond. On 12/7/21 at 11:10 AM during interview, V12 (LPN) stated that R4 cannot communicate well because of hearing problems. V12 stated staff from Social Services communicate with R4 through sign language, and R4 also knows how to read lips. V12 also stated that R4 is ambulatory and uses the elevator to transfer to other floors. V12 further stated that R4 has behavioral issues of touching female residents and staff. At 11:21 AM R5 stated that R4 was very aggressive towards female residents. R5 said, R4 grabs t**s and b***s of female residents. R4 does it in the hallway or at the Nurse's Station and at times goes inside resident's rooms. R5 stated R6 used to be here in R5's room and R4 followed R6 inside the room. R4 grabbed R6's breast and behind. Because of that incident R6 was transferred to another room. At 11:35 AM R6 confirmed that R4 inappropriately grabbed her in 2 separate incidents. R6 stated that first R4 grabbed her breast; second, R4 grabbed her behind. R6 said, Yes, I was in the room with R5 before. And R4 touched me inappropriately on the breast and on my behind. It happened in two separate incidents, but I cannot remember the exact dates. It was months ago. After I was transferred to this room, there have been no more incidents with R4. On 12/7/21 at 12:15 PM V9 (Regional Consultant/Acting Administrator) stated that the incident related to R1 and R4 on 10/10/21 does have a preliminary report but does not have a time stamped that it was sent to the State Agency. V9 stated the final report has a time stamp dated 10/15/21 but does not have the details of the investigation. V9 stated that based on the preliminary report, R4 touched R1's breast. V9 also stated that for the notes dated 10/15/21, V9 thinks the writer (Social Services) was referring to the incident dated 10/10/21 when she wrote those notes. V9 stated the incident dated 10/31/21 was not reported because according to V5 (LPN) R1 was not making any sense and that due to R1's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V9 said, If I am in that situation, I will ask R1 who raped her, when did it happen, and so on and so forth. Then R1 called the police, and the incident number was given to us, but we don't have hard copy. I think the police report number was written on the progress notes. I did not know that R4 has other sexual inappropriate behavior incidents beside what happened to R1. I don't know about R4's incidents on progress notes dated 8/28/21 and 8/29/21 which document R4 having inappropriate sexual behavior directed towards facility staff and peers. But if the behaviors were directed towards facility staff, we do not report it to the State Agency since it does not involve residents as victims. R4's Progress Notes documentation multiple incidents related to R4's inappropriate sexual behavior. On 6/17/21 V13 (Registered Nurse/RN) documented: R4 was seen going into female peer's room. On 7/22/21 V7 (Social Service Director) documented: R4 left the shower area without putting on his clothes. On 8/22/21 V15 (LPN) documented: R4 was sexually inappropriate with peer. On 8/27/21 V16 (LPN) documented: R4 was observed going in female resident's room. On 8/28/21 V10 (Wound Care Nurse/Floor Nurse) documented: R4 was sexually inappropriate towards staff. Shortly after, resident attempted to be sexually inappropriate toward peer. On 8/29/21 V10 (Wound Care Nurse/Floor Nurse) documented: R4 again attempting to be sexually inappropriate towards peer. On 10/2/21 V11 (Psychiatric Rehab Services Coordinator) documented: Social Services was made aware that a peer expressed concerns to nursing regarding R4 interaction with her. R4 was educated on maintaining awareness of personal boundaries and the personal space of his peers. On 10/10/21 V10 (Wound Care Nurse/Floor Nurse) documented: It was communicated to her (V10) that R4 was witnessed exiting from (R1's) peer's room. Peer (R1) states: He touched my breast. Multiple notes by V17 (Minimum Data Set/MDS/Care Plan Coordinator) document that during look back period R4 has displayed symptoms of being sexually inappropriate. R4's care plan documents that R4 exhibits sexually inappropriate behavior symptoms related to severe mental illness. Behavior symptoms are manifested by: Making crude, sexually-oriented, profane or suggestive remarks, physical touching, grabbing, sexual behavior in public place. V9's (Regional Consultant/Acting Administrator) email dated 12/8/21 documents that there was no reportable or investigation for the month of August 2021 related to multiple incidents documented on R4's progress notes. On 12/9/21 at 10:35 AM V18 (Psychiatrist) stated R1 and R4 are his patients. R1 has baseline of paranoid behavior because of her mental diagnosis. R1 expresses leaving the facility but in his professional opinion, R1 will not survive because of many factors including unable to take medications and her mental state. V18 stated R4 has sexual inappropriate behaviors. When V18 was informed that R1's notes documented that she (R1) had thoughts to harm herself, V18 stated, I was not informed about previous incidents with R4, and I was not aware that R1 had thoughts of harming herself. The facility should update me of all situations. Any female person with mental illness or medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The person will develop fear to a specific race or will fear that something or someone is out to get them and will have aggressive behaviors. When asked if the allegation by R1 regarding R4 would result in a need to separate R1 from R4 or vice-versa, V18 stated, Definitely yes. They (R1 and R4) should not cross paths with each other. The Facility needs to think about alternatives, like transferring residents to a safe environment. The Facility should be on top of it. R5 is a [AGE] year old female with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's BIMS score dated 9/15/21 was 15, indicating intact cognition. R6 is a [AGE] year old female with a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to provide supervision for an oriented, wheelchair-bound male resident who has the tendency to wander into female residents' room and exhibit inappropriate sexual gestures for one (R2) of 3 residents reviewed for supervision in the sample of 4 residents. This failure resulted in R2 propelling himself onto another resident floor via elevator and entering R1's room where R2 wiggled R1's toes waking R1 out of deep sleep and scaring R1. Findings include: R2 is an oriented, deaf, mute wheelchair-bound [AGE] year-old male who requires supervision for his Activities of Daily Living (ADLs) per the quarterly Minimum Data Set (MDS) dated [DATE]. R2 is assessed to have a Brief Interview for Mental Status (BIMS) of 10. R2's diagnoses include [CONDITION(S)], deaf, mute and [CONDITION(S)]. R2 has resided in the facility since 3/28/14 per MDS. On 10/5/21 at 11:55 AM, R1 stated the incident happened in the middle of the night between 2 AM to 4 AM. R1 stated she was sleeping in the first bed of a 3-bed room when she was awoken by R2. R2 was touching and wiggling her toes. R1 stated she grabbed R2's hands and yelled for help. R1 stated she saw R2's penis was out of his pants and she can describe it. R1 stated that she was pushing R2 out of her room as she was yelling. R1 did not know the names of staff or descriptions of them that came to the room. R1 stated R1 did not recall speaking to police but staff say she did talk to police for 20 minutes. R1 stated that R3 is her roommate and believes R3 told the nurse. R2 is from another floor. On 10/5/21 at 12:07 PM, R2 was interviewed using an interpreter (V4/Outside Mental Health Program Professional for in-house programming) to communicate using sign language. V3 (Outside Mental Health Program Director) was also present. V4 stated R2 is oriented times person and place with periods of confusion, is deaf and mute and uses the sign language to communicate. V4 stated that R2 was signing that he went to R1's floor to have sex which is different from the original story. The original story was R2 was hearing voices and followed the voices to R1's room. V4 stated that R2 signed that R1 was dressed in bra and panties and screaming. Staff came and yelled at R2 to get off the floor and stay off floor. Both V3 and V4 stated that they have never heard or witnessed any inappropriate behavior from R2. Both stated that R2 does like to wander in his wheelchair, but it was never sexual. V4 stated that R2 likes to go to the 4th floor to visit a male, Polish friend and watch television with him. V4 stated that the friend's room is next to R1's room. On 10/5/21 at 12:28 PM, V11 (Restorative Director) stated the residents are supposed to stay on their own floors and if they want to visit, it should be done in the patio during the day. On 10/5/21 at 12:35 PM in R1's and R3's room, R3 stated she remembers the incident of 9/18/21. R3 stated she was awoken by R1 screaming and seeing R1 grab R2 saying Get the nurse. R3 stated she reported it to the nurse and does not know the nurse's name. On 10/5/21 at 1:35 PM, V5 (Certified Nurse Aide/CNA) stated she was working the 3 to 11 shift on the 5th floor when she saw R2 starting up with his episodes of wanting to fight, exhibiting sexual gestures, going in and out of the female rooms on the 5th floor. V5 stated she reported this behavior to V7 (5th floor nurse). V5 stated that V7 was redirecting R2 out of a female's room when he gestured to V7 that R2 wanted sex. V5 stated that V7 asked V5 if she saw R2 make the sexual gesture with his hands, but V5 did not see it because V5 had turned her back. V5 stated it was then shift change at 11 PM and V5 stated she headed down to the 4th floor to work a double. V5 stated she saw V6 (4th floor CNA) who told V5 that R2 was in R1's room and R1 was screaming rape. V5 stated she asked V6 if she informed the nurse. V5 stated it was 30 minutes later when R1 came to the nurses' station to report that R2 tried to rape her. V5 stated she questioned R1, Was it rape? V5 stated that R1 stated it was not rape but R2 was trying to persuade R1 to remove her clothes. V5 stated that R1 stated that R2 had shown his penis to R1. V5 stated that R2 is capable of transferring himself by standing and pivoting out of wheelchair. On 10/5/21 at 1:47 PM, V6 (CNA) stated she was arriving on the 4th floor for her 11 to 7 shift when she heard R1 screaming. V6 stated there was a nurse at the nurses' station but cannot identify her. V6 stated she was told the screams were from R1's room. V6 stated she saw R1 pushing R2 out of her room. R1 was screaming that R2 tried to remove her clothes as R1 was sleeping and wanted the police called. V6 stated that both nurses, V7 and V12 were informed of the incident between R1 and R2. On 10/6/21 at 8:26 AM, V8 (Licensed Practical Nurse/LPN) stated she worked the 11 PM to 7 AM shift on the 5th floor. V8 stated when she got to work, the off-going nurse V7 told V8 to keep an eye on R2 because R2 keeps going into female peers' rooms. V8 stated she was not told of the incident between R2 and R1 on the 4th floor. V8 stated that R2 likes to leave the floor and go to vending machines on 1st floor. V8 stated that this shift she watched R2 from the nurses' station. V8 stated that R2 can stand and pivot when transferring. On 10/6/21 at 11 AM, V10 (CNA) stated she was starting her 11PM to 7AM shift on the 5th floor when she approached V7 (Nurse). V10 stated that V7 informed her to keep an eye on R2 who had been going in and out of female residents' rooms during the 3 PM to 11 PM shift. V10 stated as they were talking, the elevator door opened, and it was R2 getting off the elevator which surprised both of them. V10 stated she then put R2 in his bed. V10 stated as she was doing her rounds, V7 told V10 she had a phone call. V10 answered the phone and it was V6 (CNA). V6 told V10 to come to 4th floor. V6 told V10 that R2 was down on R1's floor in R1's room and R1 was screaming. V10 went back to 5th floor and told V7 (Nurse) about the incident on 4th floor with R2 and R1. V7 questioned why V6 didn't just tell V7 when V7 answered the phone. V10 stated that V7 is on vacation this week as to why V7 is not available. There was no documentation in either R1's or R2's clinical record about this alleged abuse. R2' care plan (10/1/21) documents R2 is an elopement risk. The approach is to monitor R2's location every shift, document the wandering behavior and attempted diversional interventions in behavioral log. This care plan was developed after the 9/18/21 incident. Prior to 10/1/21, there is no documented information on supervision or that R2 likes to wander. The facility's Supervision and Safety policy, which is lacking the facility's letterhead, documents that resident's safety and supervision are facility-wide priorities. The facility-wide approach to safety addresses the high-risk groups of wanderers, behaviors and aggression. Resident supervision is core component to residents' safety. Socialization between residents will be encouraged daily in Public areas for increased supervision. Staff are to intervene immediately whenever an unfavorable event between residents, staff or visitors is noticed. Staff will make visual rounds on residents minimally every 2 hours and more often if necessary.

Based on interview and record review the facility failed to follow physicians' orders to provide wound care and administer [CONDITION(S)] medications as ordered for one resident (R4) in a sample of 4 residents reviewed for wound and [CONDITION(S)] care. This failure has the potential to have caused R4's recurrent seizures and to cause R4's wounds to deteriorate. Findings include: R4 was [AGE] years old first admitted in on 3/31/2017 and last readmission of 6/12/2021. R4 was discharged to community hospital on 8/12/2021 for evaluation of fever and confusion. Hospital records showed that upon admission at the hospital R4 was having recurrent [CONDITION(S)] and the levels of anti-[CONDITION(S)] medications were low. On 8/3/2020, V7 (Wound Physician) documented wounds on R4's left and right heels. Wound evaluation documentation dated 08/2/21 and signed by V7 noted wounds to right and left heels deteriorated. Progress note dated 8/12/2021 at 10:51PM, showed R4 was hospitalized on [DATE] when R4 spiked a fever and was confused and documented Followed up with (hospital's name), res is admitted for infected ulcer, and [CONDITION(S)]. Treatment Administration Record (TAR) was reviewed for R4 for April, May, June and July2021. In April, May, June and July, the treatments were sporadically done or not done at all. In June 2021, R4 was hospitalized from 6/3/2021 until 6/12/2021. TAR noted there was no treatment documented from 6/13/2021 to 6/30/21. R4 was seen by V7 (Wound Physician) on 7/16/2021, at which time V7 documented R4 had a diabetic wound on left heel for 154 days and it measured 2.5x3.0x0.2cm. The right heel wound measured 4.8x5.3x0.3cm. On 8/2/2021 prior to R4's hospitalization on [DATE], V7 documented the size of R4's wounds as follows: right toe 3.5x3.5x0.5cm (deteriorated), left heel wound measured 4.5x4.0x0.2cm (deteriorated), right heel wound measured 5.3x5.8x 0.4cm (deteriorated). On 9/18/2021 at 11:30AM, V2 (Director of Nursing/DON) acknowledged there was no documented treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ? It was not done. V2 said, I do not know how the nurses forgot to put in the order for the treatment to R4's wounds. On 9/19/2021 at 2:10PM, V6 (Substitute Wound Nurse) said she was at the facility mainly to go with V7 (Wound Physician) on wound rounds. V6 said, If it was not documented, it was not done. Record shows R4 was prescribed two anti-[CONDITION(S)] medications for his [CONDITION(S)] conditions, however, the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/19/2021 at 2:10PM, V2 (DON) said she expected the nurses to sign out for the medications after administered. On 9/20/2021 at 11:10AM, V10 (Nurse Practitioner/NP) said if medications ordered for seizures were not administered consistently, then seizures could occur. In relation to treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility presented undated policy on pressure ulcer prevention which did not address treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to provide supervision for one (R1) of three residents reviewed for supervision. This failure resulted in R1, a highly delusional resident with no community survival skills, eloping from facility and was out in the community alone for 9 days with the weather bitterly cold. Findings include: On 2/10/21 at 12:30 PM in R1's room, R1 was sitting on edge of bed eating her lunch. R1 was asked about how she eloped from the facility and where she was for 9 days in the community. R1 responded she did not want to answer because she may want to elope again. R1 appeared highly delusional saying she has married many celebrities and has had babies by them. R1 stated her babies were taken away along with all her money, her cars, her businesses and her homes. R1 stated she does not feel safe, because there is someone who is trying to kill her. R1 stated she is currently going through a divorce and she is pregnant. As surveyor was leaving R1's room, V3 (Psychiatric Rehabilitation Service Director/PRSD) was at the doorway. R1 got up and walked slowly holding up pants that were loose and exposing her belly, saying to V3 that she is worried about her baby. V3 re-directed R1 back inside R1's room and reassured R1 that everything is okay. Record review documents R1 is an ambulatory female who has been a resident of this facility since 6/14/11 per the face sheet and annual Minimum Data Set ((MDS) dated [DATE]. R1's [DIAGNOSES REDACTED]. R1 requires supervision of her activities of daily living. R1 is alert and orient times three with a Brief Interview for Mental Status (BIMS) score of 9. R1 is care planned (11/18/20 through 1/30/21) for her delusions of thinking the facility is trafficking women and children, the facility has taken her children, believes the staff use razors at night to take her babies from her, the behavior of refusing medications and care, displaying talking and laughing to self and being very agitated. R1 has also made 911 calls for non-emergency issues. The outside entity providing psychosocial in-house programming documents in a 8/6/2020 assessment that R1 presents with grandiose and paranoid delusions, her experience of delusional belief system are severe and chronic in nature which impacts her willingness to be medication compliant, to engage in reality testing and the ability to build trusting relationships. R1 has trouble remembering information and events, but able to identify general information and current events. R1 presents with continued delusional thoughts about her environment. On 2/10/21 at 11:10 AM and 1:15 PM, V1 (Administrator) stated he received a call from V12 (Licensed Practical Nurse/LPN) around 5:20 AM on 1/23/21 about a missing resident (R1). V1 stated he was told that R1 eloped. V1 stated he was told that the exit door did alarm but could not say how long it took for staff to respond to the alarm. V1 stated the camera monitor was viewed on Monday morning, 1/25/21. It showed R1 exiting out the north patio door and setting off the alarms. The time stamp was 11 PM but V1 stated the time stamp is not accurate and has been broken since he started working here.V1 stated he interviewed all staff but was only able to provide staff interviews for V9 (Certified Nursing Assistant/CNA) and V10 (CNA) and V13 (LPN), one of 2 nurses working the 3rd floor. There were no interviews from V11 (R1's assigned CNA), V12 (the other nurse assigned to 3rd floor), or V5 (Receptionist). On 2/11/21 at 7:42 AM, V5 (Receptionist) stated she usually works 4:30 PM to 12 midnight but on 1/22/21 she worked until 3 AM. V5 stated she heard the exit alarm go off on the 1st floor around 2 AM and she called a code white. V5 stated that V12 (LPN), the other 3rd floor nurse, was down on 1st floor in reception area doing paperwork. V5 stated she called all nursing floors to ask about head counts and all nurses said the count was correct on floors. V5 stated she left the facility at 3 AM. V5 stated that the assistant administrator called her at home the next day and asked what happened. V5 stated, No one responded to the alarm exit door because the resident count was okay. V5's time sheet validates V5's time in facility on 1/22-23/21. On 2/10/21 at 1:55 PM, V2 (Assistant Administrator) stated there is a 24 hour receptionist. V2 stated she spoke with V5 (Receptionist) and V12 (LPN) about the elopement of R1. V2 stated V5 called a code white when she heard the exit alarm go off. V2 stated V5 called all nursing floors and spoke to nurses to get head count on each floor. Each nurse responded that the count on floor was correct and that no one missing. V2 stated she is not sure when staff left the facility to look for R1. On 2/10/21 at 11:20 AM and again at 12:45 PM, V3 (PRSD) stated R1 is currently highly delusional believing she is pregnant and in the hospital, which is untrue. V3 stated it was not determined how R1 got out of the facility or where R1 was for the 9 days she was gone. V3 stated that R1 believes that someone is trying to kill her. V3 stated that it was the police that picked her up in the community and took her to the local hospital. R1 gave a fictitious name and stated she was pregnant (which is untrue). A former employee of the facility recognized R1 in the hospital and informed hospital staff that R1 is a resident in a nursing home. A hospital nurse called and informed the facility of R1's whereabouts. Nurses note 2/2/21 documents local hospital calling and saying R1 is there. R1 had been in the community from 1/23/21 to 2/2/21, 9 days in the community. On 2/10/21 at 1:25 PM and again at 2:30 PM, V6 (Program Director for an outside entity that provides in-house psychosocial programming services) stated R1 has been a resident of this facility since 2011. V6 stated that R1 has eloped 5 times since her admission. The last time prior to 1/23/21 was in 2016. V6 stated that it is R1's behavior to give a fictitious name when she goes to the hospital. V6 stated that R1 is an elopement risk and has no community survival skills due to her being non-compliant with medication and being very delusional. On 2/10/21 at 1:28 PM, V7 (Outside Caseworker) stated V7 came to see R1 on 1/23/21 at 2:30 PM and discovered R1 was missing per a Certified Nurse Aide (CNA) on the floor. V7 stated she spoke with V2 (Assistant Administrator) who stated that the receptionist (V5) failed to announce the code white when the alarm went off and failed to have the outside area searched. V7 stated it was much later when V5 made the announcement for staff to do head count on the floors and the head count was okay per nurses. Review of the facility's investigation into R1's elopement has a written statement by V10 (3rd floor CNA) who wrote V11 (assigned CNA to R1) discovered R1 missing at 4 AM when doing rounds. That is when the search was conducted for R1, which was two hours after the exit alarm was set off by R1. The temperature for 1/23/21 in the early morning was in the upper teens to near 20 degrees Fahrenheit per V14's (Meteorologist) weather forecast. R1's December 2020 and January 2021 Medication Administrator Record (MAR) documents R1 is non-compliant with her medications due to R1's refusal. The last time R1 took any medication including the psychoactive medication was 12/11/20. R1's community survival assessments (11/18/20 and 1/25/21) document R1 is not capable of an unsupervised community pass due to her delusions. V3 (PRSD) completed both assessments. The facility's policy Elopement Prevention Devices and Systems documents elopement alert exit door device will be inspected for proper working order. If the alarm at exit door is malfunctioning, maintenance will be notified, and a staff member placed at door to prevent unauthorized exits. Staff to begin facility and neighboring communities search immediately upon inability to locate a resident.

Based on observation, interview, and record review, the facility failed to monitor, supervise, and protect four residents (R12, R13, R24, and R25) from serious bodily harm. These failures resulted in R12 sustaining a right [MEDICAL CONDITION], R13 sustaining a left knee fracture, R24 sustaining a serious head injury where he suffered a change in condition that required emergency medical services, hospitalization , and intubation, and R25 sustaining a right arm fracture. Findings include: 1. According to the face sheet, R12 was admitted to the facility on [DATE]. R12's [DIAGNOSES REDACTED]. A Brief Interview for Mental Status indicates that R12 is not cognitively intact and requires extensive to total assistance from staff. Fall risk assessment dated [DATE] notes that R12 is a high risk for falls and has a history of falls. Record Review of R12's resident records document the following: Progress note dated [DATE], notes in part, R12 alert and responsive. Displays pain upon movement of right leg. Also, pain to touch and unable to give range of motion. The doctor was notified of condition. Orders were given to send resident to a local hospital. X-ray report dated [DATE], notes right [MEDICAL CONDITION]. Unusual Occurrence Report dated [DATE], notes R12 complained of right leg pain. Pain medication was administered. The medical doctor was notified and R12 was sent to a local hospital. R12 was unable to verbalize how the incident occurred. All staff and residents with contact with R12 were interviewed. R12 was diagnosed with [REDACTED]. R12 is noted with a history of impulsive behaviors, poor safety awareness, and noncompliance with using his wheelchair or asking for assistance with transfers. R12's roommates were also interviewed. No reports of seeing or hearing any falls or unusual occurrences. 2. R25's [DIAGNOSES REDACTED]. A review of R25's care plan notes that she is not very alert, is at risk for falls related to impaired mobility with an unsteady gait. R25 presents with an alteration in the ability to communicate due to impaired speech and cognitive abilities. R25 has behaviors that include wandering, pacing, and roaming. Review of R25's resident records documents the following: Progress note dated [DATE], notes R25's right shoulder was noted to be bulging out, no injuries witnessed. Resident is cradling affected arm to her side, not compliant, unknown cause at this time. R25 was sent to a local hospital for an x-ray. The x-ray result was a right arm fracture. On [DATE], at 3:30PM, V31 (Nurse) stated, A CNA (Certified Nursing Assistant) informed me that R25's shoulder is 'coming off'. I assessed her shoulder and it did not look right. I informed the doctor what was going on. It looked abnormal. R25 ambulates a lot. For residents that are higher risk we try to monitor more closely. If the resident is not alert and oriented, they are not going to remember the safety awareness. She is not very alert and oriented. She is very confused and needs to be monitored. The surveyor conducted interviews regarding the incidents that occurred on [DATE] and [DATE] involving residents R12 and R25. On [DATE], at 10:41AM, V24 (CNA) stated, Staff should be making rounds every two hours. R12 needs more frequent rounding. He will sit up on his own and try to get out of the bed. He is not an independent resident. He cannot get up on his own. He is a total care resident with extensive assistance. On [DATE], at 10:53AM, V23 (Nurse) stated R12 was having [MEDICAL CONDITION]. R12 does not talk at all. He is a fall risk and requires more frequent monitoring and supervision. On [DATE], at 11:30AM, V13 (Licensed Practical Nurse/LPN) stated, The care plan is supposed to get updated by the nurses. In my opinion, R12 has several predisposing factors such as decreased safety awareness, confusion, incontinence, gait imbalance, impaired memory, and weakness. R12 is not able to speak much. He is not very alert and oriented. He can get up by himself, but he is unsteady. He is a total care resident and he is very confused. He requires supervision. On [DATE], at 2:50PM, V18 (Quality Assurance/Fall Coordinator) stated, The care plan needs to be updated after every fall, what may have caused the fall and what we can do to prevent the fall again. R12 was sent out because he complained of pain. This was not reported as a fall that day. R12 tends to be impulsive, needs redirection, and supervision. The predisposing factors in the incident reports should be checked off as part of the investigation. On [DATE], at 2:25PM, V28 (Medical Doctor) stated, I am very familiar with R12 and R25. R25's type of arm fracture usually results from a fall. R25 ambulates aimlessly. Staff should be overseeing them and making sure there is enough staff to monitor. R12 is a high risk for fracture due to his [MEDICAL CONDITION]. The staff have to be more aware of the residents' risks. On [DATE], at 3:14PM, V22 (CNA) stated, R25 needs to be redirected because she is confused. She is set in her ways. She walks around and is incontinent. She goes in everyone's room. She needs supervision because she takes things and walks around. I am not aware if she is a fall risk. Monitoring every two hours and as needed will help prevent a resident from falling and injuring themselves. Record review of R12 and R25 assessments and care plans note: Fall Risk assessment dated [DATE] notes R12 has had three or more falls in the facility. R12 is frequently incontinent and disoriented. He is still a high risk for falls. After [DATE], R12 had four more falls within the facility. On [DATE], R12 had a fall where he sustained a small cut to his forehead. R12's care interventions include staff need to anticipate and meet R12's needs, follow the facility fall protocol, increase monitoring and toileting every two hours, review information on past falls and attempt to determine cause of falls, record possible root causes, remove any potential causes if possible, educate resident, family, and caregivers and staff as to the causes, educate the resident, family, care givers about safety reminders and what to do if a fall should occur, be sure the call light is within reach and encourage the resident to use it for assistance as needed, continue interventions on the at-risk plan, place resident in high visual areas while awake and staff provide frequent checks to ensure that all needs and wants are met. Fall risk assessment dated [DATE] and [DATE] note that R25 is a high risk for falls. R25's care plan interventions include anticipate and meet the resident's needs, educate the resident, family, caregivers about safety reminders and what to do if a fall occurs, follow facility fall protocol, review information on past falls and attempt to determine cause of falls, record possible root causes, observe resident for impaired balance, lethargy and implement preventive intervention strategies. 3. R13's [DIAGNOSES REDACTED]. R13's cognitive assessment score dated [DATE] is 5, which indicates severe cognitive impairment. dated [DATE]. During observation of R13 at 10:04AM with V18 (Quality Assurance Nurse), V18 stated R13's call light string is not long enough and should be close to him. During an interview on [DATE] at 11:27AM V13 (Licensed Practical Nurse/LPN) stated, I keep R13 in my field of vision. R13 used to be in a room where he could be seen more frequently located across from nurses' station. Most of R13's falls occur at shift change. During an interview on [DATE] at 12:06PM V18 stated the care plan should be updated with a new intervention after each fall. During an interview on [DATE] at 1:08PM V12 (LPN) stated R13 fell in his room, located at the end of the hall away from nurses' station, and she was aware of R13's risk for falls. V12 stated, We monitored him, reinforced for him to call for assist when he wanted to get up. I followed the fall protocol. I was not given further instruction to prevent R13 from falling again. We continued to do what we did before. V12 stated any staff interviews she made would have been documented. V12 stated, I don't know what caused him to fall. I try to do rounds every 2 hours on all my residents. During an interview on [DATE] at 2:12PM V18 stated R13's fall care plan has no intervention following the fall on [DATE]. During an interview on [DATE] at 2:24PM V22 (CNA) stated, I take R13 to the bathroom when I see he has started to pull his pants down. When I seem him like that, I know that he was trying to take himself to the bathroom. V22 stated, I tell R13 to lock his wheelchair when he gets up because we can't be with him at all times. V22 stated R13 can stand, but if he stands up he can fall. V22 stated R13 sometimes remembers the reminders, other times he does not. During an interview on [DATE] at 9:19 AM V18 stated the standard fall precautions from the Fall Prevention Program are used on all residents. During an interview on [DATE] at 10:15AM V34 (Occupational Therapist) stated R13 received physical therapy from [DATE] until [DATE] and occupational therapy from [DATE] until [DATE]. During an interview on [DATE] at 10:58AM V33 (Therapy Director) stated R13 is a fall risk. V33 stated R13 can recall safety interventions ,[DATE]% of the time; the other times he does not follow them. V33 stated R13 requires one-person assist with transfers. Review of R13's fall care plan notes intervention date initiated [DATE]: Be sure the resident's call light is within reach. Review of fall report for [DATE] notes resident on the floor in bathroom. The intervention noted on care plan dated [DATE] states remind to call for assistance, provide toileting assistance every 2 hours and as needed, refer to therapy for screening. Review of R13's assessments include Functional Status assessment dated [DATE] which notes R13 requires extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. Balance assessment for moving from seated to standing position dated [DATE] notes the resident is not steady, only able to stabilize with staff assistance. Fall history assessment dated [DATE] notes a history of a fall in the last month and in the last ,[DATE] months. Review of fall report for [DATE] notes R13 stated, I slid out of my chair. Intervention dated [DATE] states encourage him to come out of his room. Review of R13's fall report on [DATE] noted R13 stated his legs give out. Intervention dated [DATE] was for a therapy screen. Review of R13's fall report on [DATE] notes R13 fell in his room. Review of X-ray reports a knee x-ray was obtained and left knee shows faint linear vertical fracture of patella (knee bone). Review of R13's Fall Risk Review dated [DATE] notes R13 has been determined to be high risk for falls. Fall Risk Reviews for [DATE], [DATE] and [DATE] note R13 is determined to be high risk for falls. R13's Fall care plan initiated [DATE] notes he is at risk for falls/accidents related to medical complexities, impaired mobility, incontinence, multiple medication use, history of falling, (and) [MEDICAL CONDITION] medication use. The focus does not include a fall risk classification of high risk, as mentioned on the Fall Risk Reviews. Interventions of placing the call light in reach are listed on [DATE] and [DATE]. There is no care plan intervention documented following the fall on [DATE]. Review of R13's fall care plan notes interventions for therapy screen following falls on [DATE] and [DATE]. As written above, V33 stated R13 began therapy on [DATE] and continued on therapy until [DATE]. Review of R13's fall care plan notes interventions following the fall on [DATE] included remind resident to call for assistance. This intervention had already been added as intervention on [DATE] when the fall care plan focus was initiated. 4. R24's [DIAGNOSES REDACTED]. Review of R24's Fall Report dated [DATE] notes R24 fell in the hallway, was unconscious, emergency services called, and the paramedics arrived to the scene. During an interview at 1:30PM V2 (Director of Nursing) stated R24 did not return to the facility after [DATE]. During a phone interview on [DATE] at 2:04PM V26 (Family Member) stated, R24 has expired. He passed away last month. He would always say he wanted to come home. The facility does not monitor these residents or keep them safe. V26 stated R24 fell several times at the facility and hit his head. V26 stated they neglected R24. During an interview on [DATE] V25 (CNA) stated R24 needed cues. V25 stated she had seen R24 running in the halls and knew he had dizzy spells in the past. During a phone interview on [DATE] at 12:09PM V18 stated R24 sustained an injury from the fall on [DATE] and he received stitches. V18 stated the care plan should have an intervention following his fall on [DATE]. During a phone interview on [DATE] at 2:18PM V28 (Physician) stated, I expect the staff to look for the cause of the fall and address it to prevent falls. Review of R24's Fall Risk Review dated [DATE] and [DATE] notes R24 is at high risk for falls. R24 was noted to have a history of ,[DATE] falls in last 6 months. Review of Fall Report for R24 dated [DATE] notes R24 fell in the hallway after running with unsteady gait. Report states resident fell and hit right side of his head. Predisposing factors are unanswered on the report. Review of R24's care plan for fall focus initiated on [DATE] document interventions listed as initiated [DATE]. The exception was on [DATE] when a new intervention was put in place for increased monitoring when ambulating and neuro checks. No intervention was listed following the [DATE] fall. Review of Progress Notes dated [DATE], written by V2, state resident was not extubated due to possible [MEDICAL CONDITION] (a condition that occurs when your body does not produce enough [MEDICAL CONDITION] hormone). Review of R24's final report sent to IDPH on [DATE] states R24 was admitted to the hospital with [REDACTED]. At this time resident remains hospitalized . Further review of R24's care plan does not include R24's behavior of running in halls or being dizzy. The facility's undated Policy for Fall Prevention Program notes the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementing appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: 10. Care Plan incorporates: identification of all risk/issue. Standards include safety interventions will be implemented for each resident identified at risk using a standard protocol. Standard Falls/Safety Precautions for all residents includes 2. The nurse call device will be placed within the resident's reach at all times. 7. Residents will be observed approximately every 2 hours to ensure the resident is safely positioned in the bed or a chair. 8. Call lights are kept within reach and answered promptly. 16. All nursing personnel will be informed of residents who are at risk of falling. The fall risk classification will be identified on the care plan. Safety Precautions for residents at risk notes any resident who falls at least twice within 30 days will be considered AT RISK. Care Plan incorporates: Identification of all risk/issues. Interventions are changed with each fall, as appropriate. Preventative measures.

Based on interview and record review the facility failed to ensure that residents were free of abuse/physical assault. This affected two (R1 and R3) of three residents, reviewed for abuse, resulting in R1 sustaining an eye globe rupture that required surgery. In addition, R3 sustained scratches to the face. Findings include: On 10/19/20 at 10:15am, V1 (Administrator) stated that R2 was moved to the third floor and became physically aggressive toward three other residents. V1 added not all the three residents involved in the physical assault were R2's roommates. At this time, V1 presented the facility's preliminary incident investigation report that states that there was a resident to resident altercation on 10/16 20 at 8:50pm where R2 injured R1 and R3. On 10/20 20 at 11:50am, V13 (Certified Nurse Assistant/CNA) stated, When I went into R1's room to help his roommate get in bed on 3-11 shift around 8:30pm, R1 told me that R2 hit him in the eye. I did not witness the incident. I went to tell the nurse immediately. That day, I worked a double (3-11 and 11-7 shifts). No, R1 was not sent to the hospital on the 3-11 shift or 11-7 shift. I am not sure when he was sent to the hospital, but not on my shift. On 10/19/20 at 11:10am, V16 (Registered Nurse/RN) stated that no staff witnessed the physical altercation between the residents. V16 added, The staff noticed that R1's eye was swollen, and he said that R2 hit him in the eye. R1's progress notes dated 10/17/20 at 4:33am written by V6 (Wound Care Nurse) states, Resident received with swollen bloody eye. Resident stated that his new roommate hit him in the eye. Resident is alert. Blood noted to bed. R1's progress notes dated 10/18/20 at 2:25pm written by V10 (Licensed Practical Nurse/LPN) states that the Hospital Physician called to inform V10 that resident had a ruptured eyeball and surgery to repair it went well. V17 (Hospital Trauma Resident Physician) stated, Resident was either pushed or punched in the face resulting in a globe rupture of the eye. Resident needed surgery and is in stable condition. Social Services at the hospital reports that this is not the first time this has happened. Resident has had several altercations with his roommate in the past resulting in injury. R3's progress notes dated 10/17/20 at 3:07pm states that R3 sustained multiple small superficial scratches to right side face and one scratch to left side cheek. On 10/19/20 at 1:15pm, V3 (Nurse Consultant) was asked about all aggression incidents involving either R1 or R2. V3 returned with the document that shows that R2 initiated aggression incidents on 6/2/2019 and 12/24/2018, in addition to this incident that happened on 10/16/20 where R1 was seriously injured. There was no other incident documented in the past that involved R1. Facility's undated policy titled Abuse Prevention Policy states in part: Residents have the right to be free from abuse, neglect, and exploitation, misappropriation of property or mistreatment. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Based on interview and record review, the facility failed to ensure a timely physician notification regarding a resident sustaining a traumatic eye injury and failed to send the resident to the hospital in a timely manner. This affected one of one resident (R1) reviewed for quality of care. R1 sustained a globe rupture of the eye, and the Physician or Nurse Practitioner was not notified until after seven hours, and R1 was not sent to the hospital until about fourteen hours after the injury. Findings include: On 10/19/20 at 10:15am, V1 (Administrator) stated that R1 was hit on the eye by another resident. V1 presented the facility's preliminary incident investigation report that states that there was a resident to resident altercation on 10/16/20 at 8:50pm where R2 injured R1 and R3. On 10/20 20 at 11:50am, V13 (Certified Nurse Assistant/CNA) stated, When I went into R1's room to help his roommate get in bed on 3-11 shift around 8:30pm, R1 told me that R2 hit him in the eye. I did not witness the incident. I went to tell the nurse immediately. That day, I worked a double (3-11 and 11-7 shifts). No, R1 was not sent to the hospital on the 3-11 shift or 11-7 shift. I am not sure when he was sent to the hospital, but not on my shift. On 10/19/20 at 11:10am, V16 (Registered Nurse/RN) stated that no staff witnessed the physical altercation between the residents. V16 added, The staff noticed that R1's eye was swollen and R1 said that R2 hit him on the eye. On 10/20/20 at 4:07pm, V15 (Nurse Practitioner) was interviewed regarding the delay in sending R1 to the hospital for treatment. V15 stated, I'm very familiar with the resident. I expect that the resident be sent out by 911 immediately. There should be no delay because you may not see blood on the eye at first, but it could be internal bleeding since it's the eye. On 10/17/20, V20 (Hospital ER Physician) stated that R1 was sent to the hospital for a Level 2 Trauma. R1's progress notes dated 10/17/20 at 4:33am written by V6 (Wound Care Nurse) states, Resident received with swollen bloody eye. Resident stated that his new roommate hit him in the eye. Resident is alert. Blood noted to bed. R1's nurse's notes written by V5 (Licensed Practical Nurse/LPN) on 10/17/20 at 11:40am (over 14 hours after the injury occurred) states that the Nurse Practitioner was called and notified about the bleeding and increased swelling to left eye and face. It was at this time that the nurse received orders to send R1 to the hospital. The ambulance transport staff then told the nurse that the expected time of arrival (ETA) for pick up would be 30-45 minutes. Facility's Incident Report states that time of incident was 8:50pm on 10/16/20 and R1's progress notes shows that the first time the Nurse Practitioner was notified of R1's injury was 10/17/20 at 4:25am and at 6:23am by V6 (LPN). This was about 7 hours after the injury. Also, R1 was not sent to the hospital until over 14 hours after the injury occurred. On 10/17/20, V20 (Hospital ER Physician) stated that R1 was sent to the hospital for a Level 2 Trauma. Facility's policy dated 4/14, titled Change in Condition Physician Notification Overview Guidelines states in #3: Medical care emergency problems are communicated to attending physician and family immediately (generally within two hours or sooner). The facility did not follow these guidelines.

Based on interview and record review, the facility failed to adequately supervise and monitor a resident who has a history of physically assaulting other residents. This failure affected one of one resident (R2) reviewed for supervision. R2 went into the rooms of two other residents and physically abused them, injuring his new roommate on the eye, which resulted in a globe rupture of the eye that required surgery. Findings include: On 10/22/20 at 3:44pm, V1 (Administrator) stated that he completed the final investigation on the incident where R2 assaulted three other residents, and he was puzzled that not a single staff member witnessed the incident. V1 stated that from his investigation, R2 was probably upset because he was moved to another unit, and R2 became physically aggressive toward the residents. V1 explained that R2 went to attack each of the residents in their rooms. No records to show that any staff observed the incident to explain how R2 left his room and went to the room of the other resident and attacked them. The assigned nurse V14 (Licensed Practical Nurse/LPN) and V13 (the assigned Certified Nurse assistant/CNA) both stated that they did not know when the incident happened. Both V13 and V14 stated that none of the staff members on the floor witnessed the incidents with R2 versus R1 or R2 versus R3. On 10/20/20 at 11:40am, V14 stated that she was the assigned nurse for R1, but she went on lunch break and when she came back around 8:30pm on that day, the other nurse told her that R2 had attacked 3 residents, injuring two of them. On 10/19/20 at 11:10am on the third floor, V16 (Registered Nurse/RN) stated that no staff witnessed the incident and that they knew about it when R1's eye was noted to be swollen. On 10/17/20, V20 (Hospital ER Physician) stated that R1 was sent to the hospital for a Level 2 Trauma. V17 (Hospital Trauma Resident Physician) wrote, Resident was either pushed or punched in the face resulting in a globe rupture of the eye. Resident needed surgery and is in stable condition. Social Services at the hospital reports that this is not the first time this has happened. Resident has had several altercations with his roommate in the past resulting in injury. On 10/19/20 at 1:15pm, V3 (Nurse Consultant) was asked about all aggression incidents involving either R1 or R2. V3 returned with the document that shows that R2 initiated aggression incidents on 6/2/2019 and 12/24/2018 against other residents, in addition to this incident that happened on 10/16/2020 where R1 was seriously injured. R2's care plan dated 3/11/20 states that R2 is at risk for falls/accidents and R2 requires continued monitoring when ambulating. R2's MDS (Minimum Data Set) dated 10/14/20, section G, #D shows that R2 requires one person physical assistance to walk in the corridor on the unit (a score of 2). Also, #E shows that R2 requires one person physical assistance to move on adjacent corridor on the same floor (score of 2). If staff followed what R2's MDS says regarding his functional status, R2 could not have gone from room to room to physically assault other residents without any staff knowing about it. Facility's policy on Resident Rounds dated 5/14 states under Purpose: To evaluate provision of resident care and to supervise and monitor staff adherence to the president's plan of care. #1 states: Rounds will be conducted at varying times and residents observed to assure care is provided according to assessed needs and changes in condition by all staff daily.

Based on observation, interview, and record review, the facility failed to provide appropriate person-centered and individualized psychosocial and mental health services to meet the assessed needs of the resident. This affected one of two residents (R2) reviewed for psychosocial and behavior health needs. R2 did not receive the therapeutic interventions from social services staff as stated in his care plan, resulting in R2 becoming physically aggressive towards other residents and causing R1's globe rupture of the eye. Findings include: On 10/19/20 at 10:15am during the entrance conference, V1 (Administrator) presented the facility census as 159 residents. V1 stated that R2 was probably upset because he was moved to another unit, and R2 became physically aggressive toward three other residents. No records to show that a social service staff spoke to R2 to explain the reason for moving him before he was moved from the second floor to the third floor. No records of a behavior note in R2's progress notes written by any social services staff regarding the incident. On 10/19/20 between 10:30am and 12pm, residents and nursing staff, including V18 (Licensed Practical Nurse/LPN) and V19 (LPN) were observed and interviewed on the nursing units regarding the availability of social services staff to speak with residents individually. V18 (on the fifth floor) stated that the social worker was not there on the floor, but she could call their office downstairs if a resident needs a social worker. V19 (LPN) stated that residents' activities are on a one to one basis because of the pandemic, however, no staff from activities or social services department was observed on the floor talking with any resident. On 10/19/20, V9 (Social Services Director/Psychiatric Rehabilitation Services Director/PRSD), was observed monitoring residents who were smoking outside. V9 was later interviewed regarding the individualized mental health services the facility provides for residents. V9 stated that he currently has two psychiatric rehabilitation services coordinators, PRSCs/social workers (V7, V8) working with him and they do the best they could do. Again on 10/20/20 at 11:25am, both V7 and V9 were called into the conference room to express the concern that the surveyor did not observe social services staff on the nursing units interacting with the residents. Both V7 and V9 stated that they had 3 social workers the previous day, but today (10/20/20), only the two of them are working. V9 explained that in the past, there were seven social workers in the department, but the rest of the staff no longer work at the facility. V9 was asked how many residents were on the case load for each PRSC; V9 did not respond. V9 later brought the list of all 159 residents with who each social worker assigned to; the list indicated each social worker is assigned 53 residents. V7 was asked how she was able to provide individualized psychosocial and mental health therapy to 53 residents on her case load. V7 did not respond. At this time, V1 (Administrator) was called in by the surveyor to express the concern that only three social services staff were responsible for 159 residents. V1 stated that they had advertised the positions and made efforts to hire more social workers to meet the needs of the residents. On 10/22/20 at 3:44pm, V1 (Administrator) stated that he completed the final investigation on the incident, and he was puzzled that not a single staff member witnessed the incident. V1 stated that from his investigation, R2 went to attack each of the other two residents in their rooms. Records show that R1 and R2 were roommates, but no staff observed the incident to explain how R2 (who was supposed to be in his room) went to attack and scratch the face of R3 who lived in a room down the hall. The assigned nurse (V14) and the assigned CNA (V13) both stated that they did not know when the incident happened. Both V13 and V14 stated that none of the staff members on the floor witnessed the incidents with R2 versus R1 or R2 versus R3. On 10/20/20 at 11:40am, V14 (LPN) stated that she was the assigned nurse for R1, but she went on lunch break and when she came back around 8:30pm on that day, the other nurse told her that R2 had attacked 3 residents with two of them injured. V14 stated that she did not know if R2 went from room to room to attack each resident. On 10/19/20 at 11:10am on the third floor, V16 (Registered Nurse/RN) stated that no staff witnessed the incident and that they knew about it when R1's eye was noted to be swollen. On 10/17/20, V20 (Hospital ER Physician) stated that R1 was sent to the hospital for a Level 2 Trauma. V17 (Hospital Trauma Resident Physician) wrote, Resident was either pushed or punched in the face resulting in a globe rupture of the eye. Resident needed surgery and is in stable condition. Social Services at the hospital reports that this is not the first time this has happened. Resident has had several altercations with his roommate in the past resulting in injury. On 10/19/20 at 1:15pm, V3 (Nurse Consultant) was asked about all aggression incidents involving either R1 or R2. V3 returned with the document that shows that R2 initiated aggression incidents on 6/2/2019 and 12/24/2018, in addition to this incident that happened on 10/16/2020, where R1 was seriously injured. There was no other incident documented in the past that involved R1. R2's progress notes dated 10/15/20 at 10:20pm written by V8 (Social Worker) states that R2 often wanders into other residents' rooms and has been refusing some medications. Also, on 10/8/20 at 11:06am, V4 (LPN) documented that R2 refused his medications. R2's care plan dated 8/28/2019 states that R2 was physically aggressive with another resident; intervention states to encourage R2 to talk to social services when feeling frustrated. Another care plan dated 11/30/2018 states that R2 experiences hallucinations due to his medical diagnoses; intervention states to provide R2 with a safe place to sit or stand when responding to hallucinations. Another care plan intervention dated 12/26/2019 states to listen carefully to the resident's description of his concerns, assure resident that his satisfaction is important, and to work cooperatively to resolve the complaint. These interventions cannot be achieved if the social services staff are not available. Facility's undated document titled Responsibilities of the Psychiatric Rehabilitation Service Coordinator (PRSC) states, To provide and/or coordinate the delivery of the psychiatric rehabilitation services programs; to monitor the resident in the areas of self-directed care and for overall compliance with the treatment plan. #13 states to provide active listening with individuals on the assigned case load. The PRSC needs to establish a good rapport with residents and be available to provide behavioral intervention/counseling.

Based on observation, interview and record review the facility failed to notify the physician of resident change in condition, failed to obtain vital signs, failed to document a physical assessment, failed to implement an incident report, and failed to provide timely care/services for one of three residents (R1) reviewed for change in condition. These failures resulted in R1 sustaining severe pain related to left femoral neck fracture. Findings include: On 3/22/20, V10 (Licensed Practical Nurse/LPN) documented in the progress notes that staff on duty informed her that (R1) was noted to have facial grimacing while being changed. Writer assessed and Tylenol given as ordered for pain. (R1's 3/22/20 Medication Administration Record [REDACTED]. Staff will continue to monitor and follow up as needed. (There is no documentation regarding vital signs and/or physician notification.) On 8/26/20 at 9:56am, surveyor inquired about R1's cognitive status. V10 stated Usually he's sitting up making facial expressions. He's not able to talk, he makes like moaning expressions. Surveyor inquired about R1's (3/22/20) assessment. V10 stated One of the staff members came to me with concern that he may be having possible pain. He had a facial grimace with some pain and discomfort, I really couldn't tell where. When I went to assess him, he wasn't guarded or anything but that was not the norm for him. Surveyor inquired if she filled out an incident report (on 3/22/20). V10 affirmed We did not; we did not know at that time what was going on. I wasn't informed to do one at that time with the manager on duty. R1's (3/25/20) summary of investigative findings states on 3/22/20, nurse observed resident in pain, assessed and noted change in range of motion to left lower extremity. On 3/23/20, V11 (LPN) documented in the progress notes that (R1's) left knee and ankle x-ray was performed. Will continue to monitor. (There is no documentation regarding vital signs, physical assessment, and/or x-ray results). On 8/25/20 at 3:39pm, surveyor inquired why R1 required knee/ankle x-rays (on 3/23/20). V11 stated I was told to carry out that order from the 24-hour report. Surveyor inquired why R1's (3/23/20) physical assessment and/or vital signs were not documented. V11 responded I wasn't aware I had to fill out a separate assessment for each patient. Surveyor inquired if she documented an incident report for R1 (on 3/23/20). V11 replied No. Why would I fill out an incident report if I didn't know if he fell , if he didn't fall on my shift and I didn't witness it? Surveyor inquired when an incident report is required. V11 responded To my knowledge if there's a fall or if the patient is injured. R1's Physician order [REDACTED]. R1's (3/24/20) Medication Administration Record [REDACTED]. R1's (3/24/20) femur/hip x-ray includes reported date and time 3/24/20 at 5:58pm. R1's (3/25/20) SBAR (Situation Background Assessment Recommendation) affirms he was not transferred to the hospital until approximately 12:00pm (18 hours after the fracture was reported). R1's (3/25/20) History & Physical states the patient was brought to the emergency room for inability to ambulate with severe left-sided pain. X-rays and CT (Computed Tomography) shows non-displaced (left) femoral neck fracture. On 9/1/20 at 12:30pm, surveyor inquired about R1's aforementioned injury. V20 (Physician) stated R1 went out to the hospital for a [MEDICAL CONDITION] and they did surgery. R1's (3/29/20) discharge summary states: patient underwent percutaneous screw fixation of left femoral neck fracture. On 9/1/20 at 12:30pm, surveyor inquired about nursing requirements for R1's (3/22/20) change in condition. V20 (Physician) stated They should contact the physician if there's any change in condition. They should do vital signs. If the patient is having pain that should be assessed. If there was an incident on the 22nd or any kind of pain they should have notified me to get orders for an x-ray. I would never wait on ordering an x-ray. Surveyor inquired about potential harm to R1 if care/services were not provided and/or timely (on or about 3/22/20). V20 responded Compromised care if the physician is not notified right away. If he's in pain that might also be a problem. The (11/14) pain management program states pain assessment protocol will be initiated under the following situation: a change in resident condition occurs to require pain control. Documentation of assessments and the resident's response to the pain management plan will be made with each assessment. The (4/14) change in condition physician notification guidelines state these guidelines were developed to ensure that: all significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and to be documented in the medical record. When contacting the physician the nurse in charge should have the following information available: nature of problem or complaint with symptoms, signs, and results of current physical assessment, including vital signs and mental status. Any calls to or from the physician will be documented in the nurse's notes indicating information conveyed and received.

Based on observation, interview and record review the facility failed to provide immediate medical attention for a right leg fracture to 1 out of 1 resident (R1) in the sample of 4 (R1, R2, R4 and R 5) reviewed for nursing care. This failure resulted in severe pain to R1's right leg fracture. Findings include: On 3/3/20 at 1:05 PM R1 was observed inside R1's room with right leg cast from above the knee to foot, exposing only the toes. R1 was grimacing and moaning; R1 was unable to move her right leg. R1 was alert and oriented to person, place and time, with a Brief Interview for Mental Status (BIMS) score of 13. R1 stated that she suffered severe pain and has not been able to move her right leg since it was twisted by R3. R1 stated that the pain was getting worse and worse and that R1 could not sleep well at night. R1 stated R1 has a fracture which was caused by her roommate (R3) when R3 grabbed her leg and squished it as hard as she could while she was sitting in her wheelchair. R1 stated that no one saw what happened because they were alone during the incident. On 3/3/20 at 1:30 PM R3 was observed inside the 3rd floor dining room sitting in a wheelchair. R3 stated that she was living on the 2nd floor before and had a fight with her roommate (R1). R3 stated that she grabbed R1's leg and pulled and twisted it. R3 stated she doesn't think she broke R1's leg but just twisted it. R3 stated the fight started over R3 wanting to buy some pizza, but R1 did not want to give R3 money. On 3/4/20 at 11:56 AM V1 (Administrator) stated that R1 stated that her roommate (R3) twisted her leg. R3 was sent to the hospital for psych evaluation and was admitted . V1 stated that no nursing staff witnessed the incident. V1 stated that he was not in the facility when the incident happened. V1 received a call from V6 (Nurse Supervisor) that R1 was complaining of pain on the leg and that pain medication was given. On 3/4/20 at 2:04 PM V8 (Attending Physician) stated that he was informed by the nurse on 2/12/20 that R1 had right leg pain and swelling. V8 stated that he ordered an X-Ray and was informed that R1 had a fracture on her right leg. V8 stated that he ordered the nurse not to send R1 to emergency department or to the hospital but to schedule R1 to see V9 (Orthopedic Physician) in an outpatient orthopedic clinic. V8 stated that if he sent R1 to emergency department or to the hospital they would do nothing but refer R1 to an Orthopedic Specialist. On 3/4/20 at 3:10 PM V2 (Director of Nursing) stated that R1 was not sent to the ER because V8 (Attending Physician) ordered the facility not to send R1 to ER. According to V8, all they would do in the ER is to refer R1 to an orthopedic doctor. So instead V8 wanted to refer R1 directly to an orthopedist. V2 stated that the orthopedic walk-in clinic was open on Saturdays only and because of insurance issues, transportation was not available for R1 to see V9 until 2/22/20. V8 was informed that R1 was scheduled to see V9 on 2/22/20. V2 stated, From 2/10/20 to 2/22/20 we gave R1 pain medication as an intervention. But I do not recall other interventions; I would have to look it up. V2 stated that she spoke to V8 about faxing his progress notes and documentation about R1's incident because V8 has no written documentation of his multiple visits that can be found in the Progress Notes. On 3/4/20 at 3:35 PM V6 (Nursing Supervisor) stated, V4 (Registered Nurse) called and informed me that R1 was complaining about leg pain. We assessed R1 and saw that her knee was swollen. Then V4 gave her pain pill. I instructed V4 to call V8 (Attending Physician) and V8 ordered an X- Ray. R1 stated that her roommate (R3) said that R1 stole her money. R1 said that R3 messed up her knees. Since that is abuse, I called the administrator. V1 (Administrator) told me to call the psych doctor for R3. The psych doctor ordered that R3 be sent to the hospital for psych evaluation. R3 was sent to the hospital and was admitted . On 3/4/20 at 4:00 PM V4 (Registered Nurse) stated, I was taking care of R1 the day of the incident. Later during the shift, R1 complained of right knee pain. R1 stated that R3 messed with her leg by twisting it. R1's right leg was swollen during assessment. V6 (Nurse Supervisor) instructed me to give pain medication and to inform V8 (Attending Physician). V8 was informed and ordered an X-Ray. Right leg X-Ray result dated 2/12/20 read: Findings: There was an acute mildly displaced comminuted fracture distal tibia and fibula. Normal ankle mortise. Impression: Acute mildly displaced comminuted fracture distal tibia and fibula. On 3/6/20 at 1:08 PM V9 (Orthopedic Surgeon) stated, When I saw R1 in my clinic on 3/22/20, I did my assessment and an X-Ray was done. Based on physical examination, R1 was unable to move the right leg and was observed with green and blue bruising. R1 was complaining of severe pain of 10 on a 1-10 pain scale. R1's X-Ray result revealed that R1 had a complete fracture on her right tibia and fibula and right ankle. It is very important to provide immediate medical attention when a fracture happens. There are many complications that may happen. The skin may break open because bones are rough or sharp on the edges. For sure a fracture like this needs immediate medical attention. At the very least it would need a splint. On the X-Ray, R1's ankle showed a complete fracture, as shown in my report. I do not know why on the facility X-Ray, the result was normal ankle mortise. V9's (Orthopedic Surgeon) report dated 2/22/20 read: Physical Exam: R1 was unable to move right leg, green/blue ecchymosis at right knee, right knee appears to be displaced. Right tibia/fibula x-ray - complete fracture. Right ankle 3 view x-ray - complete fracture. Right knee 3 view x-ray - will be reviewed at next appointment. Procedure: Long leg cast application. R1's Minimum Data Set (MDS) assessment dated [DATE] reads: Brief Interview for Mental Status (BIMS) score as 13. R1's needs 2-person extensive on bed mobility and 2-person total assist on transfers. R1 cannot ambulate and uses wheelchair for locomotion. R1's Care Plan does not include any interventions done or updated from 2/12/20 to 2/22/20 for right leg fracture. Updated interventions, which were done after 2/22/20, include altered comfort level for [DIAGNOSES REDACTED]. From 2/12/20 to 2/22/20 R1 had no Care Plan Focus, Goal and Intervention addressing R1's right leg fracture. Policy on Change in Condition Physician Notification Overview Guidelines dated 4/14 reads: All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical records.

Based on interview and record review the facility failed to prevent staff from physically abusing 1 of 3 residents (R9) , reviewed for abuse in a sample of 3. This failure resulted in R9 sustaining a fracture to the left arm. Findings include: On 6/24/11 at 11:00am in the conference room, E2 (Director of Nursing), said R9 was assessed to be alert and oriented to person, place, and date. R9 said that about a month ago she was told by E18 to leave the dining room and that when she was getting up to leave E18 grabbed her left arm and bent it back. R9 said that "it really hurt when E18 pulled my arm back". R9 said she informed the nurse that E18 had hurt her arm and denied falling. Later R9 was transferred to the hospital for an evaluation after the incident occurred. The radiology report dated 5/17/11, exam left elbow and forearm denotes mild soft tissue swelling with limitation of flexion and what appears to be [MEDICAL CONDITION] epicondyle of the distal humerus with no significant displacement. Clinical correlation requested. On 6/24/11 at 1:15pm E2 said she called E18, E18 denied bending R9's left arm. E2 told her, that R9 was yelling in the dining room and he asked R9 to leave. E2 told E18 that R9 said that when she got up to leave he grabbed her arm and forced her out of the dining room. E18 denied the alligation. On 6/24/11 at 1:45pm, E6 (nurse) said on 5/16/11around 2:00pm while making rounds, R9 told her that her left arm was hurting, R9said E18 (CNA) hurt her arm twice while they were talking. E6 said that she didn't know what to think of what R9 had just told her, E6 said she left the room. Nursing notes dated 5/16/11 2:00pm indicates that R9 complained to the nurse that a CNA hurt my arm. On 6/24/11 at 1:15pm that on R9 made an allegation that E18 bent her arm back. E2 said that she called E18 and E18 denied bending R9's arm. E2 said that E18 said that R9 was verbally yelling in the dining room and was asked to leave. E2 said that R9 said that when she got up to leave E18 grabbed her arm to force her out of the dining room. The facility's abuse policy denotes, physical abuse is the infliction of injury to a resident that occurs other than by accidental means and that requires medical attention. R9 sustained a fracture to the left arm as a result of force. E18's employee file the employee report indicates after a through investigation of the incident it was decided to terminate E18 employment.