Every finding on record at California Terrace

Based on observations, interviews and record review, the facility failed to ensure nurses' station central call light notification systems were plugged in and operational and hall indicator lights were operational. These failures affected four residents (R2, R4, R5, R7) out of five residents (R1, R2, R4, R5, R7) reviewed for call lights and has the potential to affect all 172 residents residing on the first, third, and fourth floors of the building.Findings include: On 08/24/2026 at 10:20 a.m., R4 reported they often must get in their wheelchair and go to the first-floor nurses' station to get help and ensure their call light is functioning, but after a recent incontinent episode, R4 was in a wet bed for over an hour while waiting for staff to respond.On 08/24/2026 at 10:50 a.m., R2 stated his call light was broken for one week before maintenance replaced the call light box on the wall in his room, and during that time he had to yell out for staff assistance because he cannot get out of bed on his own.On 08/24/2026 at 11:30 a.m., the central call light notification system at the fourth-floor nurses' station was observed off and unplugged. V14 (Licensed Practical Nurse, LPN) confirmed normally it would alarm and display room numbers when residents push their call light button, but staff keep it unplugged because the system is malfunctioning. V14 (LPN) observed plugging in the central call light system for the fourth floor, and it was then powered on, and the call light alarm was heard. Four out of four resident room hall indicator lights on the ceilings adjacent to the fourth-floor nurses' station failed to light up as intended when resident call lights were tested. V14 (LPN) explained that when functioning, these lights show staff that a resident down a corresponding hallway has pressed their call light button. A fifth hall indicator light on the ceiling adjacent to the nurses' station corresponds to the resident parlor, and it was lit up, but V14 (LPN) stated the light was stuck in the on position in the parlor and unable to be turned off. The call light above R5's room was lit up, but V14 stated the light was stuck in the on position and unable to be turned off. Observed maintenance log behind the nurses' station, and R5's room, the parlor, and the hall indicator lights were not listed for repair.On 08/24/2026 at 11:45 a.m., random call light checks were completed with V15 (Licensed Practical Nurse, LPN), during which time a resident call light became stuck in the on' position and was unable to be turned off. V15 (LPN) stated that every resident should have a working call light to reach staff otherwise if there was a fall or other urgent need, the resident would have to wait for staff to round.On 08/24/2026 12:05 p.m., the central call light notification system at the third-floor nurses' station was observed as silent, and Gateway Error was displayed on the screen. One of four hall indicator lights on the ceiling adjacent to the nurses' station failed to light up as intended when corresponding resident call lights buttons were pushed. V16 (Registered Nurse, RN) stated the central call light notification system, and the hall light indicators help to notify staff that a resident needs assistance.On 08/24/2026 at 12:25 p.m., the central call light notification system at the first-floor nurses' station was observed off, and V17 (Licensed Practical Nurse) stated it was broken.On 08/25/2026 at 10:30 a.m., R5 stated his call light has been broken for a week stuck in the on position, and therefore unusable to him should he need it. R5's room is the furthest away and not visible from the fourth-floor nurses' station.On 08/25/2026 at 10:45 a.m., V7 (Maintenance Director) stated no audits, or maintenance is completed on the call light system, maintenance logs are used inconsistently, and needed repairs are not always reported. V7 (Maintenance Director) stated he is currently without supplies to make repairs, and that some repairs needed are beyond his capabilities. V7 (Maintenance Director) confirmed R2's call light was repaired approximately one week ago, after it had been broken for a week.On 08/25/2026 at 2:20 p.m., V3 (Certified Nursing Assistant, CNA) stated R2 had been reporting issues with R2's call light for about three weeks before it stop working completely, and before R2's call light was fixed, the call lights for all of the residents on R2's floor stopped working.On 08/25/2026 at 2:05 p.m., V2 (Director of Nursing, DON) stated staff is asked to aim for hourly rounding and that rounding times are not increased during call light malfunctions. V2 (DON) acknowledged a resident could need their call light for assistance in between rounds.On 08/25/2026 at 2:40 p.m., V1 (Administrator) stated that any repairs needed should be noted on the maintenance log on each floor behind the nurses' station, along with the date repairs were completed. V1 (Administrator) confirmed every resident should have a working call light and the ability to reach staff with that call light for resident safety.On 08/26/2026, 10:15 a.m., R7 stated that two days prior R7 felt ill and had concerns about their blood sugar, and after waiting for over an hour for someone on the third floor to answer the call light, they had to call a family member for help.On 08/26/2026, at 10:35 a.m., V22 (R7's Family Member) confirmed that on two occasions over the last two days, V22 has had to call staff at the facility to notify third floor staff that R7's call light is on and unanswered, and to request that they provide needed assistance to R7.R2's admission Record Sheet showed in part R2 had diagnoses including quadriplegia, chronic obstructive pulmonary disease, muscle wasting and atrophy, and diastolic heart failure.R2's Care Plan dated 07/07/2026 showed in part that R2 is at risk for falls, with an intervention for the resident to use the call light for assistance as needed; R2 has a has a self-care deficit, with an intervention to encourage R2 to use the call light prior to attempting self-care.R2's Brief Interview of Mental Status (BIMS) dated 07/082026 showed in part a score of 13, which indicates the resident was cognitively intact.R4 admission Record Sheet showed in part R4 had diagnoses including type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery, non-ischemic myocardial injury, intracardiac thrombosis, acquired absence of left leg above knee, and peripheral vascular disease.R4's Care Plan dated 07/20/2026 showed in part that R4 is at risk for falls, with an intervention for the resident to use the call light for assistance as needed; R4 has a has a self-care deficit, with an intervention to encourage R4 to use the call light prior to attempting self-care.R4 Brief Interview of Mental Status (BIMS) dated 07/20/2026 showed in part a score of 14, which indicates the resident was cognitively intact.R5's Care Plan dated 08/07/2026 showed in part that R5 is at risk for falls, with an intervention for the resident to use the call light for assistance as needed.R5's admission Record Sheet showed in part R5 had diagnoses including bipolar disorder, schizoaffective disorder, and asthma.R5's Brief Interview of Mental Status (BIMS) dated 08/04/2026 showed in part a score of 15, which indicates the resident was cognitively intact.R7's admission Record Sheet showed in part R7 had diagnoses including combined systolic and diastolic heart failure, unspecified chest pain, chronic obstructive pulmonary disease, type 2 diabetes mellitus, acute kidney failure, cerebral infarction, and acquired absence of right leg above the knee.R7's Care Plan dated 08/07/2026 showed in part that R7 is at risk for falls, with an intervention for the resident to use the call light for assistance as needed; R7 has a has a self-care deficit, with an intervention to encourage R7 to use the call light prior to attempting self-care.R7's Brief Interview of Mental Status (BIMS) dated 06/14/2026 showed in part a score of 10, which indicates moderate cognitive impairment.Facility Census Report with printed date of 08/24/2026 documents, in part, that a total of 172 residents resided on the first, third, and fourth floor of the facility.Facility's document titled Policy and Procedure Call Light, dated 01/2025, showed in part that all residents shall have the nurse call light system available, and call light/bell system defects will be reported promptly to the maintenance department for servicing.Facility's document titled Policy and Procedure Preventative Maintenance, dated 05/2026, showed in part that the facility should maintain a safe and functional environment for residents, random audits should be conducted to ensure call light systems are operational, and issues that are identified shall be logged.Facility's documents titled Facility Work Order Sheet, from the first, third, and fourth floor showed multiple call light maintenance requests to all floors over the last 30 days. However, R2's, call light box malfunction from approximately two weeks ago is absent from this sheet.Facility's document titled Job Description Maintenance Director showed in part the primary purpose is to maintain the orderly functioning of all equipment in the facility with duties including knowledge of regulations relevant to maintenance and proper functioning of all equipment, performing repairs, and assuring the proper maintenance and running condition of all nurses' station call systems.Facility's document titled Job Description Facility Administrator showed in part duties include assuring policies and procedures are being implemented and followed, and assuring the facility is maintained in a safe manner for resident comfort and convenience.

Based on observations, interviews and record review, the facility failed to ensure the fourth-floor call light notification system at the nurses' station was plugged in and functioning and the facility failed to ensure R1, R2, and R5's call lights were operational. These failures affected three residents (R1, R2, and R5) out of four residents (R1, R2, R3, R5) reviewed for call lights and had the potential to affect all 50 residents on the fourth floor. Findings include: On 08/03/2026 at 10:50 a.m., the call light outside of R1 and R5's room was flashing red. A call light indicator observed in the hallway ceiling (not above a resident room) adjacent to the nurses' station which activates for the unit, and this call light indicator was flashing red in error. The central call light notification system at the nurses' station on the fourth floor was observed off and unplugged. R1 and R5's room is located at the end of the hall, farthest away from the nurses' station. On 08/03/2026 at 11:10 a.m., V5 (Licensed Practical Nurse, LPN) stated that the call light notification system at the fourth-floor nurses' station in the central board for all rooms and should beep and display the room numbers when a resident pushes their call light. V5 stated the system is unplugged, possibly due to a call light malfunction, and that the system should never be unplugged because it helps alert staff that residents on the fourth floor need assistance. V5 observed plugging in the central call light notification system for the fourth floor where it then was powered on and displayed multiple room numbers where the call lights had been activated. On 08/03/2026 at 11:15 a.m., V7 (Certified Nursing Assistant, CNA) tested the call light for the bathroom and the call light for R5's bed in R1 and R5's room. V7 stated both call lights were broken and stuck in the on position, and that residents in this room (R1 and R5) would be unable to use them to notify her they need help until maintenance completes repairs. On 08/03/2026 at 11:25 a.m., R1 stated that the call light system for his room has been inoperable for approximately three weeks. On 08/03/2026 at 11:45 a.m., R5 was observed awake lying in his bed in R1/R5's shared room. R5 did not respond to attempts at conversation in English or Spanish to surveyors questions. On 08/03/2026 at 11:55 a.m., V6 (Licensed Practical Nurse, LPN) stated that the call lights are continuously flashing red due to a malfunction. R1 and R5 do not have a working call light to notify staff they need assistance, and the error light flashing in the hall adjacent to the nurses' station interferes with our ability to note when another room on this side of the floor uses their call light. V6 stated that this would be a problem if a resident had an emergency. On 08/03/2026 at 12:15 p.m., R2 stated that approximately one week prior, he pressed his call light at 11p.m. in his current room/bed and did receive assistance until 6 a.m. R2 explained that staff later informed him his call light button was malfunctioning and required repair. On 08/03/2026 at 1:15 p.m., V14 (Maintenance Assistant) stated that he believes the call light issue for R1 and R5's room is related to the box that is on the wall for R5's bed. V14 stated the facility did not have a replacement in stock, and new box ordered on 07/20/2026 had not yet been received. V14 explained call light audits are not completed, and that staff communicates needed repairs by documenting a request on the work order sheet on each floor. V14 stated there have been recent failures at the facility related to the buttons on residents' call lights not working explaining that when residents press the buttons to initiate a call, it wouldn't activate the call light system. When asked about R2's call light button not functioning properly, V14 stated that he can't say for sure because they (maintenance) don't keep records of work completed if it's not on the maintenance log. On 08/04/2026 at 11:15 a.m., the call light outside of R1 and R5's room and the call light indicator adjacent to the nurses' station for the unit were still flashing red. V8 (Assistant Director of Nursing, ADON/4th Floor Unit Manager) acknowledged that in an emergency, such as a fall, residents with a malfunctioning call light may have no way to notify staff and would have to wait until staff made rounds and checked on them. On 08/05/2026 at 9:50 a.m., V2 (Director of Nursing, DON) stated the facility policy is that every resident has a working call light so that every resident concern can be addressed in a timely manner. The call light system at the nurses' station should never be unplugged. From a safety standpoint, repairs need to be completed as soon as possible, or a backup plan needs to be in place such as a room change. On 08/05/2026 at 12:50 p.m., V1 (Administrator) stated that the call light system needs to be properly functioning for resident safety, so that residents can communicate with staff in case of an emergency. R1's Brief Interview of Mental Status (BIMS) dated 05/06/2026 showed in part a score of 14, which indicates the resident was cognitively intact. R1's admission Record Sheet showed in part R1 had diagnoses including asthma, schizophrenia, major depressive disorder, generalized anxiety disorder, type 1 diabetes, and unsteadiness on feet. R1's Care Plan dated 05/08/2026 showed in part that R1 had a self-care deficit, with an intervention to encourage R1 to use the call light prior to attempting self-care. R2's Brief Interview of Mental Status (BIMS) dated 06/09/2026 showed in part a score of 15, which indicates the resident was cognitively intact. R2's admission Record Sheet showed in part R2 had diagnoses including quadriplegia, chronic obstructive pulmonary disease, muscle wasting and atrophy, and diastolic heart failure. R2's Care Plan dated 07/07/2026 showed in part that R2 is at risk for falls, with an intervention for the resident to use the call light for assistance as needed; R2 has a has a self-care deficit, with an intervention to encourage R5 to use the call light prior to attempting self-care. R5's Brief Interview of Mental Status (BIMS) dated 06/30/2026 showed in part a score of 9, which indicates the resident has moderate cognitive impairment.R5's admission Record Sheet showed in part R5 had diagnoses including dementia, type 2 diabetes, and schizoaffective disorder.R5's Care Plan dated 07/02/2026 showed in part that R5 has a self-care deficit, with an intervention to encourage R5 to use the call light prior to attempting self-care. Facility Census Report with printed date of 8/3/26 documents, in part, that 50 residents reside on the fourth floor in the facility. Facility's document titled Policy and Procedure Call Light, dated 01/2025, showed in part that all residents shall have the nurse call light system available. Facility's document titled Policy and Procedure Preventative Maintenance, dated 05/2026, showed in part that the facility should maintain a safe and functional environment for residents, random audits should be conducted to ensure call light systems are operational, and immediate risks to safety must be corrected at once or the area taken out of service. Facility's document titled Facility Work Order Sheet, from the fourth floor, showed a maintenance request for a broken call light for R1 and R5's room dated 07/20/2026, with no work completed date noted. Facility's document titled Facility Work Order Sheet, from the first floor from 7/5/2026 to 8/2/2026, showed multiple maintenance requests; however, R2's call light button malfunction from approximately one week ago is absent from this sheet. Facility's Census List dated 08/05/20206 showed in part that R1 has resided in R1's current room from 02/08/2025 through 08/04/2026, and that R5 has resided in R1 and R5's room from 05/22/2026 through 08/04/2026. Facility's document titled Job Description Maintenance Assistant showed in part that main duties include assisting in assuring the proper maintenance and running condition of all nurses' call station systems.

Based on observations, interviews, and record review, the facility failed to protect and promote a resident's (R1) right to feel respected and comfortable in the resident's room. This failure affected one (R1) of four residents (R1, R2, R3, R5) reviewed for resident rights. Findings include: On 08/03/2026 at 11:25 a.m. outside a resident room, surveyor observed no name plates present next to the door, with scribbles drawn (marked) in place of where the name plates should be. Inside this room, surveyor observed drawings of people, names and dates, crosses, words in Spanish, and unidentifiable words and symbols were drawn on two walls in this room. On 08/03/2026 at 11:30 a.m., R1 stated this room is R1 and R5's shared room. R1 stated he has been having an issue with his roommate, R5. R1 stated R5 writes on the door and the walls inside their room. R1 stated R1 tries to make sure R5 has paper instead so R5 won't write on the room surfaces. R1 stated R5 touches his personal things, his bed, opens his refrigerator and drawers, and moves his blanket and curtains. R1 stated R5 takes things from other people, and R5 takes all the housekeeping supplies he can. R1 stated R5 doesn't respond when R1 asks him to stop touching his belongings and because R5 is Spanish speaking, R1 doesn't know if R5 understands. R1 stated he doesn't know why R5 does these things, but it makes him uncomfortable, and he worries about what R5 will do with his things if he is not watching. R1 explained he should not have to live with this in his space. R1 stated R1 didn't want to complain to the state agency, but he felt like he didn't have a choice. R1 stated he has talked to all the staff at the facility regarding his concerns with his roommate's (R5) behavior, especially V8 (Assistant Director of Nursing, ADON/Fourth floor manager) and V1(Administrator). R1 stated he calls V1 (Administrator) almost daily at her extension from the phone in the hallway. R1 expressed he doesn't know what to do because he has been in this specific room for a long time, and he is comfortable there; he likes the room and the floor. R1 states R1 was in the room before R5, yet he worries he will have to move, even though he feels he didn't do anything wrong. R1 expressed he has lived at the facility for 12 years and doesn't understand why staff isn't helping him. R1 stated R1 feels disregarded, disrespected, and ignored. On 08/03/2026 at 11:45 a.m., R5 was observed awake lying in his bed in R1/R5's shared room. R5 did not respond to attempts at conversation in English or Spanish and did not make eye contact. R5 continued to stare at the wall, expressionless. On 08/04/2026 at 11:15 a.m., V8 (Assistant Director of Nursing, ADON) stated R5 is a hoarder and takes linens, housekeeping supplies, and items from the nurses' station. V8 stated the facility keeps cleaning up R5's room vandalism, but the behavior continues because R5 is difficult to redirect. V8 stated V8 doesn't believe R5's behaviors are an issue for R1. V8 stated two to three weeks ago, he asked R1 to compile a list of residents he would be agreeable to room with. R1 compiled a list for V8. V8 stated no one on the list wanted to live with R1. V8 stated no other follow up has been completed for R1. On 08/05/2026 at 12:50 p.m., V1 (Administrator) stated she speaks to R1 regularly regarding R5, and R1's concerns have been discussed among staff at morning team meetings. V1 stated there is no documentation related to these discussions. V1 stated she offered to move R1 to a different room, but R1 expressed he didn't want to change rooms. No additional intervention was taken by V1. V1 stated she does not feel R5's behaviors affect R1. Facility's document titled Residents' Rights showed in part the facility must treat residents with dignity and respect and must care for them in a manner promotes the resident's quality of life; the facility must be safe, clean, comfortable, and homelike, with reasonable arrangements to meet resident needs and choices. R1's Brief Interview of Mental Status (BIMS) dated 05/06/2026 showed in part a score of 14, which indicates the resident was cognitively intact. R1's admission Record Sheet showed in part R1 had diagnoses including asthma, schizophrenia, major depressive disorder, generalized anxiety disorder, and type 1 diabetes.R1's Psychiatry Progress Note, dated 07/17/2026 and signed by V17 (Physician's Assistant), showed in part R1 was seen for a follow-up visit related to a chief complaint of impending agitation secondary to ongoing roommate conflicts. The document showed in part R1 expressed having roommate challenges for a long time, and this has been slowly wearing on him; R5 has been messing with R1's curtains, TV (television), belongings, and not respecting his boundaries; V17 encouraged R1 to reach out to staff calmly with his concerns in effectively communicating. It was documented in part R1's thought process was linear and goal directed; associations were intact; no paranoid content or other delusions were elicited; mood frustrated and is getting closer to agitation. R5's Brief Interview of Mental Status (BIMS) dated 06/30/2026 showed in part a score of 9, which indicates the resident had moderate cognitive impairment. R5's admission Record Sheet showed in part R5 had diagnoses including dementia, type 2 diabetes, and schizoaffective disorder. R5's Care Plan dated 07/02/2026 showed in part the following focus areas for R5: R5 has taken his peers belongings without permission; R5 has attempted to take items out of the nurses' station; R5 displays poor boundaries related to removing residents name tags from their doors and drawing on the walls in his room, which can lead to property damage and may disrupt the shared living environment; R5 is not easily redirected. This document showed in part the following interventions: counseling R5 on being respectful of others' personal space and belongings; routinely searching the resident's person and personal space and confiscating items belong to others; staff will provide R5 with acceptable materials for drawing. Facility's document titled Job Description Charge Nurse showed in part main duties include honoring resident's personal and property rights, making daily rounds to ensure care plans are being followed, and being responsible for the well-being of all residents on the unit. Facility's document titled Job Description Facility Administrator showed in part responsibilities include assuring all residents receive care in a manner and in an environment maintains or enhances their quality of life, and to review resident complaints and make written reports of action taken. Facility's Census List dated 08/05/20206 showed in part R1 moved to R1's current room (bed A) on 02/08/2025, and R5 moved to into bed D in the same room as R1 on 05/22/2026.

Based on interview and record review, the facility failed to a) provide a physician ordered non-invasive imaging test in a timely manner b.) follow treatment/dressing changes as ordered for one (R1) resident out of three residents reviewed for quality of care. As a result of the facility's failures, R1's left foot wounds worsened, demonstrated signs of infection, and, according to documented measurements, increased in size. Findings include: R1's face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to peripheral vascular disease, unspecified, quadriplegia, unspecified, acquired absence of left leg above knee, pressure ulcer of unspecified heel, unspecified stage, muscle wasting and atrophy, not elsewhere classified, multiple sites, hyperlipidemia, unspecified.R1's Minimum Data Set (MDS), dated [DATE], documents R1 has a brief interview for mental status (BIMS) of 15 out of 15, indicating R1 has intact cognitive response.R1's medication admin audit report dated 07/21/2026 documents in part, left AKA (above-the-knee amputation): cleanse with wound cleanser, and cover with a dry dressing every day shift every Tuesday, Thursday, and Saturday was administered on 07/21/2026 at 1:12 PM. R1's order dated 01/14/2026, documents in part, other order category. Arterial doppler to bilateral lower extremities related to new wound development.R1's arterial doppler report for date of service 01/17/2026, documents in part, findings note triphasic waveform (a normal, healthy pattern of blood flow) to both right and left leg. Impression notes findings suggest severe peripheral vascular disease. There was a discrepancy (findings do not match impressions) noted to R1's arterial doppler (01/17/2026) results. R1's progress note dated 01/21/2026, 2:39 PM documents in part, received results for arterial duplex doppler. V12 (Nurse Practitioner) made aware of NNO (no new order) at this time. R1's progress note dated 1/28/2026 11:12 AM documents in part, writer received arterial doppler study results. Doctor wants test to be repeated for better understanding of results. Order noted and carried out.R1's order dated 01/28/2026 documents in part, diagnostic order category. Arterial doppler study to bilateral lower extremities to r/o (rule out) poor circulation. There were no records provided of R1 of having an arterial doppler study following this order. R1's order dated 03/11/2026, documents in part, diagnostic order category. Ultrasound duplex scan, lower extremity arteries/arterial bypass grafts. R1's note dated 3/12/2026, 10:06 AM documents in part, received results for ultrasound -duplex scan, bilat single level with findings of atherosclerotic plaques in visualized arteries. Findings are likely to represent severe peripheral arterial disease with possibility of hemodynamic significant stenosis (a narrowing of a blood vessel or heart valve is severe enough to abnormally restrict and reduce blood flow, thereby causing downstream complications or symptoms). No flow seen in right SFA (superficial femoral artery) and left lower extremity arteries. V13 (R1's Nurse Practitioner) made aware with new orders for Vascular appt. (appointment) and to monitor resident for evidence of acute ischemia (sudden reduction in blood flow) to the leg/foot, he will need to be transferred to ED (emergency department) for more urgent care.R1's arterial doppler report for date of service 03/11/2026, documents in part, indication to rule out poor circulation. Findings are likely to represent severe arterial disease with possibility of significant hemodynamic stenosis. R1's after visit summary dated 05/18/2026, documents in part, vascular surgery. Active wound care, for nursing facility, clean left foot wound with saline, apply xeroform gauze, or ABD (abdominal) pad, and kerlix. Change dressing daily.R1's nursing progress note dated 06/22/2026, at 2:43 pm documents in part, was made aware by patio staff the resident (R1) had collided with another resident on the patio. After the incident occurred the resident stated he had pain in his left foot r/t (related to) the collision. However, when it came to assessing the resident's left foot, he refused. Upon observation without touching his foot, writer observed dressing was shifted with some exposed areas to the foot from the incident. No documentation social services were notified/collaborated. R1's change in condition report dated 06/22/2026 documents V13 (R1's nurse practitioner) was contacted on 06/14/2026.R1's change in condition report dated 06/22/2026 does not document up to date hear rate pulse, respirations, and temperature. R1s nursing progress note dated 06/22/2026 does not document up to date vital signs following this incident. R1's January 2026 treatment administration record (TAR) dated 01/11/2026 wound care not administered per order (left heal-cleanse with wound cleanser, apply Silvadene cover with dry dressing one time a day start 01/08/26- d/c 01/14/2026). R1's February 2026 TAR dated 02/13/2025 documents in part R1 did not receive any of the wound care treatment on this date.R1's July 2026 TAR reviewed, and documents R1's wound care treatment was administered on 07/21/2026 despite R1 stated he did not receive it. R1's July 2026 audit report documents in part, left AKA (above the knee): cleanse with wound cleanser, and cover with a dry dressing treatment was administered on 07/21/2026 at 1:12pm.R1's wound provider's subjective, objective, assessment, and plan (SOAP) note signed by V6 (Physician Assistant) dated 01/20/2026 documents in part, traumatic wound to L (left) dorsal foot. Measures 0.5 x 0.5 x 01 cm (centimeter). Wound of unknown etiology to L heel. Measures 2.2 x 3.5 x 0.1 cm. R1's wound provider's subjective, objective, assessment, and plan (SOAP) note signed by V6 (Physician Assistant) dated 04/16/2026 documents in part, traumatic reclassified as arterial wound to L dorsal foot extending to L lateral foot. Measures 12 x 26 x 0.2 cm. Wound is 50% necrotic tissue, 50 % skin. Moderate serous exudate. Deteriorated in surface area. Wound of unknown etiology reclassified to arterial wound to L heel. Measures 2.5x 2.2x0.1cm. Deteriorated in surface area. R1's wound provider's subjective, objective, assessment, and plan (SOAP) signed by V6 (Physician Assistant) dated 05/12/2026 documents in part, traumatic reclassified as arterial wound to L dorsal foot extending to L lateral foot. Measures 14 x 20 x 0.2 cm. Wound is 100% necrotic tissue. Deteriorated in surface area. Unstable wound. Wound of unknown etiology reclassified to arterial wound to L heel. Measures 2.5x 2.5x0.1cm. R1's wound provider's subjective, objective, assessment, and plan (SOAP) note signed by V6 (Physician Assistant) dated 06/09/2026 documents in part, traumatic reclassified as arterial wound to L dorsal foot extending to L lateral foot. Measures 23 x 23 x 0.3 cm. Wound is 100% necrotic tissue with tendon exposed. Heavy serious exudate. Odor present. Unstable wound. Wound of unknown etiology reclassified to arterial wound to L heel. Measures 4 x 5x 0.5cm. R1's wound provider's subjective, objective, assessment, and plan (SOAP) note signed by V6 (Physician Assistant) dated 06/30/2026 documents in part, post-surgical wound to L AKA. Measures 13.6 cm long. Sutures and staples are present. R1's active care plan documents in part, R1 exhibits the symptom of resisting care. Interventions document in part, conduct an evaluation of the behavioral symptoms to determine what strengths or needs are communicated via the behavior. On 07/21/2026 at 1:26 PM, R1 was sitting on his bed, responsive, and in no apparent distress. R1 stated a small sore started on the left foot heel and a little one started on the center top of R1's left foot. R1 stated it started hurting badly and R1 told the staff. R1 stated his left foot wounds started growing, especially the one on the top of his left foot. R1 stated my foot started getting burnt scabs and they were dark. R1 stated the only thing they kept putting on my wound was iodine. R1 stated his left foot wounds started smelling bad in April 2026. R1 stated he went back to vascular surgery for a follow-up appointment on June 23rd, 2026. R1 stated his dressing was not changed from Saturday to Tuesday June 22nd, 2026. R1 stated the vascular surgery removed his dressing, and it was smelling bad. R1 stated, I saw the maggots on my foot, crawling around, and it shocked me so badly. R1 stated he would refuse wound care treatment occasionally because V4's (Wound Care Nurse/Licensed Practical Nurse) attitude was 'off the chart'. V4 stated, How are you going to take care of someone's wound and you speak to them like they are nobody? R1 stated they would spray and soak the gauze in iodine. Then, staff would apply it on my foot, cover with dry gauze, and wrap it with gauze. R1 stated the reason he finally decided to make the decision for the amputation was because he couldn't deal with the pain anymore. R1 stated the wound care treatment was not being done three times a week. R1 stated the wound care nurse came around twice a week but that was it. R1 stated he thinks that it could have been prevented from the wound getting maggots. R1 stated the facility itself is so nasty around here. R1 stated, I didn't refuse wound care today.On 07/21/2026 at 2:24 PM, V5 (Licensed Practical Nurse) stated, R1 had a few refusals, but R1 was able to be redirected. V5 stated, As a nurse we try to redirect and educate. I would encourage the resident to be changed, and then I would document. We would try to prevent any kind of infection and promote wound healing. If it looks bad and it smells that is prone to infection. We also will let the doctor know, and other departments, such as social services. V5 stated sometimes after calling the doctor and social services, the residents may change their mind. V5 stated sometimes the residents may not want specific nurse or they don't want it at time. On 07/21/2026 at 3:19 PM, V4 (Wound Care Nurse/Licensed Practical Nurse) stated R1's left heel wound developed on 01/08/2026. The left dorsal foot wound developed on 01/13/2026 and the left lateral foot wound developed on 03/17/2026. V4 stated the wounds were caused due to his (R1) circulation and diagnosis of PVD (Peripheral Vascular Disease). V4 stated R1 had arterial dopplers done on 01/28/2026 and on 03/11/2026. V4 stated she saw R1's 03/11/2026 doppler results but could not see or find any results for 01/28/2026 arterial doppler order. V4 stated she could not answer how the resident may get affected if R1 didn't have a doppler done on 01/28/2026. V4 stated staff should be following up with pending orders to be completed. V4 stated a doppler study is just a test and it will not affect the development of a wound or the healing process of the wound. V4 stated V4 didn't get to see R1's wound on 06/23/2026, because R1 refused to have the dressing changed. V4 stated if the wounds' measurements decrease then the wound is making progress. V4 stated if they continue to increase, it is worsening progress. V4 stated R1's left foot wounds were worsening. V4 denied receiving any information about the new orders. V4 stated she didn't follow the vascular surgeon's wound care orders because V4 was not aware of them. V4 stated it was not carried out. V4 stated V4 saw R1 this morning due to R1 having an order for dry dressing to the stable site. V4 stated, I (V4) signed out his treatment orders after I administered the treatment. He (R1) probably forgot I saw him. Whoever, the nurse that received this resident when he came back should have carried this out. The issue with this scenario is R1 shouldn't have been seeing the vascular for wound care while R1 is seeing in-house wound care. V4 stated it is a conflict of interest.On 07/22/2026 at 1:29 PM, V12 (Nurse Practitioner) stated R1 is not one of V12's patients. V12 denied ordering R1 a left foot doppler. On 07/22/2026 at 1:31 PM, V5 (Licensed Practical Nurse) stated she mistakenly documented that V5 relayed the doppler results to V12. V5 stated V5 had notified V13 (R1's Nurse Practitioner) and not V12. On 07/22/2026 at 1:37 PM, R1 stated the wound nurse never came to see R1 yesterday. The dressing was changed this morning by the nurse on the floor. R1 stated, Nobody came to see me yesterday. She thinks I'm ignorant. On 07/22/226 at 2:22 PM, with V2 (Director of Nursing) stated, R1's wound care was administered on July 21, 2026, at 1:12 PM. V2 stated she will follow up with this matter. On 07/22/2026 at 3:19 PM, V4 (Wound Care Nurse/Licensed Practical Nurse) stated she saw R1 yesterday to provide his wound care. V4 stated, I am not sure exactly what time, I think more so in the afternoon. If I (V4) said the morning it was a mistake; I saw him in the afternoon. On 07/22/2026 at 2:25 PM, V9 (Certified Nursing Assistant) stated, I've worked for the facility for one year. V9 stated V9 mostly works on the 2nd floor. V9 stated she was familiar with R1. V9 stated R1 required help with getting in and out of the wheelchair and ADL (activities of daily living) care. V9 stated she worked on 06/23/2026, as R1's assigned CNA. V9 stated that day R1's wound had a strong odor; an infection smell. V9 denied seeing any maggots in R1's wound dressing. V9 stated, I'm (V9) not sure if he was getting it on time or if he felt comfortable. I feel like he does care about himself and wanted to get better.On 07/22/2026 at 3:07 PM, V6 (Physician Assistant) stated she recalled ordering the arterial doppler for R1 because the wounds were not healing as V6 expected them to. V6 stated she ordered the doppler ultrasound due to pain from exam and to see if there is enough blood flow to the wound. V6 stated, In January he (R1) had two new wounds in left foot extremity. At the time I (V6) needed to have a full clinical picture of the resident. I saw the resident on 01/20/26 and I noted the results were still pending. I (V6) think the note by the wound nurse is referring to me (V6) because it mentions the ultrasound doppler to be repeated for a better understanding of the results. V6 stated, There was something wrong, I think the results within the impression and findings didn't correlate with each other. There was a gap between 1/20/2026 to 02/24/2026 where V6 didn't see R1. V6 stated on her February 24th, 2026, note it documents the doppler was pending. V6 stated after February, V6 saw R1 on March 17th, 2026, and noted the doppler results noted severe disease. V6 stated, I think he was hospitalized , because I wrote per wound nurse, patient refused interventions including amputation in the hospital. Ideally, we should get things right way, including exams ordered. V6 stated V6 does not know exactly the cause of the delay. V6 stated Best practice, in theory, we want results faster so we can preserve limb and prevent deterioration. V6 denied there were any specific instructions the vascular surgeon gave the resident. V6 stated, I have nothing documented so I am going to say none I am aware. I (V6) would consider the vascular specialist recommendation. I (V6) think it is important to hear another clinician's thoughts and collaborate to help heal a wound as fast as possible.On 07/22/2026 at 4:29 pm, V1 (Administrator) stated, she sent a reportable to the state agency because the resident alleged he did not receive wound care on 07/21/26. V1 stated, I would have to look at cameras. V1 stated V4 is suspended upon investigation.On 07/23/2026 at 11:18 AM, V7 (Licensed Practical Nurse) stated on 06/22/2026, she did not witness R1's collision with another resident. V7 stated V7 was called to the scene because V7 was the unit manager. V7 stated R1 told V7 they bumped into their wheelchairs on accident. V7 stated, R1 refused V7 to change his wound dressing despite the area being affected by the collision. V7 stated, I made sure to document he (R1) refused to allow us to do wound care. I noticed it was unraveled a little bit, but he didn't want us to touch it. V7 stated V7 attempted a second time to change R1's dressing after R1 received pain medicine. V7 stated R1 was out of R1's room and told V7 R1 was fine and didn't want his wound dressing change. V7 stated she documented in the Situation, Background, Assessment, and Recommendation (SBAR) assessment and V7 contacted V13 (R1's Nurse Practitioner). V7 stated no new orders were given. V7 described the exposed skin area as top of the left foot. V7 stated, It was brown colored, drainage was yellow/green color, and the odor was horrible. V7 stated even after explaining everything to R1, R1 refused care. V7 stated sometimes V7 has seen flies in the bathrooms or moist areas. V7 stated, Every now and then I (V7) will see them in the hallways. On 07/23/2026 at 10:52 AM, V6 (Physician Assistant) stated she would like her supervisor on the call. V14 (Doctor of Medicine/V6's supervisor) was added to the call. V14 stated a wound could present with wet gangrene and maggots when there is a high volume of dead tissue/necrotic tissue. V14 stated wet gangrene of a limb would be consistent of absence of adequate blood supply. V14 stated you cut out the circulation then get a gangrene foot. V14 stated anyone who is exposed to the street, where there is a fly in any environment can get maggots. V14 stated R1 didn't want to be touched. V14 stated it could take 48 hours to 72 hours for a larva to get to a maggot. V14 stated it is unlikely vascular clinic found the maggots that proceeded from that incident. V14 stated there is no other treatment besides debridement or amputation for a wound presents with wet gangrene and maggots. On 07/23/2026 at 11:44 AM, this surveyor explained to V2 (Director of Nursing) R1's doppler was ordered on 01/28/2026 and an ultrasound doppler was not done for R1 until 3/11/2026. V2 stated, I see the order and the note regarding the ultrasound doppler ordered on 01/28/26, but I (V2) do not see the results. He went out to an appointment on 03/16/2026, related to the 03/11/2026 ultrasound doppler results. Orders should be carried out in a timely manner. V2 stated it should have been carried out within 24 hours after receiving order. V2 stated this may affect the quality of care but R1 would be resistant to care.On 07/23/2026 at 1:17 PM, via electronic mail, V1 (Administrator) stated, V1 couldn't pull any of the north side hallway cameras to confirm if the wound nurse saw R1 on Tuesday 07/21/2026.On 07/23/2026 at 3:30 PM, V17 (Director of Social Services) stated, he was not involved when R1 refused wound care on 06/22/2026. V17 stated V17 was aware of the collision but V17 was not aware R1 refused wound care. V17 stated he did ask R1 and that V17 didn't know what R1 said, he (R1) just didn't want it. V17 stated R1 didn't really give V17 information about why R1 would refuse. V17 stated that social services advocate seek what the next plan after or during the residents' clinical care, and discharge planning. Basically, anything to make them comfortable. V17 stated staff may call social services if social services can assist and see if things can change. V17 stated, If I can I try to change the situation that is happening. V17 stated it is important to involve the care team to ensure safe, evidence-based management. On 07/24/2026, at 11:35 AM, V13 (R1's Nurse Practitioner) stated if she were to receive a call a resident collided with another resident and their foot was involved, V13 would order to get x-ray (a type of medical imaging). V13 stated she could not specifically remember this event (R1 collided with another resident and complained about left foot pain on 06/22/2026). V13 stated if the resident is refusing care, but V13 is made aware their wound has a horrible smell, and his vitals are stable, V13 stated she would order lab tests. V13 stated the labs are helpful to know if they have an elevated white blood count and if the infection is getting systemic. V13 stated if the nursing staff are attempting to redress the wound dressing, but R1 is refusing, there is nothing they could do. V13 stated if R1 was complaining of any new pain, any signs of deformity, then an x-ray would be ordered. V13 stated it has been a long time since January 2026. V13 stated based on the first doppler results R1 had in January, we already knew he (R1) had PVD (peripheral vascular disease). V13 stated R1 was already on statin medication, and the next step would be to get an outpatient vascular consultation. V13 stated, I had no idea if R1 was being followed by vascular. An occlusion would be a reason to send him to the hospital and not severe PVD. An occlusion is a medical emergency. The most important thing to do is to make sure the resident is medically optimized. In my standard practice, if someone has severe PVD, I will make sure they are medically optimized with an outpatient vascular consultation.Facility document dated 07/2022 documents in part, wound policy. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. Wound will be treated based on the etiology of the wound. If infection is suspected, notify the physician and obtain clinically appropriate orders. Facility document dated 05/2026 documents in part, change in resident's condition guideline. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication. Facility document dated January 2026 documents in part, to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. All orders (telephone, verbal, written) shall be provided by licensed practitioners (physician, nurse practitioner, or physician's assistant) authorized to prescribe such orders. Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders.Facility's resident rights policy documents in part, your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source. Facility document titled psychiatric rehabilitation services coordinator job description documents in part, ability to tolerate demanding, upset people in crisis situations without taking it personally. ability to work cooperatively and harmoniously in a problem-solving manner with a variety of personalities in a fast-paced changing environment keeping in mind the welfare of the residents. The primary purpose of the position is to integrate, coordinate and monitor each resident's psychiatric rehabilitation services program of a specific case load of residents in accordance with current Federal, State and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the PRSD and/or Administrator, to assure the emotional and social needs of the resident are met and maintained on an individual basis.National Library of Medicine document dated June 16, 2022, documents in part, flies have four life stages-eggs, larvae/maggots, pupae, and adults. Female houseflies lay their eggs in compost, trash, soiled bedding, or manure containing moist and microbial-rich decaying organic matter. The eggs usually hatch within 8-12 h if the environment is moist and at an optimal temperature of 25 C to 30 C.

Based on interview and record review, the facility failed to provide specialized rehabilitative services per resident's physician order for one (R2) resident out of three residents reviewed for quality of care. This failure has the potential to affect a resident from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional and psycho-social well-being.Findings include:On 07/21/2026 at 2:04 PM, R2 was sitting on his wheelchair, in the patio during smoking break. R2 was alert, responsive and agreed to speak to this surveyor. R2 stated he has not received any physical therapy. R2 stated he has been residing in the facility for two and a half years. R2 stated R2 can move his legs. R2 stated he was seen by physical therapy when R2 was first admitted to the facility. R2 stated he wants to receive physical therapy again because R2 wants to discharge from the nursing home. R2 stated he told V5 (Licensed Practical Nurse) he wanted therapy. R2 stated he didn't get a response and R2 went about R2's business. R2 could not remember the exact date or month R2 told V5 R2 wanted to have therapy. R2 stated, maybe 6 months ago.On 07/21/2026 at 2:24 PM, V5 (Licensed Practical Nurse) stated she is familiar with R2. V5 stated, I know it was a couple of times he was interested in physical therapy. I did follow up with the doctor. V5 stated she didn't know if it had anything to do with R2's insurance as to why R2 was not picked up by physical therapy. V5 stated, but it has been a while, about three or more months. V5 stated the last time she worked with R2, he didn't mention anything regarding therapy to V5. V5 stated in general when a resident inquiry about skilled therapy, V5 would notify the doctor. V5 stated if the doctor agrees, the order will be placed, and the therapy department will be notified. V5 stated R2 requires extensive assistance with care. V5 stated R2 can move his upper extremities and needs more help with his lower extremities. V5 stated she spoke to the therapy lady to follow up on R2's therapy but did not document it in R2's chart. V5 stated she knew it should have been documented because if it is not documented, it didn't happen. V5 stated this was sometime in March 2026.On 07/22/2026 at 10:49 AM, V8 (Director of Rehabilitation) stated the rehab department has not seen R2 since the services were provided in 12/20/20/2024 through 01/03/2025. V8 stated R2 has not been screened nor evaluated for PT/OT. V8 denied receiving a referral to see R2. V8 stated, usually MDS (minimum data set) nurse will let V8 know about any referrals in the morning meetings. V8 stated V8 usually ask nurses at the nurse's station if they have any referrals or if anyone is declining. V8 stated if an order is put in the physician order set, the rehab department does not get notified electronically. V8 stated that when a resident is referred to rehab services, after V8 can verify the insurance, it usually takes 2 days to see the resident. V8 can screen them right away but the eval is usually done 2-3 days after. V8 stated the benefits of rehabilitation services depend on the patient and the specific goals they have. V8 stated the main things they focus on is transfers, ambulation, and bed mobility. V8 stated there would be documentation noting if a resident was not picked up by therapy. V8 was asked how this may affect the residents. With V8, reviewed R2's physician orders and V8 stated she sees the order for PT/OT eval and treat. V8 stated the order was put in on March 21, 2026. V8 stated V8 thinks it was a miscommunication.On 07/23/2026 at 11:44 AM, V2 (Director of Nursing) stated the rehabilitation department has access to view the residents' orders. V2 stated she was not aware R2 had an active order and was not evaluated by PT/OT. V2 stated he might have asked to be seen by PT/OT and in accordance with standards of care, we should make sure we are helping the residents maintain their highest level of functioning and mobility. V2 stated it could affect R2's right to quality of treatment because if R2 voiced concern, it should be taken seriously, do our due diligence and provide the services.R2's current face sheet documents R2 is a [AGE] year-old individual with diagnoses not limited to: paraplegia, need for assistance with personal care, muscle wasting and atrophy, weakness, and other lack of coordination.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating R2 has intact cognitive response.R2's psychiatry note dated 4/20/2026 12:00 AM documents in part, R2 was observed in the hallway in a wheelchair and expresses motivation to regain strength with interest in physical therapy, though patient has a medical diagnosis of paraplegia.R2's active orders dated 03/21/2026 document in part, for PT/OT (physical therapy/occupational therapy) Eval (evaluation) and Tx. (treatment).Reviewed R2's occupational therapy discharge summary for services provided 12/20/2024 through 01/03/2025.Facility provided document titled specialized rehabilitative services policy documents in part, specialized rehabilitative services include but are not limited to physical therapy, occupational therapy. Such services are utilized to restore, maintain or improve the resident's optimal level of functioning, self-care, independence, and quality of life. Services shall be provided in accordance with the assessments' results, and the comprehensive plan of care in accordance with physician's orders.Facility provided documents not dated document in part, Illinois Long-Term Care residents' rights for people in long-term care facilities. Your facility must provide equal access to quality of care regardless of diagnosis, condition, or payment source.

Based on observation, interview, and record review, the facility failed to provide documentation related to the maintenance and upkeep of the facility elevator and failed to provide interventions to ensure the elevator was kept in good working condition. This failure affects 85 wheelchair bound residents in the facility. Findings include:On 6/20/2026, at 9:46 AM, the left elevator on the 1st floor of the facility was not working.On 6/20/2026, at 9:47 AM, V4 (LPN) stated, The second elevator was working Thursday. Now it's down again.On 6/20/2026, at 10:24 AM, R4 stated, The elevator has been down for over a week. It came back on one day but then went off again the next day. It's been a traffic jam. It is a fire hazard and nuisance. The service elevator is only for food service. They do not let us use the service elevator. I have not seen anyone fix the elevator. The administrator is so nonchalant.On 6/20/2026, at 10:30 AM, on the 2nd floor the left elevator door was seen open with an orange cone to keep residents from entering the elevator.On 6/20/2026, at 10:43 AM, V7 (CNA) stated, The elevator has been down for one day. It was fixed the last time I was here.On 6/20/2026, at 11:26 AM, R6 stated, There is only one elevator here. I found out that we only have one elevator.On 6/20/2026, at 11:40 AM, V3 (ADON) stated, The elevator has been down for two days. The administrator already told me about it.On 06/20/2026, at 12:58 PM, V13 (Maintenance Assistant) stated, I do not remember when the elevator went down. We are waiting for someone to come out and fix it. The supervisor and I looked at the motor that opened and closed the door. The motor belt was broken because it was split in half. The right and the left elevators are new. They do not break easily. Something would have to be done for them to break down. The residents have access to one elevator on the right. I am not aware if the residents can use the service elevator.On 6/21/2026, at 10:00 AM, the left elevator was still broken.On 6/21/2026, at 10:14 AM, V19 (Maintenance Director) stated, The elevators do not break down a lot. The left elevator broke down on 6/11/2026 or 6/12/2026. It was broken for two or three days. The elevator company came to fix it. I do not remember. Then the elevator worked for three days and then it broke down again. I then informed the administrator. The facility is waiting for the company to come fix it. The elevator panel and tank were replaced. This is the third time the elevator has broken down. The residents have one elevator for them to use. The residents are not allowed to use the freight elevator. Only about three or four wheelchair bound residents can fit into the elevator at a time. The residents must wait. I think the elevators break down due to the door banging into the wheelchair doors. It has something to do with the sensors. I believe both elevators need to be replaced.On 6/21/2026, at 10:49 AM, V1 (Administrator) stated, Corporate holds the elevator contract and they schedule the routine maintenance. I let corporate know we have a situation, and they or myself will call the company. Recently, the residents have been complaining about the elevator. They ask me when it will be repaired. The company was out the following week. The first time it broke was from 6/12/2026 to 6/15/2026. It was a timing belt that that was the reason, it broke down, according to the company. There are three elevators in the building. There are 237 residents that have access to one elevator. It becomes an issue during smoke time. Staff will bring residents down on the service elevator during smoking time.On 6/21/2026, V1 stated, via email, there are 85 residents that are wheelchair bound in the facility that must use the elevator. V1 stated she has no idea when the elevators were put in and corporate does not have an exact date. Per corporate, the way their contact is set up with the company, we do not get work orders. V1 reached out to the elevator company for six months of work orders. The on-call department could only be reached, and documentation could be provided.On 6/21/2026, at 12:46 PM, via email, V20 (Corporate Employee) stated, The elevators are in pretty good condition and have not needed too many repairs. Also, the facility has multiple elevators which enable the facility to still have working elevators when one may be down. The company comes to the facility as needed. The elevator company can provide the facility work orders typically upon request. Off hand, I remember the elevator has broken down twice recently. To obtain documentation, the paperwork would need to be requested from the elevator contractor during regular business hours. During non-business hours, they have an answering service and technicians available only for emergencies. Regarding interventions, the elevator contractor provides routine maintenance are per the agreement. I am not aware of any elevators being replaced. To replace an elevator, typically an elevator tech would need to do this work. The facility is responsible for keeping the elevators in good working condition. They have contracted an outside vendor to do the repairs and maintenance. It is important to keep an elevator in good condition for safety and for accessibility.On 6/21/2026, the facility was asked to provide documentation related to the maintenance of the elevator. Work orders and any receipts were requested. V1 provided work orders for February, April, and June 2026. No other work receipts were provided for 2026. No elevator logs were provided to support the fact that the elevator was kept in good working condition.Facility assessment dated [DATE], notes physical plant needs are scheduled for routine maintenance to ensure proper functioning.

Based on observation, interview, and record review, the facility failed to provide linen inventory documentation to ensure there was enough linen for all the residents of the facility. The failure affects all 237 residents that reside in the facility.Findings include:R4 is a [AGE] year-old male. R4's BIMS (Brief Interview for Mental Status) dated 4/03/2026, notes R4 is alert.R6 is a [AGE] year-old female. R6's BIMS dated 6/11/2026, notes R6 is alert.On 6/20/2026, at 9:47 AM, V4 (LPN) stated, I have seen linen delivered on all shifts.On 6/20/2026, at 10:24 AM, R4 stated, I will ask the aides to give me linen, and they will say there is no linen. This happens on all three shifts. Residents will get linen at the end of the shift to make it seem like we have not been neglected all day. This has been going on for the last three years.On 6/20/2026, at 10:43 AM, V7 (CNA) stated, There is never enough linen. The facility encourages us to dump the linen, down the chute, so we can have more linen. I do not remember the time they delivered the linen, but it was early.On 6/20/2026, at 11:12 AM, V4 (CNA) stated, there is a shortage of linen, but I can get my work done.On 6/20/2026, at 11:26 AM, R6 stated, The facility never has enough linen. I will tell the aides about it. The aides say they must wait until the facility washes the linen.On 6/20/2026, at 11:36 AM, V11 (CNA) stated, Morning linen was received but now there is no more linen. This is not an issue for us. We receive linen in the morning and in the afternoon.On 6/20/2026, at 11:40 AM, V3 (ADON) stated, the facility does have linen but there is a delay. It does come up. It is distributed on floors based on acuity. Staff can go downstairs if they need linen.On 6/20/2026, at 12:20 PM, V12 (Housekeeping/Linen Supervisor) stated, The facility has enough linen for the residents. My laundry lady was taking laundry to the fourth floor. We call and ask the aides to put their linen down the laundry chute. We have linen that comes in every month. I count it up and give it to the administrator on what goes out. I count wash clothes, fitting sheets, gowns, bath towels. I have staff that work from 6:00 AM-2:00PM. I have a lady that comes from 2:00 PM to 10:00 PM. Then I have a night shift from 10:00 PM to 6:00 AM.On 6/20/2026, at 12:30 PM, surveyor was with V12 in the linen room. The room was full of various supplies and a lot of different boxes. The linen director had to dig for towels, wash cloths, etc. There was no way to inventory the linen the way the linen was stored. V12 was asked for laundry inventory sheets to ensure there is enough linen for all the residents of the facility.On 6/20/2026, at 12:45 PM, V12 stated, the administrator had to send the laundry counts to corporate and then she will get the laundry counts to me.On 6/21/2026, at 10:49 AM, V1 (Administrator) stated, There are 237 residents in the facility. I feel that linen fluctuates. It is a fluid process. There are some residents hoarding the linen. There are linen sweeps completed.On 6/21/2026, at 10:49 AM, V1 provided a typed document stating, we do not have any inventory linen sheets in the facility to ensure there is enough linen for the residents.

Based on observation, interview, and record review the facility failed to maintain an effective pest control that eliminated roaches in the facility. This failure affected one (R1) of three residents (R1, R2, R3) reviewed for pest control and has the potential to affect all 247 residents in the facility. Findings include:On 3/27/2026 at 9:52 am, V4 (Housekeeping Aide) stated she observes roaches at the facility when she is cleaning the building and recalls last seeing a roach about one week ago on the fourth floor. V4 then explained when she sees roaches she reports the sightings to the V1 (Administrator) continuously. V4 explained she has Roach Spray she will use when she sees a lot of roaches in residents rooms and will inform the V1 as well. V4 stated after reporting a sighting of roaches to V1, the pest control company will usually visit the facility within a few days.On 3/27/2026 at 10:03 am, V5 (Housekeeping Aide) was observed standing in the hallway at his housekeeping cart after sweeping and mopping R1's room in the facility. Surveyor spoke with V5 in the hallway outside of R1's room while R1's room floor dried. V5 stated he last saw roaches at the facility two months ago in residents rooms. V5 stated when he observes a roach in the facility, he will report the sighting to V1 (Administrator). V5 then stated after he has reported sightings of roaches to V1 the pest control company will come to the facility the next week to treat the issue.On 3/27/2026 at 10:06 am, Surveyor observed R1 in his room sitting in a motorized wheelchair next to R1's bed. R1 stated he observes roaches in his room daily, usually at nighttime. R1 then explained he cannot eat food in his room without the roaches crawling in his food. R1 explained at nighttime, R1 observes roaches on his bed and chair feel as if they are biting R1. Surveyor then observed three roaches crawling underneath R1's motorized wheelchair, one roach crawling on the side of R1's motorized wheelchair and one roach crawling on R1's wall next to R1's bathroom. On 3/27/2026 at 10:14 am, Surveyor brought this observation to V5 and V5 stated, Those are roaches. They only came out because they know we have company. I will report this to my supervisor.On 3/27/2026 at 10:34 am, V8 (Housekeeping Director) stated the staff and residents report roach sightings to V8 and V9 (Maintenance Supervisor) at the facility frequently. V8 then explained pest control visits the facility bi-monthly and as needed (prn) when a roach is reported being sighted. V8 then stated V8 or V9 will notify the pest control company to visit the facility and address sightings reported to V8 or V9 for a as needed visit. V8 further explained there is a book on each unit that staff can report pest sightings such as roaches, however V8 and V9 do not check the pest control sighting book, and the book is only checked by the pest control company when they come to the facility bi-monthly. V8 explained there could be potential sightings reported in the pest control book on each unit that V8 and V9 are not aware of because V8 and V9 do not check the pest control book. V8 explained that an effective pest control program is needed to eradicate any sightings of pest or rodents in the facility. V8 stated he last saw a roach at the facility one week ago, in the pantry on the second floor and further explained he killed the roach but did not follow up with pest control company for a as needed visit regarding the sighting.On 3/27/2026 at 10:44 am, V9 (Maintenance Supervisor) stated the staff and residents report roach sightings to V9 and V8 (Housekeeping Director). V9 stated when V9 or V8 receive a report regarding a sighting of roaches they notify the pest control company to visit the facility if it is not the pest control company's bi-monthly visit. V9 denied any knowledge of a pest control book on each unit staff can report pest sightings such as roaches. V9 then explained the pest control will treat whatever areas V9 or V8 instruct them to treat when they visit the facility bi-monthly. V9 finally stated he last saw a roach about a month ago in the hallway on the third floor shower room. V9 stated he did not inform the pest control company to treat the shower room area for any as needed visit and the pest control company treated the area when they returned for their next visit at the facility. On 3/27/26 at 10:49 am, Surveyor, V8 (Housekeeping Supervisor), and V9 (Maintenance Director) inspected the facility's dumpster area and observed old food and trash beginning from the outside ramp area to the outside dumpster. Surveyor, V8, and V9 observed one of two dumpsters with the lids open, and large amounts of overflowing trash, and garbage surrounding the dumpster area. V8 stated the dumpster should remain closed at all times to avoid attracting rats and roaches to the facility. V9 stated it is the responsibility of the housekeeping department and the kitchen department to maintain the dumpster area. V8 stated it is the responsibility of the housekeeping department and the kitchen department to maintain the dumpster area.On 3/27/26 at 11:30 am, Surveyor requested V8 (Housekeeping Director) to provide the pest control book on each unit. V8 stated, Oh we don't have it. (V1 Administrator) said she lets the pest control company know where to visit when we inform her of the sightings.On 3/27/26 at 2:20 pm, V1 (Administrator) stated R1 has reported to his nurse regarding roaches in his room. V1 stated she is notified by nurses or supervisors regarding any sightings of roaches, and any other pest in the facility. V1 explained once she is notified regarding a sighting of a roach or any other pest, she relays the information to the pest control company who will come within a few days and treat the area. V1 explained the pest control company is scheduled at the facility bimonthly and as needed. V1 explained the last report of a resident reporting roaches in the facility was on 3/23/26 and the pest control company treated the reported area for roaches on 3/25/26. V1 stated it is important to eradicate the facility of roaches in order to provide a homelike environment and promote a safe and clean safety standard. The facility's undated policy titled Safe Handling Dumpster documents, in part: Policy: All food will be handled safely and disposed of in a safe manner. Procedure: Dietary trash will be disposed of in a sealed plastic trash bag. The sealed bags will be disposed of in the outside dumpster. The dumpster will be on a solid surface. The ground surrounding the dumpster will be free of trash and debris. The facility's undated policy titled Pest Control Policy documents, in part: Purpose: To prevent or control insects and rodents from spreading disease. Standards: 1. The Environmental Service Director will be responsible for coordinating the facility pest control program . 3. The pest control program will be conducted on a regular and as needed basis . 5. Employees are instructed to promptly report all observations of pests to their department heads 10. The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents. 16. Outside dumpsters shall be of sufficient size so the lid can be tightly closed. The container shall be stored on a smooth surface of non-absorbent material. 17. The dumpster shall be kept clean and maintained in good repair.

Based on observations, interviews and records reviews, the facility failed to follow their policy on providing a clean home-like environment to residents. This failure affected all 244 residents residing in the facility.Findings include:R2R2's medical diagnosis in current face sheet includes but not limited to schizoaffective disorder, bipolar type, muscle wasting and atrophy, not elsewhere classified, multiple sites, rheumatoid arthritis, unspecified. MDS (Minimum Data Set) section C dated [DATE], documents R2's Brief Interview for Mental Status (BIMS) as 9/15 indicating R2 has moderate cognitive impairment. R3R3's medical diagnosis in current face sheet includes but not limited to: Unspecified dementia, unspecified severity, with other behavioral disturbance, dysphagia, oropharyngeal phase, muscle wasting and atrophy, not elsewhere classified, multiple sites. MDS (Minimum Data Set) section C dated documents R3's Brief Interview for Mental Status (BIMS) as 8/15 indicating R3 has moderate cognitive impairment. R4Medical diagnosis in current face sheet includes but is not limited to: immobility syndrome (paraplegic), unspecified diastolic (congestive) heart failure, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side. MDS (Minimum Data Set) section C dated [DATE], documents R4's Brief Interview for Mental Status (BIMS) as 15/15 indicating R4 has intact cognitive abilities. R5R5's medical diagnosis in current face sheet includes but not limited to: type 2 diabetes mellitus without complications, superficial frostbite of right/left foot, subsequent encounter, gangrene, not elsewhere classified, partial traumatic amputation of right great toe, subsequent encounter. MDS (Minimum Data Set) section C dated [DATE], documents R6's Brief Interview for Mental Status (BIMS) as 15/15 indicating R6 has intact cognitive abilities.On 03/18/2026 at 2:22 PM, R5 was observed in the day room sitting on a wheelchair. R5 stated he sits in his wheelchair and would never sit on the chairs in the dining room because they are 'nasty and filthy'. R5 stated, I have never seen anyone clean these seats. They are full of dirty stains and food. I am not going to sit on them.On 03/17/2026 at 1:35PM, R12 stated, Most of the time the floors are swept but not mopped and garbage is not taken out daily. It doesn't make me feel good to have overflowing garbage in my room. Sometimes there are not enough housekeepers. R12's toilet and bathroom floors were observed to be dirty with brownish stuff going down the toilet bow and floor. R12's garbage can was observed near the window with garbage overflowing. R12 stated no one has been to his room to clean or empty the garbage.On 03/17/2026 at 2:03PM, observed cobwebs and brown dust on the celling on the 3rd floor dining room and vents. Two round broken tables observed in the dining room. One leaned against the window, one was pushed against the wall. Observed residents in the dining room, some walking in and out, others sitting in the dining room.On 03/13/2026 at 2:46PM, observed 4th floor day room with food dried particles on floors and tables. Dried food and stains observed on the chairs.03/17/2026 at 3:20PM, observed 2nd floor day room chairs dirty with brownish stains and food particles stuck on crevices of the chairs. Black dust observed on ceiling in hallways.On 03/17/2026 at 2:56PM, observed on the first-floor dining room, brownish tiles stains on chairs, spills on floor, dust and old food particles on heating unit, blackish dirt/dust on ceilings near ceiling vents.On 03/13/2026 at 2:48PM, V3(Housekeeping) stated, the floors on the 4th floor are not clean and she could see used paper towels, food particles, and used cups on the floor. V3 stated the seats in the dining room were very dirty with brownish stains and caked on food and dirt. I saw the used paper towels and used cups on the floor as I was passing by and came to pick them up. V3 said The floors are not clean; they have not been mopped. They are supposed to be mopped every day. There is food on the floors. I was not responsible for cleaning the day room today. I have not cleaned chairs since I started working here and I have not seen anyone clean them. It is important to give residents a good clean environment. This is their home; they don't want a dirty home. V3 and surveyor toured the 4th floor unit and observed no curtain on showers on the big end of the unit separating two showers.On 03/13/2026 at 3:09PM, V4 (Licensed Practical Nurse-LPN/ first floor supervisor) and surveyors observed large brownish stains on R2's room walls and on the floors. Food particles were observed all-round the floor base boards. Dried up brown stains were observed on the wall and stains on the floor. V4 stated the calendar on R2's wall shows his room was deep cleaned on February 26th, 2026. Resident rooms are supposed to be cleaned daily. No privacy curtains were observed in the room. V4 stated maybe R2's curtains were being washed and there were no replacement curtains. V4 asked R2 if his room was ok. R2 stated he wants his room cleaned up.On 03/18/2026 at 1:16PM, V14 (Housekeeping supervisor) stated he has ten housekeepers all working full time. One housekeeper in the morning per floor and two floor technicians who clean the center core, day rooms, empty garbage and buff the floors on the hallways. Day rooms/parlors are supposed to be cleaned after every meal by the floor tec or housekeeper. V14 stated if the day rooms/parlors are not cleaned, the residents can feel bad eating or sitting in a dirty environment. V14 said, I would feel bad if I had to have my meals in a dirty environment. The seats in the parlors need to be cleaned. They have stains from urine and grease from food. They should be cleaned daily so they can be presentable for the residents to sit on during meals and as they relax. This is their home, and they should feel comfortable in their home. If rooms are not cleaned properly and there are food particles in the room, it can bring rodents to the facility. Garbage cans are supposed to be emptied every day to give residents a comfortable home like environment. If not emptied, the residents can pick into the garbage for items which can make them sick. The garage smells bad if left sitting there for long. Shower curtains in the shower room should always be there. We have order to order them. I do not have any shower curtains currently to replace the ones missing on the 4th floor showers. Shower curtains are for privacy. Not having shower curtains takes the resident privacy away. Broken furniture should not be left in resident area. A resident might try to use the broken furniture which can hurt the resident. It is dangerous.On 03/18/2026 at 1:55PM, during tour of the units with V14, fabric seats on the fourth-floor dayroom/parlor have stains. V14 stated the stains are from urine, sweat, dirt, grease from food and spilled milk. V14 stated the seats are very old but should still be cleaned. V14 stated he can see old food particles caked on the ridges/crevices of the seats and on base boards. Observed dirt on air/heat vents. Vent was wiped with a napkin and brown dirt was observed on the napkin. V14 stated the vents should be cleaned so that clean air can flow into the facility. V14 swiped his finger on top of the heating unit in the dining room. V14 stated his finger was filled with a substance spilled on the heating unit. V14 stated it was dried up milk which should have been cleaned. V14 stated dirty old food can cause bacteria to grow and make residents sick. It should have been cleaned.Observed broken seats in the dining room on the 4th floor. V14 stated broken furniture should be removed to prevent residents from seating or using it and risk getting hurt.On 03/19/2026 at 12:09 PM, V19 (Housekeeping/Laundry) stated each day she is assigned 30 resident rooms. Sometimes she cannot clean all 30 rooms because there are rooms that need more work than others every day. The rooms are supposed to be cleaned every day because of spilled food and foot traffic. If rooms are not cleaned daily, this can bring dirt to the residents' rooms. residents' rooms are their homes and should be clean. Policy dated 7/14 titled Housekeeping Guidelines documents:-Purpose: To provide guidelines to maintain a safe and sanitary environment forresidents, facility staff and visitors.- Trash will be removed from all areas of the facility daily and as needed to prevent spillage and odor.- Cleaning of curtains, walls, blinds, etc. will be cleaned when dust or soiling is visible.- Housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner.

Based on observations, interviews and record reviews, the facility failed to follow their residents' rights policy by failing to manage resident clothing in a clean manner. This failure affected one (R2) of six residents reviewed in sample of 15.R2's medical diagnosis on R2's current face sheet includes but not limited to schizoaffective disorder, bipolar type, muscle wasting and atrophy, multiple sites, rheumatoid arthritis. MDS (Minimum Data Set) section C-Cognitive Abilities dated [DATE], documents R2's Brief Interview for Mental Status (BIMS) as 9/15 indicating R2 has moderate cognitive impairment. On 03/13/2026 at 3:09PM, R2 observed lying in bed. R2 was difficult to understand and was observed to be teary eyed.On 03/13/2026 at 3:09PM, V4 (Licensed Practical Nurse-LPN/ first floor supervisor) opened R2's closet. V4 started pulling out R2's clothes from his closet. R2's clothes were not folded. R2's whitish pants were observed with a big brownish stain on the crotch; some pants and shirts were observed with stains. V4 stated it was difficult to know which clothes are clean and which clothes are dirty. V4 stated the CNAs are in charge of maintaining resident clothes once laundry cleans and brings them up. The CNAs are supposed to store clean clothes separately from dirty clothes. It's not ok to mix clean and dirty clothes. Staff or residents will not know which clothes are clean. V4 stated if R2 wears dirty clothes it can make him feel bad. He can smell. R2 needs supervision choosing which clothes to wear. He dresses himself.On 03/19/2026 at 12:33PM, V20 (Certified Nursing Assistant -CNA) stated, it is not ok to mix R2's clean and dirty clothes because everything will smell. R2 will not be comfortable wearing smelly clothes. This can make him feel horrible. Policy titled Resident Rights dated 11/18 documents:-Your facility must be safe, clean, comfortable and homelike.-Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects one (R8) resident out of five residents reviewed for abuse in a total sample of fifteen. As a result of this failure, R9 pushed R8 on 12/15/2025.Findings include:Facility's reported incident (FRI) document dated 12/19/2025, documents in part, upon investigation, R8 became disrespectful in his choice of words. As R9 turned to go back to his room, R8 stepped out in front of him. Staff were present and attempted to separate the two residents, but R9 reached around staff and pushed R8. R8 stumbled and subsequently fell. R8 was sent to the hospital for evaluation and returned shortly thereafter with no noted injuries and no new orders.R8's face sheet documents R8 is a [AGE] year-old individual admitted to the facility on [DATE] and discharged on 01/16/2026. R8 has diagnoses not limited to generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus, unsteadiness on feet, muscle wasting and atrophy, not elsewhere classified, multiple sites, other lack of coordination.R9's face sheet documents R9 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to schizoaffective disorder, bipolar type, opioid dependence, uncomplicated, major depressive disorder, recurrent, unspecified, insomnia, unspecified, suicidal ideations, other seizures.R9's Minimum Data Set (MDS), dated [DATE], documents R9 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R9 is cognitively intact.R9's Preadmission Screening and Resident Review (PASRR) Level II outcome dated 10/18/2025 documents in part, Date Short Term Approval Ends: November 18, 2025.R9's care plan documents in part, R9 may be at risk for potential abuse due to behavior problems as evidenced poor impulse control and boundaries. On 12/15/2025, R8 was involved in a verbal altercation in which he became the noted aggressor and displayed physical aggression toward a peer. Date Initiated was 12/15/2025.On 03/18/26, at 2:39 PM, R9 was outside in the smoking break area, a couple of staff members noted. R9 stated, He (R8) just went crazy and touched me, and I (R9) pushed him. I pushed him because he was threatening me that he was going to beat me up and kill me. R9 denied hurting any other residents or staff. R9 stated he cannot remember the staff that were there after it happened. R9 stated R13 was there when it happened. R9 denied that any staff or resident got in between R8 and R9 when R9 pushed R8. On 03/18/26, at 2:44 PM, R13 stated that he has been residing in the facility for a year. R13 stated he remembers R13 was arguing with R9 the day that R9 pushed R8. R13 stated R8 heard when R13 and R9 were arguing, R8 wanted to know what was going on and they (R8 & R9) got into it. R13 stated that R9 told R13 that R9 pushed R8. R13 denied witnessing the push.On 03/17/2026 at 1:49 PM, V6 (CNA) stated if he would witness residents arguing or being triggered, V6 would separate the residents then make the nurse and supervisors aware. V6 stated I try to redirect them, wheel them to a different location, and monitor them.On 03/18/2026 at 1:30 PM V16 (Social Service Director) stated he is familiar with both R8 and R9. V16 stated the staff that is responsible for following up with The Preadmission Screening and Resident Review (PASRR) Level 2 screenings are V16 and the previous business manager who no longer works for the facility. V16 stated V16 has not reviewed any of R8 and R9's PASRRs level one and level II. V16 stated it is important to have PASRRs in place so the facility and the government can know information about the resident such as if they are in the proper placement and the kind of care they get and have care planned.On 03/18/26 at 3:06 PM, V1(Administrator) stated, I was at the nurses' station that afternoon and I saw (R9) was trying to talk to (R13), when (R8) stepped out of his room. At first, they were joking. I looked over. (R8) was telling (R9) to leave me alone. Next thing I hear is they are getting louder. I stepped from behind the nurses' station, and I (V1) saw (V9 (Certified Nursing Assistant) go over there and separate the two of them. Then, as he turns to come back to the nurses' station, (R9) pushes (R8) to leave him in peace in Spanish. (R8) was by the guard rail. (R8) tripped and fell backwards. We all rushed to them and asked them what was going on. (R9) said that (R8) was gossiping and putting his nose where it does not belong. Of course, all residents have the right to be free of abuse. V1 stated she does not think the abuse could have been prevented. V1 thinks it was an accident, especially since they were all friends. R8's hospital record dated 12/15/2025 documents in part small left posterior parietal scalp hematoma with scalp swelling.R9's behavior note dated 12/15/2025, at 5:06 PM, documents in part, R9 stated he had a discussion with another resident when R8 came out his room and threatened him. He (R9) shoved R8. Facility document dated 01/2026 titled Policy and Procedure Abuse and Retaliation Prevention documents in part, this facility is committed to protecting our residents from abuse, neglect, exploitation, retaliation, misappropriation of property, and mistreatment by anyone. 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.The facility's PASRR policy dated documents in part, it is the policy of this facility to: Review the PASRR documents to help assess/ascertain what type of problems, needs and issues need to be addressed to help the resident function at his/her maximum level of well-being.

Based on observation, interview and record review, the facility failed to provide a homelike environment for two residents (R2, R10) in a sample of 10. This failure has the potential to affect 117 residents residing on the 3rd and 4th floor. Facility's (2/2726) roster documents 117 residents residing on the 3rd and 4th floor.1. R10's is a [AGE] year-old with diagnosis not limited to: hemiplegia and Hemiparesis, Cerebrovascular Disease Affecting Left Dominant Side, Aphasia, Cerebral Infarction, Type 2 Diabetes Mellitus with Moderate Non-proliferative Diabetic Retinopathy Without macular Edema, Bilateral, Constipation, Essential (Primary) Hypertension, Gastro-Esophageal Reflux Disease Without Esophagitis, Hyperlipidemia, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and AnxietyR10 resides on the 3rd floor.R10's (12/19/2025) Brief Interview for Mental Status Assessment documents score of 6 severe cognitive impairmentR10's care plan documents in part: Focus: R10 is at risk for skin breakdown R/T incontinence, impaired mobility and comorbidities Revision on: 09/25/2024 Goal: -Keep clean and dry -Keep linen clean, dry and wrinkle free Focus: The resident has incontinence of bladder and/or bowel Date Initiated: 09/11/2024 Revision on: 12/18/2024 The resident will be clean, dry & odor free through the next review .Date Initiated: 09/11/2024 Revision on: 09/19/2025 Target Date: 06/21/2026Interventions Administer appropriate cleansing & peri-care after each incontinent episode. Date Initiated: 09/11/20242. R2 is a [AGE] year-old with diagnosis not limited to: Bipolar Disorder, Schizoaffective Disorder, Asthma, Cocaine Dependence with Cocaine-Induced Mood Disorder, HypertensionR2 resides on the 4th floorR2's (8/8/25) Brief Interview for Mental Status Assessment documents score of 15 cognitively IntactOn 2/27/26 at 11:00 am R2 stated, sometimes when he wants to take a shower in the morning, there are no towels available on the floor.On 2/27/26 at 11:04 am V4, Certified Nursing Assistant (CNA) showed surveyor 4th floors clean linen room. There were no fresh linen available including towels. V4 stated, right now there are no towels available on the 4th floor. V4 stated, her shift is from 7:00 am to 3:00 pm and she got here this morning, and linen had not been delivered yet. V4 stated, residents will complain if they want to shower and there are no towels. V4 stated, usually laundry will deliver the linens by 10:00 am. There were no fresh linens observed on the 4th floor.On 2/27/26 at 11:54 am V8 (Housekeeping/Laundry) was observed folding clothes. V8 stated, it's just her working in the laundry room. V8 stated, she works from 6:00 am to 2:00 pm. V8 stated, there is always someone doing laundry on the second and 3rd shift. V8 stated, 4th floor has not yet had their linen delivery yet. V8 observed folding linen. V8 stated, for her shift, 1st floor got their linens at 8:35 am, 2nd floor at 9:30 am and 3rd floor at 11:00 am. V8 stated, she should be delivering 4th floor linens within 30 minutes, but usually they get it around 10 am.On 2/27/2026 at 1:54pm V16, Housekeeping and Laundry Supervisor stated, linen is distributed in the morning to the 1st, 2nd, 3rd, and 4th floor. Each shift gets a round of linen. Start distributing about 7:00am. If more linen is needed, staff will call down and we will get linen up as soon as possible. We have not run out of linen. Linen is done in house.On 2/27/2026 at 1:26pm V12, Certified Nursing Assistant (CNA) stated, we usually have some linen, if we run out, we call to laundry to get more. If there are no towels or not enough towels, we will cut up towels, if we don't have enough.On 2/27/2026 at 2:12pm facility linen room toured with V16, Housekeeping and Laundry Supervisor. Observed one pack (12) gowns, wash clothes 2 packs (24), sheets 1 pack (24) and towels 2 packs (24). V16 stated, it is the end of the month, and I am waiting for a new order. We have to get linen back from the floor so we can wash and put back on the floors.On 2/28/2026 at 11:25am 3rd floor V9, Registered Nurse (RN) stated we had a little linen that came up, not a lot but more is supposed to come up. CNAs had linen and towels but not all of them had enough linen or towels for residents. We are getting more linen; it has not come up yet. Observed 3rd floor linen room with V9, there were no towels, wash cloths, or linens to make bed. Other linen carts were empty.On 2/28/2026 at 11:27 V15, Certified Nursing Assistant (CNA) stated, We have not received linen/towels yet. I used a little from previous shift. We are waiting for the linen cart for 7:00am to 3:00pm shift delivery. Normally, linen is delivered between 8:30am to 9:00am. We were able to clean some residents; others have to wait until linen comes up. We work together to make it work.On 2/28/2026 at 11:36am V16 stated, 3rd floor linen cart should have been delivered a long time ago between 8:30am and 9:00am. I just got a call about the linen and there are not any washcloths or towels. I am on my way downstairs.On 2/28/2026 at 11:38am V12 stated, right now we do not have linen. Surveyor observed V12 with parts of a cut up sheet in her hand. V12 stated, I will have to use this to clean up residents because there are no towels or washcloths. There were not any when I came in this morning. (R10) needs incontinence care, and he had a BM (bowel movement), and I do not have a towel or wash cloth to clean him up. I was doing rounds and his roommate told me he needed to be changed. We run out of linen a lot (towels, washcloths, sheets). This is not a secret not to have linen and towels. I have not been able to change residents all day. R10 observed lying in bed waiting to be changed. V12 apologized to R10 and said, He is in bed waiting to be changed. I have not had linen/towels to change him. I have a piece of a sheet to clean him up.On 2/28/2026 at 11:47am V16 stated, When (V8) was taking linen cart to 3rd floor this morning, she had to take it to the 4th floor. Right now, she is folding linen and making a linen cart for the 3rd floor. Linen (sheets, towels, washcloths, gowns) are in the dryer.On 2/28/2026 at 11:50am V8 stated, I had to take linen for the 3rd floor up to the 4th floor. I am folding linen for them now. I just got linen out of the dryer. Surveyor observed a few washcloths, towels, and sheets on the table and linen in dryer.On 2/28/2026 at 11:52am V16 stated, I put some washcloths into circulation yesterday. The washcloths come 12 in a pack. I only have 1 pack left. They have to drop linen down so we can wash and get back into circulation. I put extras in circulation yesterday. Surveyor observed extra linen room with 1 pack (12) of washcloths. This is all I have until my order comes. I do get complaints all the time that they need linen, towels and washcloths. If they do not drop towels, washcloths, bed linens, or gowns down, we cannot get laundry back to the floors. Surveyor asked V16 how residents get the care they need if towels, wash clothes, bed linens or gowns are not available. V16 stated, They have to send laundry down so we can wash and get back to the floors.On 2/28/2026 at 12:06pm no linen had been delivered to 3rd floor. V8 continued to prepare linen cart.On 2/28/2026 at 12:30pm V1, Administrator stated, Linen is dropped down, washed, then dried back up to units. My expectation when linen comes down, wash dry separate and take up, I believe there is an order how laundry is taken up. We have enough linen for our census. We have to do linen sweeps. We sweep usually Monday and Wednesday. Comes in front door then have to find. We put linen into circulation then wonder where the linen went. We have hoarders that hoard the linen. At one point it was staff, now it is residents. Expectation, if there is no linen the assistant administrative gets call and a sweep is done. I have not had it that there is no linen. Staff should reach out to supervisor, and we will go to the floor to find the linen. (V16) has some linen he puts into circulation. We order at the end of the month, but if needed sooner I reach out to corporate for corporate to order extra linen.Review of facility laundry log documents in part of linen delivered to 3rd and 4th floors:Date: 2/27/2026 V8 documented delivery Time: 12:43 am (per V16, that should be 12:43pm) Floor: 4thWashcloths - 10 Towels - 0 Fitted Sheets - 6 Flat Sheets -16Pillowcases- 2 Pads - 1 Blankets - 8Date: 2/28/2026 V8 documented delivery Time: 12:00pm 3rd FloorWashcloths - 30 Towels - 10 Fitted Sheets - 10 Flat Sheets - 10Pillowcases - 10 Pads - 2 Blankets - 2 RESIDENTS' RIGHTS for People in Long-Term Care documents in part: Your facility must be safe, clean, comfortable and homelike.

Based on observations, interviews and record reviews, the facility failed to prevent live roaches from being in residents' rooms and crawling in bed with residents. This failure affected four residents (R2, R6, R18, and R21) in a sample of 10. This failure has the potential to affect all 250 residents residing in the facility.Findings include:a.R2's Face Sheet documents that R2 was admitted to the facility on [DATE] and R2's diagnosis includes Schizophrenia, Schizoaffective, Bipolar Disorder, Conduct Disorders, and Auditory Hallucinations. R2's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment.On 12/22/2025 at 2:32 PM, R2's family member (V6) stated R2's mattress was rotten and there were big cockroaches running throughout the mattress. V6 said that the mattress needed sterilizing. V6 added that roaches ran out of the clean sheets that were placed on R2's bed. V6 said the bug problems took place when R2 live on the second floor with R2's former roommates.b.R6's Face Sheet documents that R6 was admitted to the facility on [DATE] with a diagnosis of muscle wasting and atrophy, unsteadiness on feet, other lack of coordination, unspecified psychosis not due to a substance or known physiological condition, low vision right eye category one, low vision left eye category one, and neurocognitive disorder. R6's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact with little to no impairment.On 12/22/2025 at 2:15 PM, V26 (Certified Nursing Assistant (CNA) stated that roaches on the second floor are usually seen during first shift sometimes on the second shift. V26 added that V26 sometimes work first shift, second shift and all four floors so V26 stated that the roaches are prevalent throughout the facility where residents reside. V26 said that the roaches appear on the floor when they order food for the residents from the kitchen. V26 stated that R6 attracts roaches because R6 likes to hide food especially sandwiches under the cushion of R6's wheelchair. V26 added that V26 saw roaches in V26's room last night as well as Thursday of last week. V26 provided other rooms where roaches usually crawl but the surveyor's data was lost.c.R18's Face Sheet documents that R18 was admitted to the facility on [DATE] with a diagnosis of muscle weakness, idiopathic peripheral autonomic neuropathy, simple chronic bronchitis, major depressive disorder, generalized anxiety disorder, and cognitive communication deficit.R18's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact with little to no impairment.On 12/24/2025 at 10:39 AM, R18 stated that just last night R18's roommate killed a roach on their dresser by the television. At 10:30 AM, R21 said that R1's room had many roaches, and they were alive. While in R1's room, R1 had multiple devices that was purchased to trap and kill the roaches. R21 stated that the roaches hide and live behind the decorative wall trimming/band that was about waist-length above the wall. R21 then pulled open the trimming and a large black insect about one and half inches in diameter ran down the wall. R21 believe the roaches are embedded and live in the wall behind R21's bed and within the decorative wall trimmings. Frontline staff of CNAs (V12, V26, V29, and V42) and housekeeping (V31, V32, and V33) interviewed on 12/24/2025 stated the residents have roaches in their rooms and they are told to report on the floor's maintenance request log. They all said that they have never seen the bugs on the residents though they appear in the corners of the rooms and when residents' beds are moved to clean or provide care. On 12/23/2025 at 11:55 AM, V14 (Licensed Practical Nurse) stated that bathrooms on the second floor more roaches than other floors.Record review of the first and second floor Maintenance Request Logs documents Lots of bed bugs (8/21/2025), roaches in the room (9/14/2025), roaches on the floor and in bed (11/1/2025) and list resident rooms that contain roaches. V1 (Administrator), V2 (Director of Nursing), V4 (Director of Housekeeping and Laundry), and V16 (Social Worker Director) interviewed during the investigation stated agreed that the facility has a roach problem, and their expectation is for the problem to be corrected as soon as possible. V4 stated that they implement regular exterminations to the building and resident rooms. V1 said that V1 is confident of the extermination capabilities from the same pest control company that they have employed for twenty years. V1 added that the bug problem is indicative of the resident population due to prior issues such as hoarding, homelessness, and visiting family members who may contribute to the concern and there is nothing they can about it outside of exterminating the facility.Policies:The facility failed to follow their Pest Control Policy dated 11/2014 which documents To prevent or control insects in the facility.

Based on observations, interviews, and record reviews, the facility failed to answer call lights in a timely manner for four residents (R1, R2, R4, R9) and failed to accommodate timely repairs for furnishings for three residents (R1, R3, R4) out of a total sample of 14 residents.Findings include: R1's 'admission Report' documents in part medical diagnoses of quadriplegia, muscle wasting and atrophy in multiple sites, unsteadiness on feet, need for assistance with personal care, difficulty in walking, lack of coordination, limitation in activities due to disability, left side weakness following a stroke, abnormalities in gait and mobility, and generalized muscle weakness. R1's [DATE] Minimum Data Set (MDS) assessment documents in part R1 is cognitively intact. It documents R1 has an impairment to one side of upper and lower extremity. It also documents in part R1 is dependent with toileting hygiene and requires substantial to maximal assistance with oral hygiene, bathing, dressing, and personal hygiene. On [DATE] at 2:29 PM, R1 was alert and oriented to person, place, and time. R1 was sitting in a motorized wheelchair in the bedroom. R1 stated staff take a long time to respond to R1's needs. R1 stated at times staff would come in, turn off R1's call light, and be gone for a long time prior to tending to R1's needs. R1 stated staff can take up to an hour before they answer R1's call light. R1 stated asking staff to move a chair out of the bedroom about ten minutes ago, but staff have not done so. R1 stated the chair was in R9's (roommate who is in a wheelchair) way. R1 pushed the call light at 2:35 PM. The light on the call light box turned on. Surveyor remained in the room and continued the interview with the bedroom door closed. At 2:47 PM, R1 stated, They're supposed to be attentive. Someone could have died by now. At 3:07 PM, R1 asked surveyor to get tissue from the bathroom stating [R1's] nose was running. R1 stated [R1] could not go into the bathroom because [R1's] motorized wheelchair was too wide for the door frame. Surveyor explained role and proceeded to wait for staff to answer R1's call light. At 3:12 PM, R1 pressed the button again and stated, I wonder if it makes noise out there if you hit it. Surveyor stepped out into the hallway. The call light indicator outside the door is on the ceiling and it was flashing. There were also call light indicators near the nurses' station and those were flashing. V4 (Nurse) was sitting at the nurses' station. V4 stated the morning CNAs (Certified Nurse Aides) already left and evening CNAs haven't arrived yet. [V4] was waiting for evening nurse to come in for hand off report. At 3:19 PM, V5 (Nurse) walked past R1's room towards the end of the hall without answering the call light. V5 emerged again and walked past R1's room towards the nurses' station. V4 asked V5 to answer R1's call light. V5 entered R1's room at 3:21 PM (46 minutes after R1 turned it on). During this same observation, R1 also mentioned the bedside table was broken. R1's bedside table had a black, plastic siding was peeling off and hanging from the table. The part hanging was greater than the length of surveyor's laptop keyboard (nine inches). R1 stated it's been since July and the facility has not fixed it. R1 stated its rough at the edge where the siding came off. R1's 'Care Plan Report' documents in part R1 has a self-care deficit (initiated [DATE]) and is at risk for falls (initiated [DATE]). Interventions include to encourage the resident to use the call light for assistance and for staff to respond promptly to all requests for assistance (initiated [DATE]). --- R2's 'admission Report' documents in part medical diagnoses of muscle wasting and atrophy in multiple sites, muscle weakness, need for assistance with personal care, repeated falls, lack of coordination, and abnormal posture. On [DATE] at 11:59 AM, R2 was alert and oriented to person, place, and time. R2 stated staff take about an hour to an hour and a half to respond to call lights. R2's 'Care Plan Report' documents in part R2 has an alteration in musculoskeletal status (revised [DATE]), is frequently incontinent (revised [DATE]), has a self-care deficit (revised [DATE]), and is at risk for falls (revised [DATE]). Interventions include to encourage R2 to use the call light for assistance and for staff to respond promptly to all requests for assistance (initiated [DATE]). --- R3's 'admission Record' documents in part diagnoses of weakness, other lack of coordination, abnormal posture, muscle wasting and atrophy in multiple sites, repeated falls, need for assistance with personal care, and unsteadiness on the feet. R3's [DATE] Quarterly MDS assessment documents in part R3 has an impairment to one side of upper extremity. It also reads R3 requires partial to moderate assistance with toileting hygiene. R3's [DATE] progress note documents in part R3 has a history of stroke with left side weakness. R3's [DATE] 9:17 AM progress note documents in part R3 has left upper extremity with severe limitation. Facility's Resident Council Minutes document in part during the [DATE] meeting, R3 complained of a broken toilet knob. On [DATE] at 11:17 AM, R3 was oriented to person, place, and time. When asked about meeting minutes from July, R3 stated it was not the toilet knob was broken but rather the toilet handle/grab bar. R3 stated the toilet has a grab bar on one side but the other one fell off and is in the bathtub. R3 stated it's been months and staff have not fixed it. R3 stated [R3] needs both sides to help get on and off the toilet. Surveyor observed the toilet with one grab bar to its left, but the grab bar was supposed to be in between the toilet and sink was in the bathtub. 'Facility Work Order Sheet' for R3's unit does not document in part a request to fix R3's toilet grab bar. R3's 'Care Plan Report' documents in part R3 is at risk for falls (revised [DATE]) and has a self-care deficit (revised [DATE]). Interventions include to offer safety reminders with mobility and to use appropriate assistive device (revised [DATE]). --- R4's 'admission Report' documents in part diagnoses of muscle wasting and atrophy in multiple sites, need for assistance with personal care, lack of coordination, and abnormal posture. Facility's Resident Council Minutes document in part during the [DATE] meeting, R4 complained of failure of staff answering R4's call light. On [DATE] at 11:41 AM, R4 was oriented to person, place, and time. R4 stated staff do not respond to R4's call lights and when they do, it is hours later. R4 stated staff will cut the light out and say they're busy and will do it later but won't return until hours after. R4 also reported having a broken bedside table. R4's bedside table was missing one wheel. When R4 attempted to push it out of the way, the table did not roll. R4 stated the bedside table has been broken for two to three weeks. R4 stated a staff member said they would bring R4 a new one but have not done it. 'Facility Work Order Sheet' for R4's unit does not document in part a request to fix R4's bedside table. R4's 'Care Plan Report' documents in part R4 has a self-care deficit (initiated [DATE]), alteration in musculoskeletal status (revised [DATE]), and is at risk for falls (revised [DATE]). Interventions include for R4 to use the call light for assistance and for staff to respond promptly to all requests for assistance (initiated [DATE]). On [DATE] at 11:06 AM, V7 (Maintenance Supervisor) stated staff are supposed to communicate when resident furnishings are broken. V7 stated does not go into the residents' rooms daily and rely on staff to report any broken items. V7 stated maintenance department can usually fix simple things like bedside tables within a day. V7 stated no reports about R3's toilet grab bar or R1 and R4's bedside tables. On [DATE] at 12:13 PM, V2 (Director of Nursing) stated staff are to either verbally report or write down any maintenance issues. When it comes to call lights, V2 expects staff to answer the residents' call lights in a timely manner. If the staff are available, they are to answer them. Facility's Policy and Procedure Call Light (revised 1/25) documents in part: All call lights will be answered by staff within a reasonable time, depending on the task required. All staff should assist in answering call lights. A non-nursing staff member may seek out nursing staff for further assistance when needed. Staff members may go to the resident's room to respond to the call system and promptly cancel the call light. Procedure: Answer the light (signal) promptly. Facility provided a copy of the 'Illinois Long-Term Care Ombudsman Program - Resident Rights for People in Long-Term Care Facilities.' It documents in part residents have the right to receive the services and/or items included in the plan of care. Facility's Preventative Maintenance Program (11/2022) documents in part the purpose is to conduct regular environmental tours/safety audits to identify areas of concern within the facility. The Preventative Maintenance Program will review resident equipment are in working order.

Based on observations, interviews, and record reviews, the facility failed to provide a clean and home-like environment for six (R2, R4-R8) out of a total sample of 14 residents with a potential to affect multiple residents on the first, second, third, and fourth floors.Findings include: On 9/16/2025 at 11:35 AM, there were multiple brown and dark tan-colored splatter stains on the central walls on the fourth floor including the wall across from the East stairwell. On 9/18/2025 at 11:56 AM, the central walls and wall across from the East stairwell still had brown and dark tan-colored splatter stains. On 9/16/2025 at 11:41 AM, R4 stated facility is slow to fix things. There are brown stains to three ceiling panels by the window, two ceiling panels above bed B, and others by the bathroom. One of the ceiling panels above bed B is curved/bubbled. R4 stated the hallways and dining rooms are also dirty. On 9/16/2025 at 11:53 AM, the third-floor dining room had multiple food particles and other debris (pieces of sugar packets, white paper shreds) on the floor. On the left side of the dining room, there was a table with six dirty/used trays from previous meals. One tray had left over chicken, mashed potatoes, carrots, peas, and bread. The other trays had left over milk and scrambled eggs. At 12:14 PM, facility started serving lunch to the unit. The dining room remained with the used trays and debris on the floor. R6, R7, and R8 were eating lunch in a nearby table to the dirty trays. On 9/16/2025 at 11:59 AM, R2 was alert and oriented to person, place, and time. R2 stated maintenance was slow to fix things and housekeeping do not do a good job cleaning specifically with sweeping. R2's room had brown stains to two ceiling panels in the back left corner of the bed and there was chipped paint to the corner wall near the bathroom. On 9/16/2025 at 12:26 PM, R5 was in the room when [R5] stated facility maintenance department is slow to fix things. R5 pointed to the ceiling tiles near the window. There were tan and brown stains on some of the ceiling panels. R5 pointed to the wall by the head of R5's bed. R5 stated the floor trimming was peeling off and there was chipped paint on the wall. On 9/18/2025 at 10:15 AM, the second-floor dining room had multiple food particles and other debris on the floor. There was a used brown paper towel on the floor near the window. On a table near the proximal wall to the nurses' station, there were five dirty meal trays. At 11:59 AM, R5 and multiple residents were in the dining room for lunch. The paper towel remained on the floor and the used trays were stacked on top of each other on the same table as earlier. Multiple staff walked by the brown paper towel on the floor without picking it up including V12 (Certified Nurse Aide - CNA) and V22 (CNA). On 9/18/2025 at 10:27 AM, the first-floor dining room had multiple food and other paper products (brown paper towel) on the floor by the vending machines. There was also a dark brown spill stain. There was a clear plastic bag in the middle of the room and a bath towel by the cabinets on the other side. At 12:03 PM, residents were eating in the first-floor dining room, but the paper towel, plastic bag, and bath towel remained on the floor. On 9/17/2025 at 11:06 AM, V7 (Maintenance Supervisor) stated staff are supposed to communicate when there are any environmental issues. V7 stated does not go into the residents' rooms daily and rely on staff to report any issues. V7 stated if there's tan or brown stains to the ceiling panels, V7 needs to check on it right away to check for a leak. V7 stated if there's a leak that's causing the ceiling panel to bubble, then it might fall. V7 was not aware of the ceiling panels in R2, R4, and R5's room. On 9/17/2025 at 1:08 PM, V17 (Housekeeping Supervisor) stated the housekeepers are to clean the dining rooms after each meal. V17 stated the purpose is to get the dining rooms ready for the next meal or for when family and friends visit the residents or for when residents want to hang out in there. V17 stated housekeeping staff are also supposed to clean the hallways and resident rooms daily. Staff are to clean the walls whenever they see a spot or dirt on them. On 9/18/2025 at 12:13 PM, V2 (Director of Nursing) stated housekeeping is to ensure the environment is clean for the residents. V2 stated housekeeping should go in after each meal and clean up any issues so that it is clean and readily available to the residents. Facility provided a copy of the 'Illinois Long-Term Care Ombudsman Program - Resident Rights for People in Long-Term Care Facilities.' It documents in part that residents have the right to a safe, clean, comfortable, and homelike environment. Facility's Housekeeping Guidelines (7/14) documents in part that the purpose is to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors. Housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner. The Administrator and Environmental Services Director will routinely make visual quality control observations to ensure that a high level of sanitation is maintained. Cleaning of curtains, walls, blinds, etc. will be cleaned when dust or soiling is visible. Trash will be removed from all areas of the facility daily and as needed to prevent spillage and odors. Facility's Preventative Maintenance Program (11/2022) documents in part that the purpose is to conduct regular environmental tours/safety audits to identify areas of concern within the facility. The head of maintenance and/or housekeeping are to conduct random rounds to conduct environmental tours/safety audits of the facility. This includes to ensure that all facility areas ae kept clean and in safe condition, paint is free from watermarks and peeling, ceiling tiles are free from watermarks or spots, and wall coverings are intact and free of tears or loose seams.

Based on observations, interviews, and record reviews, the facility failed to follow a resident's (R2) plan of care and failed to recognize potential accident/hazard in the patio. This has the potential to affect all residents who go out to the patio.Findings include: R2's 'admission Report' documents, in part, muscle wasting and atrophy in multiple sites, repeated falls, need for assistance with personal care, lack of coordination, abnormal posture, left hemiplegia, muscle weakness, and lack of coordination. R2's 6/24/2025 Minimum Data Set assessment documents R2 is cognitively intact. R2 has an impairment to one side of lower and upper extremity. R2 is dependent on staff when using the wheelchair. 'Facility Incident Investigation Report' documents on 7/10/2025 R2 complained of left ankle pain. Facility conducted an x-ray which resulted in closed left ankle fracture. Facility investigation reads R2 believes the injury occurred when left leg fell off the leg rest while propelling in the wheelchair. Facility intervention included to place a leg strap on R2's left leg to keep leg from falling off the leg rest while in the wheelchair. 'Facility Incident Investigation Report' reads staff and R2 were educated to use the leg rest strap to prevent further injury. R2's 'Care Plan Report' documents R2 has an alteration in musculoskeletal status related to fracture of the left ankle (initiated 7/11/2025). R2 will utilize an adjustable wheelchair footrest belt strap to maintain support/stability to the ankle when in the wheelchair (initiated 7/18/2025). Intervention includes for staff to ensure the footrest belt strap is in place to maintain support/stability to the left ankle (initiated 7/18/2025). On 9/16/2025 at 12:32 PM, R2 was oriented to person, place, and time. R2 stated R2 cannot move left leg and has minimal feeling to the left leg. R2 stated there has been a few incidents where left leg has fallen out of the footrest while up in the wheelchair. On 9/17/2025 at 11:32 AM, R2 was up in the wheelchair playing bingo in the dining room. R2's left leg was elevated on top of a pillow was on top of the wheelchair's footrest. There was no leg strap. On 9/17/2025 at 11:52 AM, V11 (Nurse) stated R2 is supposed to have a left leg strap when up in the wheelchair but it is missing. V11 was not sure how long it's been missing. On 09/17/2025 at 12:04 PM, V12 (Certified Nurse Aide) stated R2 had a leg strap but it's missing today and don't know when it disappeared. On 9/17/2025 at 1:24 PM, R2 remained up in the wheelchair in the dining room. There was no leg strap to the left leg. R2 stated facility staff could not locate the leg strap. --- On 9/16/2025 at 12:32 PM, R2 mentioned left leg has fallen out of the leg rest while going over the ramp in the patio. R2 stated the bottom of the ramp was uneven and had multiple cracks need to be filled in. On 9/17/2025 at 11:23 AM, V7 (Maintenance Supervisor) and surveyor went out into the patio. There was a cement ramp led from the building to the cement patio. At the end of the ramp there were multiple cracks in the cement. One crack extended past both sides of the railing (V7 measured railing width to be 49 inches). Some of the cracks had 0.5 to 0.75-inch height difference. When the facility opened the smoking patio at 2:02 PM, there were multiple residents in wheelchairs (including R10, R11, R12, and R13) who got caught on the cracks. They had to wiggle or use the handrails to assist them out of the cracks. On 9/17/2025 at 2:13 PM, V19 (Psychosocial Aide) stated roles include to assist residents during smoke breaks. V19 stated the ramp is a hazard because of the multiple cracks. V19 stated asking facility to fix it for almost a year now. V19 stated some residents have a hard time getting over the humps where the cracks are. At 2:18 PM, R14's rollator got caught on a crack. R14 and the rollator started to tip over. V19 caught R14 and assisted [R14] further out into the patio. Interview resumed and V19 stated people can come down the ramp out of control if they hit the cracks the wrong way. V19 stated when going up the ramp, some residents must pull up or lean back to get over the humps. V19 stated it can also cause them to fall back. V19 stated residents can also trip on the cracks or on the loose pieces coming off the cracks. V19 kicked a loose piece of cement was about 4 inches in length out to the dirt. R10-R14's 'Care Plan Reports' document they are all fall risks. R14's 'Care Plan Report' documents multiple falls while out in the patio with one resulting from R14 tripping while coming up the patio ramp. On 9/18/2025 at 12:13 PM, V2 (Director of Nursing) stated to prevent accidents staff are to ensure the environment is free from hazard. Facility provided a copy of the 'Illinois Long-Term Care Ombudsman Program - Resident Rights for People in Long-Term Care Facilities.' It documents residents have the right to a safe, clean, comfortable, and homelike environment. Facility's 'Fall Prevention Program' documents: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. Facility is to identify risk factors and remove hazards. Facility's Preventative Maintenance Program (11/2022) documents the purpose is to conduct regular environmental tours/safety audits to identify areas of concern within the facility. The head of maintenance and/or housekeeping are to conduct random rounds to conduct environmental tours/safety audits of the facility. This includes to ensure all facility areas ae kept clean and in safe condition.

Based on observation, interview and record review, the facility failed to ensure that foods were stored and/or prepared under sanitary conditions. These failures have the potential to affect all 229 residents residing at the facility. Findings include:1. On 08/11/2025 at 10:12 AM, during the initial tour with V31 (Dietary Manager), the Surveyor observed boxes of cheese (5lbs), pork loins (50lbs), and deli turkey (20lbs) boxes placed in the middle of the floor of the walk-in refrigerator. There were several boxes of other products placed above the ones on cement floor. Also, the entire floor of the walk-in refrigerator was covered with water due to a leak in the ceiling.There were also cartons of milk in thin (so thin that the milk cartons were exposed to the concrete floor) plastic crates were set on top of puddle of water. This includes four crates directly on the floor. According to V31, each crate contained 50 cartons of milk. There were 15 subsequent crates on top of the 4 bottom crates of milk. According to V31, the puddle of water in the walk-in refrigerator was probably due to the ceiling leak.The Surveyor and V31 observed the following items on the floor of the walk-in- freezer: one box of zucchini (24 lbs.), one box of tater tots (frozen potato snacks) (24 lbs.) and one box of roast beef (40 lbs.). One large 3-level shelve in the storage room was completely empty.There were several boxes of food observed on the dirty (dark brown substances throughout the floor) sticky floor in the storage room. These items include cans of sweet potatoes, canned sliced apples, Ready Care Shakes, and boxes of chocolate chips cookies, corn flakes and rice crispies.V31 stated that the boxes of frozen meat, dairy products and dry storage goods should be six inches above the ground to prevent cross contamination. V31 added that following this food safety practice prevents residents from get sick from foodborne illnesses.On 08/13/2025 at 12:32 PM, V1 (Administrator) stated, It is my expectation that delivered boxes and food should be at least put on a pallet to raise it off the ground. I asked that the dietary consultant speak with the foodservice company to let them know to never again place boxes on the ground.The facility's Storage of Refrigerated/Frozen Foods, Section: Food Safety & Sanitation policy dated 4/22 documents Food should be stored at a minimum of 6 inches from the floor. The facility's Storage of Dry Foods/Supplies, Section: Food Safety & Sanitation policy dated 4/22 documents Foods and goods shall be stored at minimum of 6 inches off the floor. 2. 08/12/2025 10:10 AM, While observing the purees, V34 (Dietary Aide), had plated 2.5 trays of brownies on dessert cups with his lower face partially covered with a beard mask. V34's beard was covered but not V34's mustache.When asked should V31's mustache be covered as well, V31 responded V34 should have both his beard and mustache covered. V31 then asked V34 to cover his mustache.On 08/12/2025 at 11:25 AM, V34 was observed a second time placing food on the residents' trays without facial hair (mustache) covered. At 11: 28 AM, V34 re-entered the kitchen without beard and mustache covered. V31 immediately left the tray line and gave V34 a beard covering. V31 stated the beard covers are distributed to dietary aides with beards as they enter the kitchen because the beard covers are not available at the kitchen door entrance.At 11: 41 AM, V34 stated that he has worked at the facility for 21 years and was not aware that both beard and mustache needed to be covered until today.On 08/13/2025 at 12:32 PM, V1 stated, It is my expectations that facial hair be covered to prevent hair in food, cross contamination and food borne illnesses. The facility's Employee Health & Personal Hygiene, Section: Food Safety & Sanitation policy dated 4/22 documents Hair restraints will be worn at all times. Beards should well-trimmed and covered with an appropriate hair restraint. 3. On 08/12/2025 at 10:35 AM, various size serving and mixing spoons were openly displayed on a dusty rack filled with grime on the wires. Earlier during the puree demonstration, V33 grabbed a large mixing spoon from the same display to portion out the chicken broth. There were approximately 20 serving spoons some had dust, some had grease build-up and others black specks. Two 1/4 serving spoons that contained black speckles were washed by V31 and the discoloration/speckles disappeared, and the spoons were clean, again.V33 stated that his expectations are that all serving spoons should clean in order to prevent cross-contamination, bacteria build-up, and food-borne illness among the residents.On 08/13/2025 at 12:32 PM, V1 stated, Expectations are that serving spoons and mixing spoons be clean, sanitized and good repair after each meal. This is important due to cross-contamination concerns. 4. On 08/11/2025 at 10:30 AM, during the initial tour with V31 (Dietary Manager), the Surveyor noticed that crates of sliced whole bread were not labeled. V31 stated that the bread upon entering the storage room should be dated and dated again upon opening. V31 said, It is important to label the bread because it helps to show that the bread is usable and not molded. This important because it helps to prevent residents from becoming sick.On 08/12/2025 at 10:40 AM, crates of sliced whole bread were still un-labeled. V31 said Yes, they are not still labeled.On 08/13/2025 at 12:32 PM, V1 stated, Food should be labeled upon entering the building.

Based on observation, interview and record review, the facility failed to ensure that the dumpster grounds were free from food related trash and that the dumpster lid was closed. These failures have the potential to affect all 231 residents residing at the facility.Facility Ray, Carlyn (36383) - KitchenFindings include:On 8/11/2025, V1 (Administrator) stated that the resident census was 231 residents at the facility.On 8/13/2024 at 11:00 am, Surveyor and V31 (Dietary Manager) inspected the facility outside dumpster area and observed dietary trash covering the grounds and one dumpster lid open. Trash items surrounding the dumpster grounds included open individual-sized milk cartons, used paper plates, foam drinking cups, dietary napkins, and other dietary related trash. V31 stated that all garbage and refuge should be disposed of properly by kitchen staff and referred me to the facility's maintenance director for further guidance.On 8/13/2024 at 11:10 am, Surveyor and V26 (Maintenance Director) inspected the facility outside dumpster area and observed dietary trash covering the grounds and one dumpster lid open. When V26 was asked about the outside dumpster lid open and surrounding trash and debris, V26 stated, Trash is supposed to be placed securely into the dumpsters and not unto the ground. This is ridiculous especially since both dumpsters are not even full. V26 added that not placing trash in the dumpsters properly can attract various animals unto the property.On 8/13/2024 at 12:32 PM, V1 stated the dumpster lid should be closed and the grounds around the area should be clean. V1 said that area surrounding the facility has a [NAME] issue, so trash be disposed of properly. V1 added that having trash disposed of properly prevents pests and animals from entering the facility's premise and surroundings. The facility's undated document titled Safe Food Handling - Dumpster, documents Dietary trash will be disposed of in a sealed plastic trash bag. The dumpster will be securely covered. The ground surrounding the dumpster will be free of trash and debris.

Based on interview and record review, the facility failed to implement a facility wide system to monitor the use of antibiotics. This failure has the potential to affect all 231 residents that reside in the facility. Findings include:On 08/11/25 at 3:07pm V10 (Infection Preventionist/IP) handed surveyor a list with three residents in the facility are currently receiving antibiotics.On 08/11/25 at 3:07pm V10 (IP) stated the list with the three residents was just typed to give to surveyor. V10 stated he delegated the antibiotic stewardship monitoring to V2 (Director of Nursing/DON). V10 (IP) stated V2 (DON) has not been keeping up with monitoring residents on antibiotics because V2 (DON) has a lot of personal things going on. V10 (IP) stated he is unable to provide previous months monitoring of residents who received antibiotics.On 08/13/25 at 9:49am V2 (DON) stated she assists the IP nurse with some of the IP duties. V2 (DON) stated she is not up to date with the antibiotic stewardship monitoring log. V2 (DON) stated it is important to keep up with the log to track the residents and keep up with the antibiotics so they can keep up with what's going on in the facility.Facility's policy titled Policy and Procedure Antimicrobial Stewardship Policy dated 01/2022 documents in part, Policy Statement: An Antimicrobial Stewardship program (ASP) is established under the leadership of the Infection Preventionist (IP). The responsibility of the program is to develop and maintain a system to monitor antibiotic use. Additionally, the ASP will promote safe and effective antibiotic use to improve resident care and strive to reduce antimicrobial resistance.Procedures: the core elements for antimicrobial stewardship in the facility include.Appropriate facility staff accountable for promoting and overseeing antibiotic stewardship.Trach measures of antibiotic use in the facility.The Antibiotic Stewardship Committee will.3. Review a subset of antibiotic prescriptions for appropriateness of dose, duration, and indication.

Based upon observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that the facility free of insects. This failure has the potential to affect all 231 residents at the facility. Findings include:R114's has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Difficulty in Walking, Abnormal Posture and Hypertension.R114 has a Brief Interview of Mental Status score of 15 that indicates resident's cognition is intact.On 8/11/2025 at 11:06am surveyor observed a brown bug (roach) crawl from behind the activities calendar taped to R114's wall.On 8/11/2025 at 11:06am R114 said between the roaches and the gnats it's quite scary for her to go to sleep and she doesn't know how many gnats she has swallowed because she sleeps with her mouth open. R114 stated the exterminator did recently come but he did not spray any areas and he just applied bait in the dresser draws and put down some traps.On 8/12/2025 at about 8:35am surveyors saw a live black bug (Roly Poly) in front of the elevator.On 08/13/2025 at 1:35pm R114 stated she has seen about 5 more roaches since 08/11/2025 and they were crawling down the window screen, and she doesn't know if they are coming from other rooms or upstairs.On 8/13/2025 at 9:37am V2 (Director of Nursing) stated when insects or mice are seen staff makes V1 (Administrator) aware and she will contact pest control company to come out.On 8/13/2025 at 11:09am V26 (Maintenance Director) stated staff are to notify him (V26) if there are sightings of bugs or mice and he will notify V1, and the pest control company comes about every two weeks and more often if necessary.On 8/13/2025 at about 12:20pm V1 stated the maintenance director oversees Pest Control program, but staff will notify her so she can contact the pest control company to come out and treat the facility and this is done as often as needed.Service Inspection Report dated 7/16/2025 documents, in part, Service-General-room [ROOM NUMBER]: dead roaches were seen at time of service.Service Inspection Report dated 7/16/2025 documents, in part, Healthcare Combined-Preventative Maintenance: dead roaches were seen at time of service.Pest Control Policy with a date of 11/14 documents, in part, to prevent or control insects and rodents from spreading disease and the facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents.

Based on observation, interview, and record review the facility failed to follow their care plan policy to develop, implement, and supervise a newly admitted resident with self- injurious and suicidal behavioral concerns. These failures resulted in a resident (R3) gaining access to a shaving blade/razor and cutting his right arm; in a separate incident R3 found a spoon in which R3 was able to break in 2 places and use the pieces to cut his arm; and another incident in which R3 punched a picture with a glass frame which resulted in R3 sustaining an injury that required R3 to be sent to the ER (emergency room ) and receiving 7 sutures to the left hand. The facility's immediate jeopardy began on 05/31/24. On 11/12/24 at 10:17 AM, the Administrator and Director of Nursing were notified of the immediate jeopardy. The immediate jeopardy was removed on 11/13/24 at 01:19 PM. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings Include: R3 has diagnosis not limited to Schizophrenia, Borderline Personality Disorder, Intellectual Disabilities, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Suicidal Ideations, Generalized Anxiety Disorder, Epilepsy, Anemia, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus, Dysphagia, Oropharyngeal Phase, Unsteadiness on Feet, Personal History of Diabetic Foot Ulcer, Morbid (Severe) Obesity due to Excess Calories, Constipation, Shortness of Breath, Disorder of Urea Cycle Metabolism, Gastro-Esophageal Reflux Disease with Esophagitis, Hyperlipidemia, Insomnia and Calculus of Kidney. R3's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate cognitive impairment. R3's hospital records provided by the facility dated 03/06/24 document in part: patient admitted for psych. R3 reports plan to cut his wrists and states he had attempted to cut his wrists as a suicide attempt. admitted to hospital for hearing voices, suicidal gestures, and self-inflicted laceration to right arm. (R3 had self-harming history prior to facility admission) R3's Preadmission Screen and Resident Review (PASARR) provided by the facility dated 03/14/24 document in part: On 02/24 for having thoughts of harming yourself, and verbal and physical anger towards staff and peers at the nursing facility you (R3) were in along with destroying property, during this hospitalization , you (R3) needed regular monitoring and redirection due to self-harming behaviors of punching walls and scratching your arms with forks and spoons.(R3 had self-harming history prior to facility admission) Hospital Record dated 05/31/24 document in part: Reason for Admission: Danger to self. R3 was admitted to the facility on [DATE] with a history of self-harm from cutting himself. On 06/01/24 the facility failed to prevent R3 from gaining access to a shaving blade/razor. This failure resulted in R3 cutting his right arm with the shaving blade/razor. This incident was not care planned and no interventions in place. On 07/03/24, R3 found a spoon, breaking it in-two and started cutting himself across the arm. This incident was not care planned and no interventions in place. On 09/15/24 R3 sustained an injury to R3's left hand requiring 7 sutures after punching a picture with a glass frame on the facilities wall. This incident was not care planned an no interventions in place. R3 was hospitalized on [DATE], 07/03/24, 07/23/24, 09/15/24, 10/01/24 and 10/15/24 for self-harm/suicidal behaviors that was not care planned and no interventions in place. On 06/01/24 documentation indicates R3 said that he is hearing voices telling him to cut and kill himself. R3 used a shaving stick blade/razor and cut his right arm multiple times. R3 was hospitalized from 06/01/24 - 06/06/24 with an admitting diagnosis of Schizophrenia. Petition for Involuntary/Judicial admitted d 06/01/24 document in part: R3 cut his arm and states that he is hearing voices to cut himself and killing himself. Cut right forearm with shaving blade. Screening Assessment for Evaluation Self Harm/Suicide Risk dated 06/12/24 document in part: 2. Past History of suicidal ideations. 3. History of psychiatric/mental health problems, major depression and/or personality disorder diagnosis, significant/severe problems. 7. Chronic behavioral symptoms, control problems, behavior management issues, moderate problem. 11. Category score 6. 6-15 = moderate risk. Resident has history of self-harm. R3's progress notes dated 07/03/24, indicates writer made aware by floor staff that R3 is in parlor using spoon R3 had broken to cut his arm. R3 noted with several superficial cuts to right arm. R3 was hospitalized from 07/03/24 - 07/22/24. Petition for Involuntary/Judicial admitted d 07/03/24 document in part: R3 broke a metal spoon in half and took the broken handle and attempted to cut his throat with it. R3 is continuing to verbalize that he would like to cut my throat. R3 cannot be redirected and is a grave danger to himself. R3's progress notes dated, 07/23/24, indicates R3 became agitated with staff members due to running out of cigarettes, which led to an incident where R3 smashed a glass picture in the hallway near the nursing station. R3 was hospitalized from 07/23/24 - 08/02/24. Petition for Involuntary/Judicial admitted d 07/23/24 document in part: (R3) intentionally punched the glass mirror in an attempt to get glass to cut himself. (R3) cannot be redirected and has become increasingly aggressive towards staff. R3's progress notes dated 09/15/24 indicates R3 was redirected to leave nurses station and eat lunch. R3 became agitated proceeded to parlor and punched glass picture on wall resulted in open area to left hand. Hand Clean with normal saline, pressure applied, hand wrap tight to decrease bleeding. R3 was sent to the hospital and returned to the facility with 7 sutures to the left hand. State Report incident date 09/15/24 incident time: 1320 (1:20 PM) documented part: brief description of incident: On 09/15/24 assigned nurse observed (R3) punching picture glass on the wall in the parlor that resulted with an open area to left hand. Resident was redirected and the site was cleaned with normal saline, and bleeding controlled at this time. When asked why the behavior, resident stated I'm upset. On call NP (Nurse Practitioner) called, an order given for transfer to hospital emergency room for evaluation and treatment. Resident from hospital with 7 sutures. State Report document in part: Initial date 09/16/24, Final date 09/23/24. (R3) has a BIM's 12 (moderate cognitive impairment). (R3) is A/O (alert and oriented) x2-3 and can verbalize needs. On 9/15/24, (R3) was displaying poor impulse control with suicidal ideation (SI) with a plan to harm self by punching at a painting when redirected during dinner time. (R3) remains hospitalized for SI with a plan and schizoaffective disorder. Resident was treated for injury to left hand and observe with 7 sutures. Upon (R3)'s return from hospital (R3) was still noted with active SI with a plan, unpredictable behavior, aggressiveness, and poor impulse control. On call MD (medical doctor) was called and made aware, an order was given to be sent out for psych evaluation. V4 (1st Floor Unit Manager/Licensed Practical Nurse) Statement Dated 09/15/24 document in part: I nurse (V4) did not witness (R3) punch the wall. I heard a noise. I and my supervisor provided care after incident. Patient hospitalized . V5 (Certified Nurse Assistant) Statement dated 09/15/24 document in part: I did not witness (R3) punch into the wall, but I came present when (R3) was getting attention from the nurse. V6 (Certified Nurse Assistant) Statement dated 09/15/24 document in part: V6 wrote (R3) was pacing back and forth through the hallway stating that if he does not smoke, he is going to walk out or go crazy on his way towards double doors (R3) then punched glass picture. On 09/15/24 2155 resident was sent out for SI with plan-smashing his hand on glass picture again and strangulate himself. Resident was admitted to hospital for schizophrenia. On 09/15/24 documentation indicates R3 demanding to smoke, when R3 was told he couldn't smoke R3 began to punch window, and when he was redirected, he began to run out the front door, resident continued to punch wall and place sheet around his neck. Writer was called to floor for a resident that was hard to redirect smashing his (R3) hand into the wall that he had previously went to hospital for causing it to bleed, then talking about SI (Suicidal Ideations) if he could not smoke. Attempted to place a sheet around his neck. R3 was hospitalized from 09/15/24 - 09/23/24 with a diagnosis of Schizophrenia. Petition for Involuntary/Judicial admitted d 09/15/24 document in part: smashing wall with fist. attempted to place sheet around his neck. Hard to redirect. Talking about SI (suicidal ideations), noncompliant. On 10/01/24 documentation indicates R3 noted with aggressive behavior, punching walls with his fists, punching pictures on the wall breaking glass frames and threatening staff with physical violence. Being a danger to himself and others. Disruptive behavior threat to self and others slamming throwing hitting caregivers and staff. R3 was hospitalized from 10/01/24 - 10/07/24 with a diagnosis of Suicidal Ideations. Petition for Involuntary/Judicial admitted d 10/01/24 document in part: (R3) is noncompliant, unable to be redirected. Punching wall, attempting to ram his head into wall. Swinging objects at caregivers and other residents. On 10/14/24 documentation indicates R3 approached nursing station asking for cigarettes. R3 then proceeded to start displaying aggressive behavior, punching walls repeatedly, in the hallway disturbing peers, yelling, screaming, and threatening staff. Resident started walking behind staff member and stated, I will kill that b****. Resident is noncompliant and unable to be redirected at this time. (R3) is attempting to exit the facility, punching walls, and displaying homicidal ideations towards nursing staff threatening to kill us. (R3) attempted to have a physical altercation with nurse, lunging at her clenching his fist. (R3) is disrupting the milieu and unable to be redirected. (R3) is in need of immediate hospitalization as (R3) presents as a threat of harm to himself and others. R3 was hospitalized from 10/15/24 - 10/21/24 with a diagnosis of Aggressive Behavior. Petition for Involuntary/Judicial admitted d 10/14/24 document in part: (R3) is attempting to exit the facility, punching walls, and displaying homicidal ideations towards nursing staff threatening to kill us. (R3) attempted to have a physical altercation with nurse, lunging at her clinching his fist. (R3) is disrupting the milieu and unable to be redirected. (R3) is in need of immediate hospitalization as he presents as a threat of harm to himself and others. During the facility tour on 10/23/24 twenty-four pictures with glass coverings were observed hanging on the walls throughout the first-floor nursing unit. R3's Care Plan document in part: Focus: (R3) has a history of self-harmful ideation (thoughts) and/or behavior. Date initiated 05/31/24. Interventions: Conduct the appropriate interdisciplinary assessments upon admission. Review transfer records, including screening material to determine any history of self-harm. Date Initiated: 05/31/24. Conduct an initial psychiatric evaluation. Review the person's risk for harm. Date Initiated: 05/31/24. If there is a history of self-harmful behavior assess: what occurred, where it occurred, circumstances surrounding the event(s), precipitants, and any current plan to harm. Establish a safety contract (verbal and/or written) with the resident. Date Initiated: 05/31/24. R3's Care Plan Focus: Safety General. Interventions: Perform safety risk evaluation(s) on admission, as needed and upon changes in condition. Date initiated 07/24/24. R3's Care Plan Focus: The resident demonstrates cognitive impairment related to: Diagnosis of mental illness., Symptoms are manifested by: Poor impulse control., Symptoms are manifested by: Poor ability to control anger and frustration. Date Initiated: 07/24/24. Interventions: If the resident is agitated or becomes agitated during care, back off and try to calm the resident with soothing words. If the resident remains agitated tell him or her that you'll come back when he/she is feeling better. If the resident has a psychiatric disorder verbalize that you will help him/her stay in control. Assure the resident that he/she is safe and protected. Date Initiated: 07/24/24. Focus: (R3) demonstrates behavioral distress related to: Being challenged by mental illness., Problems are manifested by: Verbally abusive behavior when agitated., Problems are manifested by: Physically abusive behavior when agitated. Date Initiated: 07/24/24. Intervention: Ask (R3) to calmly explain what is causing this upsetting behavior. Date Initiated: 07/24/24. R3's Care Plan Focus: The resident expresses maladaptive behavioral symptoms related to: A diagnosis of chronic mental illness. Date Initiated: 07/24/24. Interventions: Review rules/behavior expectations to help the resident improve judgment & self-control. Date Initiated: 07/24/24. Use behavior management techniques to promote & shape the desired behavior such as: Look pro-actively at the behavior. Identify causal factors & work to reduce, minimize and/or treat the causal factors. This stresses prevention. Date Initiated: 07/24/24. Use behavior management techniques to promote & shape the desired behavior such as: Controlling the environment to the degree possible to moderate stress. Date Initiated: 07/24/24. R3's Care Plan Focus: (R3) has a history of self-harmful ideation (thoughts) and/or behavior. This appears related to: Evidence of severe mental illness (i.e., active psychosis, major depression, lack of sound judgment, poor contact w/ reality)., Additional risk factors include Previous self-harmful behavior. Date Initiated: 07/24/24. Interventions: Conduct an initial psychiatric evaluation. Review the person's risk for harm. Date Initiated: 07/24/24 Revision on: 10/22/24. As warranted conduct/carry out: Daily monitoring & supervision of the resident. Date Initiated: 10/22/2024. As warranted conduct a room check/search & remove: Any other objects that (in the opinion of the health care professionals) may pose a threat to safety. Date Initiated: 10/22/24. R3's Care Plan Focus: The resident displays manipulative behavior which is disruptive, insensitive and/or disrespectful to staff and peers. This behavior is related to: Feelings of powerlessness, helplessness, inadequacy, and loss of control., Strengths and Abilities: Date Initiated: 08/06/24. Interventions: Educate the staff on manipulative behavior (what it looks like, why it occurs, what needs the person is communicating), especially as it manifests with this particular individual. Date Initiated: 10/22/24. Focus: Resident has a surgical wound to the left hand. Left 5th Finger Date Initiated: 09/24/24. On 11/12/24 at 08:52 AM Surveyor asked R3 where he got the razor from and if it was given to him at this facility. R3 responded, I asked for the razor to shave myself. A certified nurse assistant gave the razor to me, but I don't remember her name. I gave the razor to the nurse. When asked was the razor given to the nurse after he had cut his arm R3 responded, yes. On 10/22/24 at 02:07 PM V17 (Wound Care Nurse) stated (R3) had some sutures to the left hand from an incident that (R3) punched a picture. Based on (R3) behavior's, I don't think that this is an appropriate setting for him. I think sometimes if (R3) gets upset about certain things and start to raise his voice it is startling to other residents. On 10/22/24 at 02:45 PM R3 stated I got mad at the nurse station and got sent out. I had sutures in the left hand. Two scabbed areas were observed to R3's left hand knuckles. I feel like I am angry. I cut my right arm because I couldn't smoke. I didn't want to wait till the smoke break. On 10/22/24 at 02:53 PM V5 (Certified Nurse Assistant) stated I was here when (R3) punched the picture, but I did not witness it. (R3) has a behavior if he does not get his way, he throws tantrums. (R3) is known for harming himself when he is angry. It is just when (R3) acts out its a danger to himself because (R3) starts to hit the pictures on the wall, when he is mad. On 10/22/24 at 03:01 PM V6 (Certified Nurse Assistant) stated If (R3) wants to smoke after smoke break time, (R3) gets agitated. (R3) is self-harming and (R3) just get to punching stuff trying to hurt himself. Maybe (R3) need to be somewhere where he can smoke all day. On 09/15/24 (R3) wanted to smoke a cigarette and he started punching the walls. (R3) said if I don't get a cigarette now, I am going to get upset. (R3) was pacing back and forth. (R3) was in the parlor and that is when (R3) punched the glass picture on the east wall of the parlor and broke the glass. The glass shattered, (R3) sat in the chair and the nurse attended to (R3)'s hand. (R3) punches walls but that was the first time (R3) punched a picture. On 10/22/24 03:19 PM V4 (1st Floor Unit Manager/Licensed Practical Nurse) stated when (R3) first got here (R3) made scratches to his right arm. It was not bleeding, (R3)'s arm was cleaned, I notified psych and (R3) was put on 1:1 supervision until transport came. On 09/15/24 (R3) was redirected to leave the nurse station. (R3) proceeded to the parlor and punched the glass picture. (R3) gets upset at times when he gets redirected. I did not see (R3) pacing. We wrapped (R3)'s hand because it was bleeding. On 09/15/24 (R3) was able to be redirected but on the 11-7 shift on 09/15/24 (R3) was not able to be redirected. The incident with the sheet around (R3)'s neck happened on the 11-7 shift. I feel that (R3)'s behaviors are escalating. On 10/22/24 at 03:58 PM V23 (Supervisor/Registered Nurse) stated (R3) scratch, pinch self and hit the wall. (R3) hit the glass picture on the north wall in the parlor. There is a risk if (R3) punches those pictures, (R3) will hurt himself. (R3) punches the walls and is attention seeking. Behavior wise, I don't feel (R3) is appropriate for this facility. (R3) hurt himself. (R3) used a broken spoon to cut himself. (R3) will pinch himself then come and show the nurse if we ask (R3) to move from the nurse station. On 10/22/24 at 04:19 PM V18 (Registered Nurse) stated on 09/15/24 they called me, so I ran down to see (R3). I saw (R3) with the sheet around his neck and (R3) said that he was going to kill himself. (R3) was smashing in things, and (R3) had just popped a loose the sutures because he had just gotten back from the hospital. (R3) started running toward the door, banging on the glass in the parlor, the pictures on the wall it was like (R3) was incoherent and could not be redirected. On 10/22/24 at 04:47 PM V15 (Registered Nurse) stated (R3) has behaviors and does this so often because (R3) always want to smoke. (R3) started punching on the window in the parlor. (R3) hit walls, pictures and want to go out the front door. I do not feel this facility is appropriate for (R3). (R3) need more supervision and almost need 1:1 when (R3) gets into that behavior. (R3) strikes out at the walls and windows. On 10/22/24 at 05:00 PM V19 (Registered Nurse) stated at first, (R3) was okay then I noticed (R3) would hit walls, doors a door frames. (R3) already had sutures in his hand, and nothing could stop him. I think that we probably should come up with a better solution because injury on top of injury, it may become harmful and (R3) may hit his hand and not be able to use it. The hitting has not deterred (R3) from hitting the wall. (R3) hit the picture by the elevator, and it tore up. On 10/23/24 at 09:57 AM V20 (Wound Care Nurse) stated (R3) had 4 sutures in his left hand. (R3) is alert and walks around. (R3) came in on readmission and I tried to take the 4 sutures out of his hand. (R3) allowed me to take 2 of the sutures out because (R3) said it was sore. When I did (R3)'s initial admission, I saw old scares on (R3)'s forearm. (R3) was implying that he did it and it was old scaring on (R3)'s arm. On 10/23/24 at 10:07 AM V6 (Certified Nurse Assistant) stated (R3) was asking for a cigarette, I did not see the sheet that was around (R3)'s neck. (R3) did punch the wall. We let the nurse know about (R3)'s behaviors. (R3) is self-harming if punching the walls is considered self-harming, yes, it is. Honestly when (R3) start up with his behaviors, I just report it to the nurse and that's it. On 10/23/24 10:34 AM Per telephone interview V21 (Former Licensed Practical Nurse) stated (R3) is very aggressive, violent, and likes to smoke cigarettes. The first time (R3) put his hand through the vending machine, picture on wall and wondered through the hallway. There were no interventions in place. I only saw them call the doctor and send (R3) out to be evaluated. (R3) was a ticking time bomb. (R3) broke a metal spoon in half, and he was scratching his wrist. (R3)'s wrist wasn't bleeding but there were noticeable scars. I believe the doctor should have been notified if I can't write what actually happened. The picture painting with glass that (R3) punched was located near the nurse station. (R3) was bleeding when he punched the glass, so (R3) got scratched. I didn't do anything with (R3)'s hand, the unit manager and social service treated (R3) once they took over, it is a protocol. On 10/23/24 at 10:49 am V3 (Assistant Director of Nursing) stated A lot of things trigger (R3) based on my opinion. Based on (R3)'s diagnosis if (R3) wants something and does not get it when he wants it (R3) gets upset. As a facility it is about safety. (R3) had 5-7 stitches to his hand. Right now, we have not gotten to the point of taking the pictures off the wall. When (R3) returned to the facility after getting the sutures to his hand (R3) was hitting his head on a glass picture and stated self-strangulation. (R3) was admitted to the hospital, and I never had a chance to interview (R3) when he came back because (R3) did not want to talk about it. (R3) was sent out for suicidal ideations and self-harm. On 10/23/24 at 11:34 AM V27 (Medical Records Director) stated (R3) like to punch things when he gets upset. On 10/23/24 11:38 AM V10 (Registered Nurse) stated (R3) said that he is going to commit suicide, so we sent (R3) out. (R3) was upset, hit the picture and (R3) still has stitches to his left hand. It may be 2 sutures on the knuckles because it has not healed completely. Sometimes it can be hard to deal with (R3). One-time (R3) took and hit the picture on the wall and injured himself, (R3) picked up a chair and threw a chair in the parlor. (R3) displays these behaviors most of the time. (R3) came out and showed his arm, (R3) said he want to kill himself; we sent (R3) out. I can't remember if I saw this shaving stick blade. I think we collected it, but I don't remember. On 10/23/24 11:56 AM Per telephone interview V25 (Former Social Worker) stated if (R3) is unable to smoke (R3) has aggressive behaviors and hit a glass picture in the parlor. I don't think (R3) is appropriate for a skilled nursing facility. (R3) gets angry and aggressive. (R3) had cuts on his hands, need a lot of tender loving care and 1 on 1 supervision. (R3) needs to be monitored at all times if (R3) is angry. On 10/23/24 at 12:46 PM V12 (Social Service Director) stated (R3) tries to cut himself, seek attention most of the time and tries to cut himself with anything he can get his hands on. We do an inventory when the residents are admitted to the facility. I don't think the shaving blade was with (R3) when (R3) came in. (R3) has a history of self-harm. Every staff is responsible to talk to (R3) and come tell us. The glass pictures on the walls are a hazard that (R3) can potentially harm himself again. They could replace or take the glass out of the pictures to prevent (R3) from harming himself by being cut with the glass if (R3) punches the pictures again. If (R3) keeps doing the same thing over and over again maybe there is something that we are not doing. You can tell when (R3) is starting to get in the mood and sometime, we indulge him. On 10/23/24 01:12 PM V29 (Registered Nurse/MDS Coordinator) stated (R3) has a behavioral diagnosis that can escalate where it is hard to redirect him. (R3) has suicidal ideations and when a resident goes out to the hospital, they may not come back with any changes but sometime there will be alterations in the plan of care. The goal for everyone is to have the residents safe in the facility. On 10/23/24 at 01:29 PM V26 (Psychiatrist) stated I saw (R3) a couple of times and (R3) had a recent hospitalization . (R3) has a temper that can't be controlled, has outburst and punching the wall. It was a little unclear what was setting (R3) off and the focus on impulsivity. (R3) has been hospitalized 7 times. No one knows how (R3) got from 0 - 100. On 10/23/24 at 01:56 PM V2 (Director of Nursing) stated Inventory of belongings is done on admission and (R3) had no belongings. (R3) was unable to tell where he got the shaving blade from. I did not see it and I believe it was discarded. (R3) had another incident shortly after that. (R3 was admitted to the facility without any belongings). V2 (Director of Nursing) also stated We try to ensure the environment and residents are free from abuse. Typically, (R3) behaviors are based on if (R3) can't get his way. (R3) has a history of self-harm. (R3) harmed himself and there was one incident that caused injury. It is hard to put something in place for instant gratification. (R3) punches the walls as you see we have pictures on the wall. (R3) got an injury related to punching the picture and breaking the glass. I understand there are not any interventions addressing (R3) not self-harming himself dated prior to 10/22/24, no ma'am. There is a possibility it could have been something that was not done that we could have done. As we see the behavior is escalating and ongoing. We may have to look for different placement. In general, the behavior (R3) was displaying was so different for the safety of himself and the residents. I was being proactive when (R3) was upset, threatening bodily harm. The main goal is to keep the residents safe and the resident safe from harming themselves. On 10/23/24 at 02:28 PM V14 (Social Worker) stated (R3) is attention seeking, suicidal and (R3) harms himself. On 10/23/24 02:54 PM V1 (Administrator) stated (R3) has attention seeking behaviors and most of them are centered around smoking. If (R3) does not get his way and get a cigarette (R3) will act out, be verbally aggressive with staff, self-injurious, with behaviors of pinching, hitting himself, punch the wall and pictures. (R3) injured himself when he hit the picture and needed sutures. (R3) has the potential to harm himself if (R3) hits the pictures and break the glass and harm himself if he hits the walls as well. On 10/24/24 at 12:34 PM Per telephone interview V30 (Former Psychiatric Rehab Services Coordinator) stated (R3) is the one that was suicidal. The risk assessment is done, it depends quarterly or annually and when they come back from the hospital, they give you a new admission. It is like a return back and social service will do a full assessment. I met (R3) when he returned from the hospital. (R3) is very suicidal, and I think (R3) need to be in a higher level of care. There should be a suicide care plan and it should be updated. The updates would be to redirect and 1:1. (R3) would say I am about to cut myself. (R3) does the same thing over and over seeking attention. (R3) would hit the walls with his fist and break plastic spoons to cut himself. We don't have a 1:1. Since (R3) did that, (R3) had to go to the hospital and should not have come back. (R3) requires one on one and someone to monitor (R3) to eat. They could have changed the picture frames. From (R3)'s admission packet if they knew (R3) was suicidal like that R3 should not have had a shaver blade. On 11/06/24 at 10:43 AM upon V2 (Director of Nursing) reviewing R3's care plan V2 stated it does not appear that the care plan was updated each time (R3) went out to the hospital. On 11/06/24 at 12:47 PM V4 (1st Floor Unit Manager/Licensed Practical Nurse) stated (R3) cuts were superficial, and it looked more like scratches. I was not aware of the shaving stick blade and don't know where (R3) got it from. The issue with the spoon was addressed. It was a metal spoon from the kitchen and somehow (R3) got the top of the spoon off. When (R3) cut himself, I would think something should have been updated. There is no preventative measure in place. On 11/06/24 02:24 PM Per telephone interview V10 (Registered Nurse) stated (R3) came to the nursing station and showed me his arm. I asked what happen and (R3) said that he was hearing voices to tell him to kill himself. I took the blade from (R3). I don't know where (R3) got it from, it was shaving blade, a shaving razor that has 3 blades that the facility supplies. There was no active bleeding, but the skin was broken. (R3) has been trying to hurt himself and we send (R3) to the hospital. I was not aware that (R3) had a history of self-harm when he cut himself with the razor. I don't know where (R3) was when he cut himself, but he came to the nurse station. If a resident has a history of self-harm, I will say no, (R3) should not have a razor. On 11/06/24 03:00 PM V12 (Social Service Director) stated I do not know why (R3) is in this facility besides the fact that (R3) has psych issues. There should have been self-harm preventative measure in place upon admission and care planned. After each incident (R3)'s care plan should have been updated related to the specific behavior that (R3) had. Somebody probably dropped the ball somewhere along the line. We are working short. At 03:48 PM V12 stated R3 should not have had a razor. On 11/06/ 24 at 04:01 PM V2 (Director of Nursing) stated the razor is typically standard, and the color is blue. Since (R3) has a history of self-harm (R3) should not have had a razor. As far as (R3)'s self-harm it should have been care planned and should have included some preventive measures for self-harm. On 11/06/24 at 04:23 PM V34 (Certified Nurse Assistant) stated I remember (R3) seem like he can make a weapon out of anything. (R3) has a lot of outbursts and had taken a piece of wood from the overbed table. I was standing in front of the desk, and I asked (R3) what he has. (R3) whispered I am going to burn this place down. (R3) paces in front of you. The nurse took the broken spoon away from (R3) and threw it in the garbage behind the desk. I remember (R3) holding the broken spoon trying to hide it. (R3) has done that with other things. (R3) will try to harm himself if he wants to go outside and smoke at night. I saw the marks on (R3)'s arm and reported it to the nurse. I see (R3)'s body language shift, pacing back with an angry face, then punching the wall by the [NAME] [TRUNCATED]

Based on interviews and record reviews, the facility failed to protect a residents' (R2, R11, and R12) right to be free from verbal and physical abuse form another resident (R1) for three out of 13 residents reviewed for abuse. This failure resulted in staff not providing needed supervision for an aggressive resident causing R1 to get into a verbal altercation with R12, R11 having to physically stop R1 from striking R11 with a cane and R1 punching R2 in the face. Findings include: R1's Admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to schizophrenia and bipolar disorder. R1's Brief Interview for Mental Status (BIMS) dated 9/09/2024 documents in part that R1 was moderately cognitively impaired. R1's care plan documents in part that R1 displays impaired decision-making ability as evidence of inattention, disorganized thought content, and hallucinations (date initiated 3/12/2024). Care plan does not contain a focus for potential/risk for abuse. R1's progress notes document in part that on 9/26/2024, R1 experienced aggressive and noncompliant behaviors. V21's (Former Licensed Practical Nurse/LPN) progress note dated 9/26/2024 2:55 AM documents in part: Resident is displaying aggressive and abusive behavior. Resident continues to walk the floor, not easily directed. Resident refused to go to [R1's] room. Resident is trying to fight another resident and stated, 'somebody is going to get hurt.' [R1] continues to verbally abuse [R1's] roommate. Noncompliant behavior continued throughout the day and needed multiple re-direction from staff. Facility sent R1 to the hospital for psychiatric evaluation and returned on 9/27/2024. V10's (Nurse) progress note dated 9/27/2024 2:25 AM documents in part that R1 returned to the unit argumentative and noncompliant. V22's (Nurse) progress note dated 9/27/2024 7:36 AM documents in part: Resident at nurses' station verbally aggressive unable to redirect. Verbally threatening staff and peers. On 10/23/2024 at 11:25 AM, V27 (Medical Records Director) stated during that Friday morning, facility assigned V27 to work as receptionist at the front lobby. R12 ran out the front door in the lobby with shirt off like R12 was getting ready to fight. V27 stated R1 and R12 were having a verbal altercation. R12 was inviting R1 to join R12 outside for a physical altercation. Social services stood outside with R12 to settle R12 down. V27 stated staff directed R1 back to the first-floor nurses' station. V27 described R12 as a resident that 'gets into moods where [R12] can be confrontational.' V27 stated I guess that morning, [R1] was feeling confrontational as well and it spear headed the whole thing. Both showed signs of agitation and when those personalities met, it wasn't good. On 10/23/2024 at 12:25 PM, R12 stated a resident put their fists up to R12 so R12 put their fist up in response. R12 stated (R1) did it first. I was outside. (R1) didn't follow me outside cause (R1) was scared. I said come outside and fight me but (R1) didn't. (R1) was too scared. I had to protect myself then. R12's Admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to unspecified psychosis not due to a substance or known physiological condition; schizoaffective disorder, bipolar type; anxiety disorder; unspecified symptoms and signs involving cognitive functions and awareness; and unspecified intellectual disabilities. R12's BIMS dated 8/25/2024 documents in part that R12 was moderately cognitively impaired. R12's care plan documents in part that R12 has impaired cognitive function or impaired thought processes related to comorbidities (initiated 5/14/2024). It does not contain a focus for potential/risk for abuse. During same interview with V27 on 10/23/2024 at 11:25 AM, V27 continued with the morning's events. After staff separated R1 and R12, V27 looked outside towards R12 and social services to make sure R12 was doing okay. When V27 turned around towards the first-floor nurses' station, V27 saw R1 having another altercation with R11 fighting over a cane. V27 stated [R1] was trying to attack R11 with the cane. V27 stated R11 had two hands on the cane stopping R1 from striking R11 with it. V27 took the cane, headed back to the front lobby, and staff separated R1 and R11. R11's Admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to abnormal posture; chronic angle-closure glaucoma, bilateral; blindness, one eye, low vision other eye; abnormalities of gait and mobility; muscle wasting and atrophy; and lack of coordination. R11's BIMS dated 8/25/2024 documents in part that R11 was cognitively intact. R11's care plan documents in part that R11 has history of aggressive behavior towards others. R11 has displayed physical aggression toward staff and peers (initiated 11/21/2023). It does not contain a focus for potential/risk for abuse. During a telephone interview with V21 (Former LPN) on 10/23/2024 at 10:22 AM, V21 stated when V21 arrived for work that morning, R1 was already irate and fighting another resident at first. V21 saw R1 and R11 tussling back and forth over a cane. V21 stated R11 struck R1 twice in the face with a closed fist. V21 stated facility called a code to have additional staff assist with the incident. R11 went back to the bedroom and R1 went into the Parlor. V21 stated leaving the facility afterwards and when V21 returned, staff informed V21 that R1 hit R2 across the face. V21's progress note for R2 dated 9/27/2024 9:30 AM documents in part: Upon arrival nurse was told by the nurse that resident was struck in the face by (R1) peer. The resident noted with facial redness and slight swelling to the left eye. No cuts or scrapes noted. Asked resident was (R2) in pain, resident pointed to [R2's] nose. Resident face was red, and the nose is slightly swollen. Patient was given Tylenol for the pain, and ice pack for the swelling. During a telephone interview with V22 on 10/23/2024 at 1:03 PM, V22 (LPN) stated seeing V21 walk out of the facility. When V22 made it to the front desk, V22 heard staff say, 'Hey they are trying to fight.' V22 went to the first-floor nurses' station where staff informed V22 that R1 got into two altercations. V22 stated separating R1 and R1 went into the Parlor by self. Staff later informed V22 that R1 punched another resident in the face (R2). V22 did not witness it but was told by staff because they saw it through the Parlor's window. V22 stated a Certified Nurse Aide (CNA) was looking at the Parlor and said 'hey [R1] just hit [R2].' Staff went to the Parlor and separated the residents. V22 stated R2 was crying and saying that R1 had hit R2 in the eye. R1 was cursing a lot and stated R1 got hit with the cane and that R1's finger was hurting. When V22 interviewed R2, R2 repeatedly stated getting hit in the eye. V22 contacted the provider and received orders for an x-ray of R1's face, which showed no fractures. V22 stated I do believe that [R1] hit [R2]. V22 stated ever since R1 returned from the hospital, R1 has been aggressive and purposely getting into it with other residents. V22's (Nurse) progress note for R1 dated 9/27/2024 8:14 AM documents in part: Resident pacing back fourth throughout unit attempting to go in other peers' room. Resident shouting and pointing finger in staff face. Resident unable to redirect [Social Service] call and administrator [psychiatric service company] made aware PRN (as needed) offer but decline. V22's following progress note (time stamp 8:34 AM) documents in part: Writer made aware by staff resident was walking pass and struck another resident in the face. On 10/22/2024 at 1:11 PM, V9 (CNA) described R1 as being loud and bossy during last days at the facility. R1 would get upset if staff and residents didn't do what R1 told them to do. V9 stated sometimes R1 would get confrontational and exchange words with other residents. V9 stated working during R1 and R2's incident. R1 and R2 were in the Parlor room. V9 stated R1 was already loud and then V9 heard R2 yell '(pronoun/R1) hit me.' When V9 turned to look, R1 was bent over in front of R2 picking something off the floor and R2 was screaming. V9 stated facility assigned V9 to watch the Parlor room but V9 went out to get coffee and did not see the incident. When V9 returned and asked R2 what happened, R2 stated '[pronoun/R1] hit me.' V9's typed and signed statement dated 9/27/2024 documents in part that V9 was at the nurses' station and did not observe the incident. State Report documents in part a reportable incident on 9/27/2024 at 9:00 AM involving R1 and R2 for an alleged peer-to-peer altercation. Under Analysis and Conclusion, it documents in part When [R1] was asked what happened, all [R1] would say is 'I got [pronoun].' [R1] would not elaborate. [R2] was rubbing [R2's] right eye and cursing, not able to be redirected to the questions at hand. R2's Admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to bipolar disorder; difficulty walking; hemiplegia and hemiparesis affecting the left non-dominant side; muscle weakness; traumatic brain injury; muscle wasting and atrophy; weakness; lack of coordination; and disorder of bone density and structure. R2's BIMS dated 3/17/2024 documents in part that R2 has severe cognitive impairment. R2's care plan documents in part that R2 may be at risk for potential abuse related to physical and/or communication challenge as evidenced by unable to propel wheelchair safely, severely limited range of motion and severe frailty/weakness (initiated 6/06/2023). Goal was for R2 to be free from harm through the next review. Additional focus documents in part that R2 may be at risk for potential abuse related to mental/emotional challenges (initiated 6/06/2023). Goal was for R2 to be free from harm through the next review. Intervention included to assure R2 that they are in a safe and secure environment with caring professionals (initiated 6/06/2023). R2's care plan also documents in part that R2 demonstrates behavioral distress related to ineffective coping mechanisms; poor verbal skills and inability to express self in a more appropriate language; poor self-esteem; feelings of inadequacy; and feeling powerless (initiated 6/06/2023). On 10/23/2024 at 11:00 AM, surveyor interviewed V3 (Assistant Director of Nursing) who was in charge during R1's altercations between R2 and R11 per V2 (Director of Nursing) and V21 (Former Nurse). V3 stated [V3] was not involved in the incidents and found out about it during morning meeting. V3 instructed survey team to refer questions to the morning staff and to V1 (Administrator). On 10/23/2024 at 1:52 PM, V2, stated the facility tries to ensure that the environment and residents are safe and free from abuse. If staff can identify early on and be proactive, the facility can get appropriate parties involved to prevent any incident from occurring. If a resident is irate and aggressive, the facility must make sure there is no immediate threat or anything to cause to escalate the situation. Staff must make sure the resident is free from other residents and there is no potential for harm to self and others. Facility will try to give the resident an opportunity for them to voice any concerns and work through it. V2 stated during R1 and R12's incident, after the staff separated the two residents, one staff should have stayed with R1 and another staff with R12. V2 stated staff should have directed R1 to another location such as to the bedroom or the office. V2 stated after R1 and R11's incident, staff should have put R1 on one-to-one monitoring. V2 stated facility has social services or psychiatric services aide to monitor one-to-one while the nurses handle the clinical portion. V2 stated if a resident is experiencing behaviors, then the staff must try the least invasive interventions first. If that doesn't work, then staff must notify the provider to get orders either for an as needed anti-psychotic medication or hospital evaluation. If the resident declines the medication, then staff are to follow-up with the ordering provider to retrieve further instruction. On 10/23/2024 at 2:40 PM, V1 (Administrator) stated staff should have informed V1 regarding R1 and R11's incident and documented it. Staff should have de-escalated the situation and kept R1 under close supervision and monitoring. They should have had the nurse evaluate and the nurse should have documented what they done. V1 stated if a resident is irate, staff needs to try to speak with the resident to try to get them to focus on the issue at hand. Staff need to call social service and nursing to speak with the resident to get clinical perspective. If needed, nursing will then call psychiatrist or primary provider to get further instructions. Facility's Policy & Procedure Supervision Policy (01/24) documents in part: additional supervision may be required in order to meet the specialized needs of residents. Additional supervision may be but not limited to 1:1 supervision, 15-minute checks, 30 minute and so forth. Purpose: to ensure resident safety. Responsibility: All staff. Facility's Abuse Prevention Program Facility Policy and Procedure (1/04/2018) documents in part: Abuse is the defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. As part of the resident social history evaluation and MDS [Minimum Data Set] assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur.

Based upon observation, interview, and record review the facility failed to follow the abuse prevention policy, failed to implement interventions, failed to acknowledge (R4's) behaviors, failed to immediately remove (R4) from resident contact to ensure safety, and failed to ensure that two of four residents (R3, R5) reviewed for abuse remained free from abuse. On (11/25/23) R5 sustained blunt head trauma during physical altercation with (R4) resulting in left frontal scalp contusion/hematoma and age indeterminate mildly displaced right nasal bone fracture. R5 also reported enduring chronic dizziness and headaches subsequent the altercation. Findings include: R4 is [AGE] years old with diagnoses which include bipolar disorder and paranoid schizophrenia. R4 resides on 1st floor. R4's (12/20/23) BIMS (Brief Interview for Mental Status) determined a score of 12 (moderate impairment). Inattention and disorganized thinking present, fluctuates. R4's care plan includes (6/14/23) resident may be at risk for potential abuse related to behavior problem as evidenced by history of verbally threatening/obnoxious behaviors, offensive antisocial habits and wandering. Intervention: monitor resident behaviors. (6/27/24) Resident has a diagnosis of schizoaffective disorder, bipolar disorder and is at risk for changes in mood, energy, and depression. Intervention: watch for behavior changes such as talking very fast, racing thoughts, easily distracted, overly restless, being impulsive. Notify physician if these changes are seen. R4's progress notes include the following behaviors (6/19/23) resident presented with physical and verbal aggression toward staff and peers stating that he was going to Kill all of the black people. (10/20/23) Resident began threatening nurse saying, I will f*** you up, come on, right here, right now. Resident threw his fist up in the position to fight. (11/25/23) Resident was standing in front of the nurse's station and another resident asked him to stay out of his room. Resident turned and looked at this person and put his face close to this person and this person reacted by putting his hand to resident's upper chest area, that's when resident hit this person with full strength (twice) to the face, knocking this person (who is elderly) to the floor. (2/10/24) Resident is verbally aggressive, calling writer profane words. Resident is delusional, thinking writer said she was going to shoot him. Writer did not say anything to him. Resident has been refusing his medications and his Haldol decanoate this month and is observed to be growing increasingly aggressive and delusional. The (11/25/23) initial state report includes incident time: 12:45am, (R4) was allegedly physically aggressive towards (R5). The (11/25/23) final state report states (R4) befriended a roommate of (R5). (R4) went into (R5's) room later in the evening on 11/24/23. (R5) came to the nursing station a little after midnight to talk to the nurse. As (R5) was talking to the nurse, (R4) came over to the nurse's station. (R5) can be hard to understand as he speaks with a thick accent. (R4) came over to (R5) and leaned in, towards (R5) as if to hear and understand what (R5) was saying. It was in that moment that (R5) pushed (R4) back, in a manner to state you are too close. As a reflex, (R4) hit (R5) and (R5) lost his balance and fell to the floor. This was an isolated event for (R4). (R4) has been with us since June 2023 and has never shown aggression towards residents or staff. The staff have never seen this behavior from (R4) nor was it ever anticipated [R4's progress notes affirm history of verbal and physical aggression towards staff and residents]. Both residents feel safe in the building [R5's subsequent interview affirms otherwise]. On 2/27/24 at 12:01pm, R4 was observed pacing (briskly) in the hallway. Surveyor(s) attempted to speak to R4, he (R4) proceeded to walk by surveyor(s), entered the room and closed the door immediately. Surveyor subsequently knocked on R4's door, R4 did not open the door and/or verbally respond. As surveyor(s) were standing in the hallway (approximately 1 minute later) R4 exited the room, walked (briskly) towards the nurse's station then wandered aimlessly about the unit. [Staff were present however failed to acknowledge R4's behavior at this time]. R5 is [AGE] years old with diagnoses which include Alzheimer's disease and bipolar disorder. R5 resides on 1st floor. R5's care plan includes (7/10/23) Resident has hearing deficit. (7/18/23) Resident presents with moderate to extreme anxiety related to persistent worry that something terrible is about to happen and verbal expressions of distress. Intervention: evaluate the potential causal factors contributing to feelings of anxiety. Work with the resident to eliminate causes whenever possible. R5's Nurse Practitioner progress notes state (11/25/23) seen in room today following a short ER (emergency room ) visit from blunt head trauma. Patient was hurt by another resident. (12/4/23) Still complaint of residual pain on the left jaw area. X-ray were negative for fracture however R5's (11/25/23) CT (Computed Tomography) scan affirms otherwise. R5's (11/25/23) history & physical states patient here due to being hit in face by resident at the facility. Computerized Tomography (CT) Head: left frontal scalp contusion. CT Maxilofacial: small soft tissue contusion/hematoma anterior to the mandible extending to the left facial soft tissues. There is an age indeterminate mildly displaced right nasal bone fracture. [R5's 10/29/23 facial x-ray states no fractures were identified therefore considering reasonable person concept the fracture likely occurred during 11/25/23 altercation]. R5's (1/13/24) BIMS determined a score of 13 (cognition intact). On 2/27/24 at 12:05pm, surveyor inquired about the (11/25/24) altercation involving R4. R5 stated I got hit and fell down, he (R4) broke my nose. He (R4) came from behind and hit my face. Surveyor inquired if R5 has encountered any problems since the (11/25/24) incident. R5 responded Because of this guy (R4) I'm still not recovery, I have headaches, dizziness I need to see the doctor, it's been more than 3 weeks (months), it's an emergency. Surveyor inquired if R5 feels safe residing in the facility R5 replied It's not safe, I'm scared for my life right now. The guy (R4) who hit me came up behind me (R5), I'm 76 and he's about [AGE] years old [R4 is 32]. Three days ago, he walked in front of me, I can't say nothing cause he gonna hit me. I need to leave from here! On 2/27/24 at 12:12pm, surveyor inquired about the regulatory requirements for abuse V1 (Administrator) stated in part We immediately separate the alleged victim and the alleged aggressor. If it's residents, we involve psych (Psychiatric) and medical doctors immediately. The victim should be assessed by nursing and medical staff and psych to address their needs. The aggressor should be separated from the individual. Surveyor inquired about the current location of R4 and R5 [both reside on 1st floor - in the same hallway]. V1 responded (R5) is in room (room #) at the end of the hall and (R4) is at the other end of the hall. Surveyor inquired why R4 and R5 reside on the same unit if the aggressor (R4) should be separated (from R5) V1 replied Because at the time that this happened after speaking with them and watching the video it seemed as if (R5) instigated it. (R4) acted to be scared and protect himself. It was my belief that there was some misunderstanding between them. There's never been issues in the past with them. Once they calmed down it wasn't like he (R4) came out of nowhere and punched the guy (R5). It was (R5) getting into (R4) face and (R4) trying to get away from him (R5) [documentation affirms otherwise]. Surveyor inquired about R4's behaviors V1 stated He's (R4) much better since we got him (R4), he was erratic in his behavior. According to his (R4) history he's a nursing home hopper. He's (R4) pretty stable right now. Surveyor relayed concerns regarding R4's current behavior (response towards surveyors, rapidly wandering aimlessly about the unit), lack of staff acknowledgement and/or redirection for R4's behaviors V1 responded I'm gonna have nursing call psych right now if he's erratic and not acknowledging that people are speaking to him, that's not his baseline. On 2/27/24 at 12:25pm, R4 yelled down the hallway (while standing at his doorway) at surveyor(s) stating Hey! If you're wanting to talk to me about my apartment, I'll talk to you. If no, skip it then! however staff failed to acknowledge that R4 was yelling. On 3/4/24 at 11:15am, surveyor inquired about the (11/25/23) incident V9 (RN/Registered Nurse) stated I was the 4th floor nurse, and the 1st floor nurse (V8/RN) asked me to come down to assist him (V8). When I (V9) came down he (R5) was rubbing the right side of his face like around the jaw. He (R5) complained of pain, he just said it hurt bad. Surveyor inquired about R4's behaviors V9 responded He's like all over the place, hard to redirect and non-compliant. Surveyor inquired about R5's behaviors V9 replied He's (R5) not aggressive at all. On 3/4/24 at 12:31pm, surveyor inquired about potential harm to a resident that gets hit in the face (twice) and falls to the ground V10 (Medical Director) stated A fracture could happen if someone is hit in the face, a nasal bone fracture, bruising those are the type of things that could happen. Surveyor inquired if R5's x-ray affirmed no nasal fracture a month prior to 11/25/23 incident would you suspect the nasal fracture occurred during the 11/25/23 incident? V10 responded Its possible it could have happened from that. R4's (2/27/24) progress notes state 1:34pm, (after surveyor concerns were reported) resident is intimidating other resident and also provoking other resident in behaviors. Resident cannot be redirected at this time. Order received for resident to be sent out involuntary for psych evaluation. R4 was also involved in a physical altercation with R3 (after 11/25/24 incident). R4 was (again) the perpetrator therefore using reasonable person concept residents likely remained unsafe. R3's (2/12/24) care plan states resident has been the target of peer aggression, placing him at risk for abuse. R3's (2/12/24) progress notes state resident noted to be physically attacked by peer. Writer met with resident to process his feelings regarding being physically attacked by peer. Resident presented with no sign of distress during well-being check, when questioned resident stated He hit me for no reason. R3's (11/28/23) BIMS determined a score of 8 (moderate impairment). On 2/28/24 at 3:13pm, surveyor affirmed that R3 speaks Spanish therefore V7 (Certified Nursing Assistant) translated the interview. Surveyor inquired about the (2/12/24) incident involving (R4) R3 stated I was hit in the face on the right side, I don't remember his name. I don't know why he hit me. The abuse prevention policy (reviewed 1/4/18) includes IV.) Establishing a Resident Sensitive Environment: this facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse. Staff Supervision: supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur. VI.) Protection of Residents: the facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused 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.

Based on observation, interview and record review, the facility failed to supervise a resident and provide individualized fall prevention interventions, for a cognitively impaired resident, who had four repeated falls. This failure affected one resident (R1) of three residents, reviewed for falls. As a result, R1 was sent to the hospital three times within seven weeks. The last fall incident of R1 resulted in an open fracture of the nasal bone. Findings include: R1's Hospital Records written by V20 (emergency room Physician), dated 12/13/23 at 11:44am documented on page 83 Patient was seen one day ago for concerns of a mechanical fall and had findings for an open fracture of the nasal bones, and was discharged with Augmentin for 7 days. On 1/10/24 at 11:02am, R1 was observed in the dining room sitting in a wheelchair that was not locked, with oxygen nasal cannula prongs on the head, and moving the wheelchair slightly forward and backward. V6 (RN/Registered Nurse/Restorative Nurse) was asked about R1's portable oxygen tank and V6 came to the dining room and put a new portable oxygen tank. At this time, V6 also locked R1's wheelchair, stating that the wheelchair should be locked. On 1/11/24, the following were observed on the fourth floor: At 9:53am, R1 was observed in the wheelchair in the dining room with eight other residents; no staff was present in the dining room to supervise all 9 residents. The surveyor stayed in the dining room for about 10 minutes and then went to the nursing station and asked V15 (RN/Registered Nurse) about who was supposed to be watching the residents in the dining room. V15 stated No one is watching them right now; I will have to call down to see what time Activities will get here. V15 made a phone call and then stated, Someone will come soon. Inquired from V15 what time the activities staff is supposed to get here to watch the residents. V15 stated Activity gets here sometimes at 10am, depending on who. At 10:02am, V6 (RN) also was at the nursing station, and the surveyor asked V6 about who was supposed to watch the residents in the dining room; V6 stated I'm not working up here today, I don't know when someone will be available, you can talk to the nurses working here. At 10:22am, V16 (Psychosocial Director) came into the dining room and stated, I will stay here and watch the residents. At 10:19am, V7 (CNA/Certified Nurse Assistant) who is the assigned CNA for R1, was asked about how many of her assigned residents still needed to be cleaned; V7 stated I have a total of five residents to get up; So far, I have done three residents. I did not get (R1) up, the night shift usually gets him (R1) up. At 10:25am, the surveyor left the dining room with V16 watching the residents (including R1) in the dining room, no Activity Staff arrived on the floor yet. On 1/10/24 at 12:40PM, V2(Director of Nursing) presented the facility's incident reports of R1's fall events dated as follows: 10/21/23 - R1 had an unobserved fall in the room with no injury. 10/26/23 - R1 observed on the floor in the dining room; R1 was sent to the hospital by ambulance. 12/11/23 - R1 fell and hit his head in the dining room and was sent to the hospital by ambulance. 12/12/23 - R1 fell and hit his head in the dining room and was sent to the hospital by ambulance. On 1/10/24 at 12:30pm, V4 (Fall Nurse/LPN/Licensed Practical Nurse) was interviewed about R1's fall prevention interventions. V4 stated that R1 is a high risk for falls because he thinks he can get up by himself and he is weak and has Dementia. V4 added, We have interventions in place, to make sure he stays in a supervised area when awake, and to monitor him. R1's records reviewed include but are not limited to the following: Face sheet shows that admission diagnoses include but are not limited to Weakness, Multiple Sclerosis, Reduced Mobility, Dementia, And Disorganized Schizophrenia. Fall Risk Review forms dated 12/12/23 and 12/29/23 both show that R1 is at risk for falls. MDS (Minimum Data Set) section GG shows that R1 requires moderate assistance for functional ability activities and transfers. MDS section C dated 10/1/23 shows BIMS (Basic Interview for Mental Status) score of 4 out of 15(severe cognitive impairment). Care plan Intervention dated 12/4/23 states: Staff will encourage participation in activities when up in chair in dining room. Care plan Intervention dated 12/12/23 states: Observe frequently and place in supervised area when out of bed. Care plan Intervention dated 12/4/23 states: Gather information on past falls and attempt to determine the root cause of the fall(s). Anticipate and intervene to prevent recurrence. R1's progress notes dated as follows documents: On 10/21/23 at 10:41am, V13 (LPN/Licensed Practical Nurse) wrote in part: Writer called by CNA to resident's room, resident noted on floor next to wheelchair. Resident denied hitting head and stated he slipped. Resident assessed head to toe no injuries noted, resident denies any pain/discomfort. On 10/26/23 at 12:11pm, V13 (LPN) documented in part: Writer's attention called to the dining parlor, resident observed on the floor lying on back. Resident stated he was going to the other spot. Head to toe assessment done, no noted injuries/bruising at the time, able to perform from upper and lower extremities at baseline. NP (Nurse Practitioner) in facility, order given to send to the Hospital. On 12/11/23 at 12:14pm, V13 documented in part: Writer's attention was called to the dining room, resident lying flat on back with nonskid footwear on. Resident stated I was getting up. Head to toe assessment done, resident hit his head but denies any pain, no swelling or bruising noted at this time. (Ambulance contacted for transportation to the hospital). On 12/12/23 at 5:47pm, V14 (LPN) wrote: Writer was called to dining room. Upon entering, writer observed resident on floor lying on his side next to his wheelchair. Staff assisted with transfer. Tolerated transfer well. Resident noted A&Ox1 (Alert and Oriented times 1). Head to toe assessment performed. Writer noted light bleeding to nose, top lip, and mouth. Vital signs obtained. Team Health phoned and spoke with NP with orders to transfer resident to the Hospital for further evaluation. On 12/13/23 at 1:36am, V21 (RN) documented in part: Resident returned to facility from ER (emergency room ) with a diagnosis of Open Fracture of Nasal Bone. On 1/11/24 at 10:30am, V13 (LPN) was interviewed regarding how R1's falls happened during three out of four incidents that V13 was R1's nurse. V13 stated that she (V13) was R1's nurse when the falls dated 10/21/23, 10/26/23, and 12/11/23 happened. V13 explained that activity staff was present in the parlor (dining room) when R1 fell on [DATE], but the staff could not catch R1 in time to prevent the fall, and it was lunch time. V13 stated I cannot remember the staff, but I remember someone was there with the residents in the dining room when it happened. For the fall of 12/11/23, I don't remember if staff was present during the fall of 12/11/23, because staff were all passing trays at that time. On 1/11/24 at 10:34am, V17 (Activity Director) was interviewed and stated It is the responsibility of nursing to watch the residents in the dining room. Activity staff usually gets to the day room at 10:00 AM, but this staff has a day-off today. On 1/11/24 at 12:01pm, V2 (Director of Nursing) was asked why there was no staff watching residents in the dining room on the 4th floor (a total of nine residents sitting there without supervision). V2 stated Formal activity programs starts at 10am, but activity staff is supposed to be on the units before then, during breakfast and after breakfast. It's not okay to have residents in the dining room without any staff watching them. It's for safety reasons; there should be someone in there. On 1/11/23 at 1:52pm, V19 (NP/Nurse Practitioner) was interviewed regarding R1's frequent falls and why the nursing staff should follow the care plan for fall prevention, especially for a resident like R1 whose fourth fall resulted in a fracture. V19 stated the reason for a fall care plan is to help reduce the incidents of falls for residents, and the interventions stated in the care plan should be followed. V19 added that residents at risk for falls should be supervised more closely by staff. Regarding R1's last fall incident that involved hospitalization and a nasal fracture, V19 stated that the ENT (Ear, Nose, and Throat) doctor saw R1 in the hospital and there is no need for surgery on R1's nose. V19 added that nasal fractures usually heal within 6-8 weeks. On 1/16/2024, at 9:50am, R1 was observed in a different room closer to the nursing station. Inquired from V15(RN) why R1's room was changed; V15 stated After you left that day, we moved him (R1) to room [ROOM NUMBER], closer to the nursing station, so we can keep a closer eye on him. On 1/16/24 at 10:32am, V4 (Fall Nurse) stated I spoke to the nurses on the fourth floor about the fall prevention interventions for (R1) and that was when they decided to move him closer to the nursing station because his room was all the way at the back. Facility's Fall Prevention Program dated 2/28/14 states: It is the policy of this facility to have a fall prevention program to ensure the safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. #3 states: Safety interventions will be implemented for each resident identified at risk using a standard protocol. Facility's document CNA Job Description states in part: Ensure that residents who are unable to call for help are checked frequently. Check each resident routinely to ensure that his/her personal needs are being met in accordance with his/her wishes.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision for a dementia resident (R1) who is a fall risk. This failure resulted in R1 falling in the hallway, sustaining a laceration to his forehead, requiring emergency department evaluation and receiving eight sutures. Findings Include, R1's clinical record documents in part: R1 is a [AGE] year-old with the medical diagnosis of dementia, vascular dementia, muscle weakness, history of falling, cognitive communication deficit, unsteadiness on feet, metabolic encephalopathy, dysphagia, weakness, and reduced mobility. Minimum data set [MDS] Brief Interview Mental Status Score indicates R1 is cognitively impaired. R1's Care Plan documented in part five falls. Two falls 5/24/23 and 9/20/23 resulted in injury. -R1 is at risk for falls due to co-morbidities: Fall 10/17/23: Resident stated, I was getting money out the drawer for a soda, no injuries. Intervention: Fall 10/17/23: When up out of bed, resident will be monitored in supervised common areas. Fall 09/20/23 observed lying face down in hallway, facial laceration Rt Forehead Intervention: Fall 09/20/23: wear safety helmet at all times Fall 06/19/23 observed sitting on floor near bathroom door, no injuries. S/P Fall res observed sitting on bathroom floor, no injuries. Intervention: Refer to Therapy for screen and treat Fall of 05/24/23 resident stated, I was going to restroom and lost my balance, laceration to Lt hand 4th digit. Intervention: Ensure proper footwear 5/24/2023 06:57-Health Status/Progress Note Note Text: Resident return from hospital. R1's left hand 4th digit 3 sutures intact no bleeding noted to site. Fall of 01/02/23 res stated, I fell trying to go to the bathroom, no injuries. S/P Fall 01/14/23 observed sitting on buttocks in front of bed (laceration to forehead Intervention: Offered and placed Urinal at bedside. R1's Progress notes documented in part: On 9/20/2023 11:00- Nursing Progress Note Note Text: Writer heard loud noise in hallway noted R1 lying face down. Noted swelling of nose open area to forehead moderate amount of blood noted ice pack applied with pressure dressing. On 9/20/2023 23:34-Health Status/Progress Note Note Text: Received a call from hospital stated that all CT scans to cervical spine, facial bones, and head/brain read negative. On 9/20/2023 22:25-Health Status/Progress Note Note Text: R1 returned to the facility from Hospital alert and oriented x1. R1 Returned with approximately 6-7 sutures noted to laceration on face. On 11/15/23 at 11:02 AM, surveyor and V9 [Licensed Practical Nurse] observed R1 was resting in bed without his soft helmet in place. V9 stated, R1 always needs his soft helmet on, even when in bed, to prevent a head injury incase R1 falls. I last saw R1 around 9:30 AM. [Surveyor observed V9 look for R1's helmet for several minutes. V9 located R1's helmet underneath R1's bed, near the foot of the bed.] On 11/15/23 at 12:42 PM, V17 [Certified Nurse Assistant] stated, I been working with R1 for months. R1 is alert only to himself. R1 need complete assistance with ADL care. R1 needs to be spoon fed one to one. R1 tries to stand up out his bed or wheelchair often, R1 constantly needs supervision. R1 is supposed to always wear his soft helmet even while in bed. I placed on R1's helmet this morning, but I'm not sure why it was off around 11:00 AM. On 11/15/23 at 11:53 AM, V9 stated, I was R1's nurse on 9/20/23, the day R1 feel and sustained a laceration to his forehead. I was at the nursing station and heard a loud noise. I observed R1 laying in the hallway, bleeding from his forehead. I applied a pressure dressing and called 911. R1 received several sutures and returned back to the facility. R1 is alert to himself only and needs constant supervision because he is very impulsive. R1 will stand up and start to walk and needs verbal queuing and redirection. On 11/16/23 at 11:44 AM, V2 [Director of Nursing] stated, R1 is confused and impulsive. R1 uses a wheelchair to ambulate the unit. R1 needs supervision, frequent queuing, extensive assist with all areas of care, and one to one feeding. On 9/20/23, R1 was observed on the floor in the hallway. The nurse controlled R1's head bleeding. R1 returned with several sutures to forehead. Intervention was to wear the soft helmet at all times. R1 should wear the helmet at all times to prevent further head injuries from occurring. Policy documents in part: Fall Prevention and Management Policy - Facility is committed to providing a safe and secure environment for residents, staff, and visitors. -. Individualized fall prevention care plans will be developed based on the resident's risk assessment. - The fall prevention care plan will be communicated to all staff members involved in the resident's care - The environment will be routinely assessed for potential hazards, and necessary modifications will be made promptly. - All staff members will receive regular training on fall prevention strategies, resident-specific care plans, and the proper use of assistive devices - Ongoing Monitoring: a. Staff will continually monitor residents for signs of increased fall risk and report changes promptly. - Communication among staff members, including handoffs during shifts, will emphasize fall prevention strategies.

Based on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention for one (R2) of three residents reviewed for falls. This failure resulted in R2 sustaining a fall resulting in fractures to the Humerus and finger of R2's left hand. Findings include: On 09/21/2023 at 2:16pm, R2 was observed sitting on her wheelchair smoking on the outside patio. R2 was observed wearing a sling on her left hand and left middle finger. R2 said she fell last Wednesday (09/13/2023), while standing up, after putting on the call light and no staff come to her assistance. R2 said her pants went down, and R8, who was her room mate come to assist her pull her pants up. R2 said as she was trying to pull her pants up, she fell . R2 said she was using her cane to support herself, but she lost her balance and fell . R2 said after she fell and shouted for help, and two staff members came to help her, then she was taken to the hospital. R2 is a [AGE] year old individual admitted to the facility on [DATE]. R2's diagnosis includes but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other reduced mobility, muscle wasting and atrophy, not elsewhere classified, multiple sites. R2's BIMS (Brief Interview for Mental Status) dated 8/2/2023 documents R2 has a BIMS score of 13/15, indicating R2 has intact cognition. R2's MDS(Minimum Data Set) dated 8/4/2023 documents R2 needs supervision with Bed mobility, transfer, walk in room, walk in corridor, Locomotion on/off unit, and need limited assistance with dressing, and further documents that R2 needs supervision or touching assistance with eating, Oral hygiene, Toileting hygiene: Shower/bathe self: Upper body dressing, Putting on/taking off footwear, Roll left and right, Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer, Toilet transfer, Walk 10 feet, Walk 50 feet with two turns. On 09/21/2023 at 2:22pm, R8 was observed on the outside patio sitting on her wheelchair smoking a cigarette. R8 said when R2 fell , she, R8 was tying to help R2 pull her pants up after they fell when R2 got up from her bed. R8 said R2 said she had put the call light on and no one came to help R2. R8 said R2 fell next to the bed. R8's BIMS dated 08/ 14/ 2023, document R8 has a BIMS score of 13/15, indicating R8 has intact cognation. On 09/21/2023 at 2:34pm, R2 was observed in bed being assisted with repositioning by V30(R2's family member). R2's bed was observed to be moving from side to side when V30 was assisting R2 to reposition. Surveyor called V13(registered Nurse) and asked her to observe R2's bed. V13 said the bed was not not stable and was moving around, and may not be locked. V13 said R2's type of bed was new, and she did not know where the wheels of the bed are locked at. V13 looked for the bed lock and found it by the bed wheels, then V13 locked the bed. V13 said the bed is supposed to be locked for safety, so that the bed does not move when R2 getsin and out of bed, to prevent R2 from falling and hurting herself. V13 said it is every staff's responsibility to make sure residents beds are in locked potion to prevent falls. On 09/22/2023 at 10:33am, V4(Falls Nurse-LPN) said when a resident first comes to the facility, the nurses perform the fall risk assessment, then the falls nurse/restorative nurse(V4) does the restorative assessment note and restorative program tracker, which tells what the resident is able to perform for ADLs, and assists in putting the resident in the right program for Activities of Daily Living(ADLs), and helps the facility know what therapy or assistant the resident will need with ADLs. The CNAs then carry out care based on the assessment. V4 said R2's Functional Abilities and Goals, dated [DATE], documents R2 needs Supervision or touching assistance with ADLs, where the helper provides verbal cues and/or touching/steadying and/or contact, guarding assistance as R2 completes activity. V4 further stated that assistance may be provided throughout the activity or intermittently. V4 further said R2's bed should be locked and in lowest position at all time, as a safety precaution to prevent falls. V4 said all staff know all residents fall precautions should be on beds that are locked and in lowest position when the resident is in bed. V4 said R2 uses a quad cane because her left side hand is impaired related to a stroke, and R2 wears a splint on the left arm, and was wearing it even before the fall, and she was using a quad cane for support. V4 said R2 is ambulatory but may require additional assist and support from staff. On 09/22/2023 at 11:50am, V2(Assistant Director of Nursing-ADON) said R2 sustained a fracture on the left shoulder and finger after R2 fall on 9/13/2023. V2 said the call light system has not been working or over a week now, and maintenance has been working on it and it is still not working. V2 said if the call light system is not working, residents cannot make their needs known in a timely manner. On 09/26/2023 at 1:32pm, V14(Director of Nursing- DON) said she was coming down the hallway when she heard R2 say she needed help. V14 said she went into R2's room and and saw R2 sitting on the floor on her buttocks, and V14 said she knew R2 had fallen, and had landed on her left side. V14 said she did Range of Motion (ROM) checks with R2 and noticed that R2 could only perform passive/limited range of motion exercises with the left hand. V14 said R2 was sent to the hospital for further evaluations, and facility was later notified that R2 had suffered fractures on her left shoulder and middle finger from the fall. Records from community hospital dated 09/13/2023-09/16/2023 document: -R2 was admitted to the community hospital because she suffered a fracture to her left humeral head and left finger due to a fall, and R2 was recommended to keep her hand in a splint -Facility incident report dated 09/13/2023 documents : R2 fell on [DATE] and suffered fractures to the Humerus and finger. Fall prevention policy, no date, documents: STANDARD FALL/SAFETY PRECAUTIONS FOR ALL RESIDENTS: -The bed locks will be checked to assure they are in locked position at all times. -Call lights are kept within reach and answered promptly.

Based on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention & Post Fall Assessment by a.) not providing individualized preventative fall risk measures, b.) not following fall risk care plan interventions prior to fall, c.)failed to complete new or updated fall risk assessment post fall, d.) failed to update care plan with any new fall interventions after fall incident for one (R3) out of three residents reviewed for falls. This failure resulted in R3 sustaining a fall resulting in a laceration requiring five sutures with risk for falls ongoing for lack of interventions. Findings include: R3 is a [AGE] year-old female, admitted to the facility 12/07/15 with diagnosis not limited to Dementia, Muscle Weakness, Reduced Mobility, Lack of Coordination, Muscle Wasting And Atrophy, Weakness, Arthritis, Peripheral Vascular Disease, Chronic Ulcer Of Other Part Of Unspecified Foot With Unspecified Severity, Osteomyelitis. R3's MDS (Minimum Data Set) dated 07/19/23 document R3's BIMS (Brief Interview of Mental Status) score of 14/15 indicating intact cognition. R3's Activities of Daily Living (ADLs) Assistance documents that R3 requires supervision with bed mobility, limited assistance with one-person physical assist with transfer and extensive assistance with one-person physical assist with toilet use. R3's MDS (Minimum Data Set) dated 07/19/23 documents that walking did not occur. Activity with balance during transitions and walking, moving on and off toilet, surface to surface transfer between bed and chair or wheelchair is not steady, and R3 is only able to stabilize with staff assistance. R3's care plan dated 06/25/23 documents in part R3 is at risk for falls related to co-morbidities with interventions including but not limited to staff will ensure resident has on appropriate footwear at all times (06/25/23), and to keep resident's immediate environment clutter free (06/25/23). On 09/13/23 at 1:16 PM, observed R3 lying in bed not in the lowest position, and R3's feet were bare. Did not observe any type of footwear nearby. R3's side table was close to R3's bed and covered in 6 cans of soda pop and papers. R3 stated that R3 does not know what caused the fall. R3 said, they got my program mixed up with the football players program and the weights from Weight Watchers. R3 then stated I was trying to use the bed pan. I went to stand up and didn't know I couldn't stand up. I was off balanced, and my legs twisted. R3 then stated that the football players injuries was messed up with my injuries and the fall was related to them wanting to weigh me. R3 then stated, I don't know what happened. On 09/13/23 at 1:20 PM, R17 (R3's Son) who is also a resident at the facility and is R3's roommate stated that R17 was lying in bed on 07/11/23 listening to music and R17 heard a loud thud when R3 fell on the floor. R3's progress notes dated 07/11/23, 2:45 AM and 4:25 AM by V11 (Registered Nurse) documents in part R3 was observed lying on her back near the bed while using the bed-pan in bed and sustained a moderate laceration on her forehead and R3 was transferred to the emergency room for CT scan of head and stitches related to fall. R3's hospital emergency room record dated 07/11/23, 3:05 AM documents in part R3 brought in with laceration to forehead after fall. (R3) states she was trying to go to the bathroom and fell hitting her forehead on floor. (R3) stated she stepped on her bed sheets causing her to slip and strike her head. (R3) has a 3 centimeter (cm) by 2 cm wound on her forehead. Radiology results of CT Head documents in part left forehead laceration with small amount of soft tissue gas and trace hematoma. R3 received five sutures in the emergency room and was discharged back to the facility. R3's progress note dated 07/12/23, 12:50 PM by V29 (Fall Nurse/Licensed Practical Nurse) documents in part R3 had a fall on 07/11/23 at 3:51 PM, observed lying on the floor on her back near the bed, requires limited assist x1 with transfers and care plan updated with interventions. R3's care plan dated 06/25/23 documents in part R3 is at risk for falls related to co-morbidities with the goal for R3 to have no falls with major injuries over next review period. All interventions in R3's fall risk care plan are dated 06/25/23 and include but not limited to staff will ensure resident has on appropriate footwear at all times, and to keep resident's immediate environment clutter free. There is no mention of low bed position in R3's fall risk care plan and R3's fall risk care plan has not been updated since 06/25/23. R3's Fall Risk assessment dated [DATE] documents R3's score at 13 indicating moderate fall risk. A new or updated Fall Risk Assessment was not completed after 07/11/23 fall. On 09/14/23 at 11:00 AM, V22 (R3's Nurse Practitioner) stated via phone interview that R3 has diagnoses that place her at risk for falls including lack of coordination, weakness, muscle wasting and atrophy. On 09/13/23 at 2:18 PM, V29 stated V29 is responsible for investigating falls and updating the fall care plan. V29 stated if a fall occurs the fall would be dated and documented in the resident's care plan and new interventions would be added to the fall care plan. V29 stated that new interventions would need to be added because something would need to change since the old interventions were not effective in preventing the resident from falling. V29 stated that these new interventions would be put in the resident's care plan immediately to prevent or combat another fall from happening. V29 stated that all care plan updates are done directly on the resident's electronic health record (EHR), no paper copies are kept. V29 stated that up until an actual fall occurs there are standard interventions that are in place for everyone who is at risk for a fall. V29 stated that once a fall occurs then this is when V29 would then adjust or add interventions to individualize the interventions in the care plan based on the root cause analysis of the fall. V29 stated, I don't change the standard interventions for fall risk care plan unless a resident has a fall. V29 stated that prior to R3's fall on 07/11/23 it was determined that R3 was at risk for a fall and therefore R3 had standardized fall risk care plan in place which included interventions such as having the call light within reach and the bed in the lowest position. V29 stated that all residents who are at risk for falling should have their bed in the lowest position for safety preventive measures, so if a fall does occur the resident will not be falling from a high place to a low position, there is less of a distance to fall. V29 stated that after R3 fell on [DATE] the intervention of using non-skid socks was added because the root cause analysis investigation determined that R3 had slipped on a sheet on the floor when R3 was using the bed pan in the middle of the night. Surveyor asked V29 to review R3's fall risk care plan and V29 acknowledged that R3's fall on 07/11/23 was not documented on R3's care plan, and interventions had not been updated since 06/25/23. V29 acknowledged that R3 did not have an intervention for R3's bed to be in the lowest position before or after the fall on 07/10/23. V29 stated having the bed in the lowest position when resident is in bed is not included in R3's care plan because it is a standard for all residents at risk for falls and that the staff knows R3's bed should be kept in the lowest position. V29 also acknowledged that care plan already had intervention that staff will ensure resident has on appropriate food wear at all times dated 06/25/23. On 09/13/23 at 3:12 PM, surveyor went to R3's room with V29 and V30 (Restorative Nurse) and observed R3 lying in bed in bare feet. V30 stated that R3's bed was in the lowest position. Surveyor asked V30 to check and V30 picked up the bed controller at the foot of the bed and was able to lower R3's bed further by at least 5-6 inches until R3's bed was in the lowest position. R3 did not protest or complain about the bed being in the lowest position. V30 stated R3's bed was not in the lowest bed position when we entered R3's room but R3's bed is now in the lowest position. V30 stated R3 does not like her bed to be in the lowest position and then stated to R3 you don't like the bed like this, right? On 09/13/23 at 3:18 PM, V31 (Licensed Practical Nurse) viewed R3's fall risk care plan and stated that V31 does not see that the bed being in the low bed position is included as an intervention or that R3's fall on 07/11/23 was documented in R3's fall risk care plan or that there were any changes made to R3's interventions relate to R3's fall. V31 stated V31 would like for R3's bed to be in the lowest bed position because she is a fall risk, and she spends all her time in the bed. V31 stated if the bed is in the lowest position R3 wouldn't have as much of a distance to fall if R3 did have a fall. V31 stated V31 cannot recall trying to lower R3's bed and R3 not letting V31 lower it. Facility policy and procedure titled, Fall Prevention Program undated, documents in part the policy is to assure the safety of all residents in the facility and to include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. A Fall Risk Assessment will be performed after any fall incident and care plan incorporates preventative measures and interventions are changed with each fall as appropriate. Facility policy and procedure titled, Fall Risk and Post Fall Assessment undated, documents in part the purpose it to improve quality of life for resident, conduct appropriate assessment prior to and after falls and procedure includes if fall prevention plan failed initiate an immediate new intervention, complete or update Fall Risk Assessment, revise resident care assignment according to fall risk type with new interventions, revise the care plan to include all new fall interventions.

Based on observation, interview, and review of records, facility failed to protect residents right to be free from accidents, falls, hazards, and injuries for 4 out of 4 residents (R1, R2, R3 and R4) for a total sample of 4 residents reviewed for accidents and hazards. Failures are as follows: Failed to follow safety resident policy for 1 resident (R4) that needs assistance on transfers and ambulation with multiple falls. Failed to review equipment (rollator/walker) after the fall involving the same equipment (walker/rollator) for 1 resident (R2). Failed to follow policy to review care plan after fall incident and to provide applicable interventions to prevent recurrent of fall for 2 residents (R3 and R1) with multiple falls. These failures resulted to 1 resident (R4) had 2 separate falls with injuries. Resident (R4) sustained forehead laceration with 10 stiches and left 4th digit laceration with 3 stiches for 2 separate incidents of fall. Another resident (R2) sustaining laceration of right lower leg with stitches. Resident (R2) also sustained long abrasions on her back for subsequent fall. And failure to review care plans for 2 residents (R1 and R3) that have subsequent falls and have the potential for recurrent of similar incidents when identified hazards were not addressed. Findings include: R4 was initially admitted on [DATE], MDS 4/7/2023 BIMS scored 6 which means R4 has impaired cognition; bed mobility, transfers, and ambulation supervision with set up, toileting requires 1-person extensive assist. R4's falls are as follows: Dated 1/2/2023 notes by V7 (Licensed Practical Nurse), R4 right side lying in his room. Dated 1/14/2023 notes by V4 (Licensed Practical Nurse) and V9 (Licensed Practical Nurse), R4 sustained frontal/forehead laceration wound with 10 sutures. Dated 5/24/2023 notes by V4 (Licensed Practical Nurse), R4 sustained left 4th digit finger laceration bleeding with sutures. Dated 1/14/2023 notes by V4 (Licensed Practical Nurse) and V9 (Licensed Practical Nurse), R4 sustained frontal/forehead laceration wound with 10 sutures. On 6/6/2023 at 1:20 PM. R4 was seen on his bed alert and answers, left hand 4th finger with sutures. R4 was alert and able to answer questions related to topic. R4 was seen not able to move with ease on the bed. R4 was asked if staff are helping him with getting up and walking? R4 said, No. R4 was asked if he needs help to get up and while walking? R4 said, No. R4 was asked if he had a recent fall? R4 said, Yes. R4 was asked if he was assisted when he fell ? R4 said, No. Then again R4 was asked if he needs help when getting up and while walking? R4 said, Yes. R4 was seen unsteady and weak when moving on his bed. V5 (Registered Nurse) said, R4 can do it on his own, but I don ' t think it is safe. R4 is unsteady. On 6/7/2023 at 10:26 AM. V2 (Director of Nursing) was asked how nursing staff regarded R4 ' s ADL (Activity of Daily Living) ability? V2 said, R4 can get up on his own and can ambulate by himself. But I am not sure if he uses walker. At 11:25 AM. At the floor V7 (Licensed Practical Nurse) stated, that R4 is ambulatory and able to get up without assistance. Upon entering the room R4 was on the bed on his back. The bed was in a low position. V7 asked R4 multiple times to get up but R4 was very slow and weak to respond. V7 elevated the head of the bed to 90 degrees making R4 sit in upright position. R4 still was not able to get up, extended his right arm for V7 to pull and helped R4 sitting on the edge of the bed. V7 instructed R4 multiple times to get up and stand. R4 tried multiple times (5 times) but every time R4 pushes himself up, R4 sat back down. V7 said, There are days that R4 is like this, there are better days. At 12:59 AM. V10 (Restorative Nurse) said, R4 needs help with transfer, it will be limited assistance. If R4 cannot get up with 5 tries, then it is not safe for R4 to get up without assistance or supervision only. R4 was not able to get up and ambulate. At 1:20 PM. V11 (Fall Nurse/Licensed Practical Nurse) said, R4 sometimes can get up by himself and sometimes he cannot. But it is true, resident should be assessed and provided care that is safer. Between supervision and assistance, R4 is safer with assistance. I made a mistake on my notes that R4 needs supervision only. Even after the fall I noted that R4 needs supervision. The staff on the floor needs to be instructed that R4 needs assistance. And level of care of R4 ' s ADL needs to be corrected. Yes, R4 had multiple falls with injuries, and we cannot let him fall again. I need to make changes so that R4 will be given assistance. I am not sure why interventions for R4's fall dated 1/2/2023 and 1/12/2023 shows that I created those interventions on 2/14/2023 but I thought I did it right after the fall. Care plan must be updated as needed or right after the fall. It is important to have interventions to prevent further falls. On 6/8/2023 at 12:42 PM. R4's bed was elevated around 2 feet from the ground and not in a low position as found prior for 2 consecutive days. V14 (Registered Nurse) was asked if there was changes on R4 ' s approach in preventing falls. V4 said, I am not familiar with residents on this floor. First floor is my regular floor assignment, And I am not sure if R4 bed needs to be in a low position. After R4 ' s 3 falls, with 2 falls with injuries. V11 notes documents as follows: Dated 1/4/2023 related to fall incident 1/2/2023, dated 1/16/2023 for fall incident 1/14/2023, and 5/24/2023 for fall incident 5/24/2023, V11 documents on all 3 notes that R4 only needs supervision with transfers. MDS assessment of V11 dated 4/7/2023 under functional status (Section G) documents also that R4 only needs set up with supervision on transfers and bed mobility. R2 was initially admitted on [DATE], MDS dated [DATE], BIMS scored 13 which means cognition was intact with moderate impairment; bed mobility, transfers, toileting, and ambulation are all supervision. R2's falls are as follows: Dated 9/1/2022 notes by V5 (Registered Nurse), fell on the hallway barefoot. Dated 4/30/2023 notes by V6 (Registered Nurse), R2 sustained hematoma to right calf with large laceration. Dated 5/26/2023 notes by V8 (Licensed Practical Nurse), R2 sustained 2 long abrasions at the back. On 6/6/2023 at 1:11 PM. R2 was seen in her room. R2 was alert and verbally able to express her thoughts within topic. R2 was seen with dressing on right lower around 14 to 16 inches in length. R2 said, An operation was done (pointing at her right lower leg dressing) because I fell on a wire that was in the middle of the way. I have a broken and not stable wheelchair that is why I fell . I was given a new wheelchair a few couple of weeks ago when I came back. At 1:21 PM with V5 (Registered Nurse) help raised R2 ' s shirt on her back showing 2 long discoloration of a healing abrasions located mid-right of R2 ' s back. V5 said, R2 ' s old walker was colored blue but was replaced when family member of R2 brought a new walker. And was not sure if the old walker was stable. But since R2 is oriented and able to express her thoughts well. R2 can tell what happened. On 6/7/2023 at 10:26 AM. V2 (Director of Nursing) was asked about the walker R2 was using during fall dated 4/30/2023. V2 said, It was a rollator/walker because it has wheels. And the difference between regular walker and the rollator/walker is that a resident can use to sit on it. Yesterday, we located it, and I don ' t know if it was defective or not. But as to the fall on 5/26/2023, I was not aware that R2 ' s sustained abrasions on her back. I will check on it. V2 was requested to see the rollator/walker which V2 agreed. V2 went to Restorative Office to look for V10 (Restorative Nurse). V2 said that V10 as the restorative nurse can help locate the walker. At 11:01 AM V10 said that they tried to locate the old walker but was not able to locate it. From V10 ' s office to basement area that goes out to exit the facility. V10 said, We cannot find R2's blue walker. We tried to find it yesterday but cannot find it. This is the place where we put things that are not used and not good to use. We may have thrown it out if it is not good to use. On 6/8/2023 at 10:24 AM V11 (Restorative Nurse) R2 had a fall on 4/30/2023 that resulted to laceration on her leg. No, R2 ' s rollator/walker was not checked after the fall because I focused on to minimize clutter on R2 ' s room. Pointed out to V11 that on facility ' s final report it was documented that the fall of R2 on 4/30/2023 were R2 sustained laceration on right lower leg was due to R2 ' s failure to lock brakes on rollator prior to attempting to sit which led to the fall. V11 said, I did not know that, but I understand that rollator/walker should have been checked. R4 fell again I think because of not locking her rollator/walker. R3 was initially admitted on [DATE], MDS dated [DATE] BIMS scored 0 which means R3 is rarely or never understood; bed mobility 1-person extensive assist, transfers 2-persons extensive assist, toileting 1-person total assist, non-ambulatory, and locomotion 1-person extensive assist. R3's Falls are as follows: Dated 12/3/2022 notes by V13 (Licensed Practical Nurse) R3 slip out of the chair. Dated 4/17/2023 notes by V6 (Registered Nurse), R3 fell on left side of his bed. Dated 5/19/2023 notes by V5 (Registered Nurse), R3 sustained a wound above left eyebrow. On 6/6/2023 at 1:32 PM. R3 was on a Geri chair with V15 (Certified Nursing Assistant) feeding R3 at the dining room. R3 was not responsive to conversation. R3 was seen with small (around 0.5 centimeter) closed wound with sutures. On 6/8/2023 at 10:24 AM V11 (Fall Nurse / Licensed Practical Nurse) I cannot find R3 ' s care plan for 12/3/2022 after the fall. For the fall on 5/19/2023, since R3 fell inside his room, it could have been avoided if R3 was placed on a common area where staff can monitor R3. If staff placed R3 in his room to perform ADL (Activity for Daily Living) then that staff needs to stay with R3. And do not leave R3 because he is at risk for falls. At 12:42 PM. V5 (Registered Nurse) said, When R3 fall last month (5/19/2023) as I remember it correctly, R3 was inside his room. Yes, R3 was by himself. Yes, R3 was not place on a common area. I did not know that R3 has multiple falls prior that his fall last month. I think V16 (Certified Nursing Assistant) transferred R3 from bed to Geri chair. V16 said, Yes, it was around breakfast time we are passing trays. I transferred R3 from bed to his Geri chair. I was not aware that R3 has multiple falls in the past. I left R3 inside his room then after maybe around an hour R3 fell . R1 was initially admitted on [DATE], MDS dated [DATE] BIMS scored 0 which means cognitively impaired. For bed mobility and transfers, R1 requires 2-persons extensive assist; Toileting 1-person extensive assist. R1 is non-ambulatory and uses wheelchair. R1's falls are as follows: Dated 12/19/2022 notes by V8 (Licensed Practical Nurse) R1 fell and sustained hematoma on right side of head. Dated 2/16/2023 notes by V6 (Registered Nurse) R1 fell by bathroom doorknob. Dated 4/30/2023 notes by V3 (Licensed Practical Nurse) sustained occipital subdural hematoma and subdural hematoma with back of the head wound with stitches. R1 undergone repaired laceration to the back head. Dated 5/10/2023 notes by V4 (Licensed Practical Nurse) R1 trying to go to restroom. On 6/6/2023 at 1:44 PM. R1 was seen with blue helmet on, sitting on his wheelchair. R1 was alert but does not respond to conversation within topic when asked. R4 was seen with healed wound at the lower back of his head. On 6/8/2023 at 10:24 AM. V11 (Fall Nurse / Licensed Practical Nurse) after review of R1 ' s care plan said, There is no care plan for R1 fall on 12/19/2022, (R1 sustained hematoma on his right side of head), care plan is scheduled to be reviewed or modified quarterly and as needed. There should be an intervention placed on 12/19/2022 after the fall to prevent another fall. On the fall incident dated 4/30/2023 helmet was added in the care plan to protect R1 from another injury in case of another fall. And I also place an intervention to put R1 in common area for staff to monitor. And on fall dated 5/10/2023 laboratory works were added, to rule out confusion due to possible UTI (Urinary Tract Infection). Yes, besides that, there is no other intervention added. The problem was during nighttime when R1 is on bed and cannot be placed in common area where staff can monitor R1. There needs to be intervention to monitor during nighttime because there are falls that occurred during nighttime. Per progress notes dated 5/10/2023 V4 (Licensed Practical Nurse), R1 fell at 1:55 AM and was made known when R1 ' s roommate yelled out. MDS assessment of V11 dated 4/7/2023 under functional status (Section G) documents also that R4 only needs set up with supervision on transfers and bed mobility. Fall Management policy dated 2/2023 as revised, in part reads all resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on interviews, and review of records facility failed to protect resident right to be free from accidents, falls, hazards, and injury. And failed to follow safe resident policy to a resident with multiple falls, that needs 1-person extensive assistance but was left by nursing staff to be independent. Failures apply to 1 out of 3 residents (R4) for a total of 3 residents reviewed for accidents and hazards. These failures resulted to 1 resident (R4) sustaining right hip fracture and undergone surgery as a result of the fall. Findings include: R4 is [AGE] years old during review, with medical diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side diagnosed on [DATE], seizure diagnosed on [DATE] and displaced intertrochanteric fracture of right femur diagnosed on [DATE] after the R4 had a fall on 04/22/2023. R4's cognition is impaired with brief interview of mental status score of 0 which indicates R4 is rarely or never understood. Incident Report initial and final was dated 04/22/2023. R4 was left in the toilet by himself. R4 transferred by himself and fell . Per Minimum Data Set (MDS) on functional status dated 04/13/2023, documents that R4 needs 1-person extensive assistance on bed mobility, transfers, and toileting. On 05/23/2023 at 04:32 PM, V11 (Certified Nursing Assistant) who was assigned to R4 during incident of fall on 04/22/2023 said, It was during dinner time, and we are busy. The nurse was passing medicine. And I was collecting trays, I was across the room of R4. When I looked up, R4 was on the floor. I cannot remember what happened if R4 was on the toilet or on his wheelchair. The first shift should have not transferred R4 on his chair. Yes, now I remember, I placed R4 on the toilet. But R4 is independent, R4 can transfer on his own, R4 is pretty much independent when he is on the toilet. The only thing R4 needs assistance or help was when I put him on the bed. I wiped him and helped him on the bed. Besides that, R4 is mostly independent. R4 ' s progress notes related to fall are as follows: - V3's (Registered Nurse) notes dated 04/22/2023 documents: R4 was observed on the floor of his bathroom. R4 fell in bathroom while transferring on or off the toilet. Order for right hip and leg X-Ray with neurological checks. During this fall R4 sustained right hip fracture and undergone ORIF (Open Reduction Internal Fixation) surgery. - V25's (Licensed Practical Nurse) notes dated 04/07/2023 documents: R4 had a fall on 04/06/2023 at 07:30 PM. R4 observed on bathroom floor fell attempting to transfer from toilet to chair. R4 requires supervision with transfers. R4 is alert and oriented times 1-3. - V3's notes dated 04/06/2023 documents: R4 was trying to transfer from the toilet to the wheelchair located in his room and fell while transferring. - V26's (Registered Nurse) notes dated 03/21/2023 documents: R4 ' s roommate notified her (V24) that R4 has fallen in the bathroom. R4 was on the floor in front of the toilet. - V27's (Licensed Practical Nurse) notes dated 03/16/2023 documents: R4 had a fall was observed laying on the floor on his right side of the bed facing his wheelchair. V3 (Registered Nurse) was assigned to R4 during the incident per V2 (Director of Nursing) and was called on the phone multiple times but did not answer. On 05/23/2023 at 02:04 PM V2 provided complete plan of care for R4 that does not include dates. After further review of R4's care plan, it was found out that V9 made multiple additions and modifications of R4's care plan although R4 was already discharged on [DATE]. On 05/24/2023 at 10:46 AM. V9 (Minimum Data Set Coordinator) said, Yes, I do some of the care plan for the residents. Care plans are reviewed when things come up as needed and also quarterly as scheduled. When a problem was identified it should be reviewed because you want it to reflect current condition. R4 does not have care plan for his right hip fracture and should have care plan on the day it was identified. Yes, I added R4 ' s right hip fracture in the care plan yesterday. I should have not done that because it should have been done when the incident happened. Or it must be added at the time of occurrence. I know that those care plan I just added does not reflect care that really happened because I just added it. But I cannot answer why I added it. V9 admitted that R4 does not have care plan for right hip fracture related to the fall. V9 presented documentation that R4 ' s care plan for alteration in musculoskeletal status related to fracture of the right hip with goals and interventions were all added on 05/25/2023 after R4 was already discharged on [DATE]. On 05/24/2023 at 11:15 AM. V2 (Director of Nursing) stated, R4 needs staff assistance for ADLs (Activity of Daily Living) like transfer, and toileting. Typically, staff needs to stay with the resident during toileting. Nursing staff needs to know care needs of resident. There is a care cards used in the floor that shows each resident needs. It is restorative department that provides those care cards. CNAs (Certified Nursing Assistants) needs to identify and follow up with the nurse and review Care Cards. Yes, V11 obviously does not know what R4 needs and should be guided. R4 is not independent or supervision, because he (R4) needs assistance. As shown in R4'ss assessment that he is rarely or never understood. Then any instructions not to get up may not be understood or followed by R4. V2 was asked that many nursing staff documents in their progress notes that R4 alert and oriented and requires supervision instead of assistance. V2 said, R4 has right-sided weakness due to hemiplegia and needs assistance not only supervision. Yes, I understand that nursing staff should direct care and assistance to residents in choosing safer side. V2 was asked about V9 modifying care plan of R4. Yes, I was informed about modification of care plan of R4. R4 is not here in the facility, and it should not have been done. On 05/24/2023 at 12:59 PM. V17 (Restorative Nurse / LPN) presented Care Alert Cards (CAC) for R4 dated 02/13/2017 and 04/28/2023. CAC dated 02/13/2017 documents that R4 needs 1-person limited assistance during transfers. V17 said that R4 does not have CAC between 02/13/2017 and 04/28/2023 because there was no change of R4 status between those dates. MDS assessment of R4 was presented to V17 that shows R4 needs extensive assistance which requires weight bearing compared to limited assistance that does not require weight bearing assistance. V17 said, Yes, R4 has right-sided weakness and needs weight bearing assistance on his right side. Comparing CAC of 02/13/2017 from CAC 04/28/2023, because of the fall that resulted to fracture of hips and surgery. R4 now requires mechanical lift (sit to stand) with 2-person assistance. V17 said, R4 never was independent in toileting and transfer. R4 needs assistance, staff needs to stay with R4 during toileting. Again, R4 has one side weakness that needs assistance during transfer because R4 cannot bear weight on that side. Minimum Data Set (MDS) of R4 dated 04/13/2023 prior to fall (04/22/2023) on cognitive patterns documents that R4 score was 0 or R4 rarely/never understood. On functional status, R4 needs 1-person extensive assists on bed mobility, transfers, and toileting. On health conditions, R4 had multiple falls since admission. Plan of Care for R4 on ADL (Activity of Daily Living) with multiple dates, documents as follows: R4 has an ADL self-care performance deficit due to hemiplegia diagnosis. R4 requires 1-person assist with toileting, transfers, bed mobility, bathing, and personal hygiene. R4 ' s hospital record dated 04/24/2023 to 04/28/2023 documents the following: R4 sustained closed comminuted fracture of the hip, other diagnosis includes impaired functional mobility and activity intolerance and right-sided weakness. Sudden fall or accident can be a life-changing event often need surgery or repair the fracture. R4 undergone a procedure Intramedullary Nail Femur, Antegrade (Right) or right femoral ORIF (Open Reduction Internal Fixation) on 04/25/2023 due to his fracture related to fall on 04/22/2023. On 05/26/2023 at 10:13 AM. Called V28 (Medical Doctor) and left a message with call back number. Safety Resident Policy not dated, in part reads: Resident transfer status will be reviewed via resident care plan time frame and on an as needed basis. Resident transfer status will be properly communicated with a resident individual Care Service Plan in Electronic Medical Record, coding system or on a Care Card or Kardex.

Based on interview, observation and record review, the facility failed to protect residents right to be free from physical abuse. This deficient practice affected 4 residents (R2, R7, R8, R13) in a sample of 8 residents (R1, R2, R3, R4, R6, R7, R8, R13) reviewed for abuse. This failure resulted in a.) R8, a cognitively impaired male resident being slapped on the hand by a staff member; b.) R7, a female resident who is non-ambulatory using a wheelchair (R7) being slapped on the face by an ambulatory male resident (R6) who has a history of physically aggressive behavior(s); c.) R1 punching R2 on the back; and d.) R7 hitting and scratching R13's wrist. Findings include, Facility's Final Incident Investigation Report dated (12/24/22) regarding incident which occurred on 12/21/22 between R8 and a staff member documents in part: R8 took a cup of juice from the food cart and V3 (Certified Nursing Assistant) grabbed R8's arm and took the cup away from R8. V3 stated that R8 took a cup of juice from the food cart and spit in it, V3 then grabbed R8's arm and took the juice from R8. R8 has diagnosis not limited Cognitive Communication Deficit, Unspecified Dementia without Behavioral Disturbances, Psychotic Disturbance, Mood Disturbance and Anxiety, Major Depressive Disorder, Schizoaffective Disorder, Hypertension, Personal History of COVID-19, Glaucoma, Gastro-Esophageal Reflux Disease with Esophagitis, Type 2 Diabetes Mellitus with Hyperglycemia. R8's Brief Mental Status Interview (BIMS) dated 12/18/22 documents that R8's cognition is severely impaired. R8's care plans dated 12/23/22 documents in part R8 is at risk for potential abuse related to behavior problems, and mental/emotional challenges. R8's progress note dated 12/21/22 at 12:40, completed by V19 (Licensed Practical Nurse), documents in part, R8 reported to writer (V19) that R8 (was) trying to get some juice off of the cart when a CNA grabbed his (R8)'s hand and hit the cup of juice to the floor. Writer (V19) took R8 to R8's room and assessed R8 for injuries (none noted). R8 denied pain. Writer (V19) reported immediately to Abuse Coordinator. On 02/14/22 at 10:57 AM, V1 (Administrator) stated that V1 did not witness the altercation between R8 and V3 (Certified Nursing Assistant) but was aware of the incident. V1 stated that it was reported to V1 that R8 was reaching for juice after R8 was told not to get the juice by V3 who was preparing the juice for lunch, and then R8 proceeded with trying to grab the juice and that V3 tapped the juice cup out of R8's hand causing the juice to fall on the floor. V1 stated that R8 was immediately separated from V3 by the unit staff and the Abuse Coordinator & V1 were notified. V1 stated at the time of the event V1 was the Social Service Director, not the Administrator. V1 met with R8 for a well-being follow up and R8 told V1 that V3 knocked the juice out of R8's hand. V1 stated that R8's care plan was updated with appropriate interventions. V1 was not sure of what steps the Administrator (V22) took with the CNA (V3) involved but V1 stated that V1 knows V3 is no longer working at the facility. V1 stated that there was a video recording of the incident however stated that after 30 days the recording is deleted. V1 stated that V1 did not view the recording of the incident but that the former Administrator (V22) did watch the video. On 02/14/22 at 1:22 PM, V1 stated to surveyors, residents have the right to be free from abuse. On 02/14/23 at 2:05 PM, V19 (Licensed Practical Nurse) stated that V19 did not witness the event on 12/21/22 between R8 and V3 but after the fact R8 told V19 that V3 had hit R8's hand during lunch pass. V19 stated that R8 will try to grab juice but when told to wait his (R8) turn, R8 responds well to verbal redirection and is cooperative. V19 stated that V19 called the administrator to report the abuse and R8 was separated from V3. V19 stated that V22 (Administrator) removed V3 from the unit immediately to interview V3 and that V3 never returned to the floor again. V19 stated that R8 was monitored for signs or symptoms of abuse and assessed for injury, harm and that no injuries were noted, R8 denied any pain. On 02/14/23 at 2:11 PM, R8 stated that R8 was thirsty and wanted something to drink so R8 took a cup of juice from the beverage cart during lunch time. R8 stated that one of the CNAs smacked my hand hard, and yelled, don't do that! R8 stated that R8 has not seen that CNA for a while, and said, I don't think she works here anymore. R8 stated that R8 feels safe at the facility and that there have been no other times that a staff member or resident has hit him (R8). On 02/15/23 at 11:56 AM, V22 (Former Administrator) stated that on 12/21/22 V30 (Activity Aide) came down to V22's office tearful and upset. V22 stated that V30 reported that V30 saw a resident being abused. V22 stated that V30 reported that V30 saw V3 slap R8's hand. V22 immediately went to the floor and separated R8 from V3 and made sure R8 was assessed to make sure R8 did not have any injuries and R8 was monitored by social services. V22 stated that V22 had V3 go down to the office to get V3's statement or version of what happened. V22 stated that initially, V3 denied touching R8 but, then V3 stated that V3 saw R8 spit into a cup of juice and that V3 asked R8 to put down the glass of juice but that R8 did not listen and that R8 tried to put the cup of juice back on the cart and that is when V3 tried to knock the cup away from R8. V22 stated that V22 watched the video recording of the event and that what V22 saw on the video did not correlate with V3's report of the event. V22 stated that video showed that R8 did not spit into the cup of juice and that V3 very aggressively made contact with V3's hand against R8's hand which was holding the juice causing the contents of the juice to fall on the floor. After V3 watched the video V3 admitted to trying to snatch the cup out of R8's hand. V22 stated V3 then got up and said, I resign and then V3 left the building and has not been in the building since. V22 stated that this event was substantiated as abuse. On 02/15/23 at 01:54 PM, surveyor spoke with V30 (Activity Aide) via phone. V30 stated that V30 did not see the altercation between R8 and V3 on 12/21/22 but that V30 heard the commotion in the hallway. V30 stated that V30 heard V19 (LPN 2nd floor) say to V3, why did you slap that juice out of his hand? V30 stated that V19 was referring to R8. V30 stated that there was juice spilled all over the floor. V30 stated the juice was just sitting there, I don't know why the CNA wouldn't let R8 have it. On 02/17/23 at 11:54 AM, surveyor spoke with V36 (Psychiatric Nurse Practitioner) over the phone. V36 stated that V36 was not aware of the altercation between R8 and a staff member. V36 stated that it is never appropriate for a staff member to hit a resident. V36 stated that the staff members should be trusted to take care of the residents and that staff members do not have any conditions and should be able to control themselves. V36 stated that if a staff member hit a resident, it was intentional and therefore would be considered abuse. Surveyor left voice mail messages for V3 the following dates/times with no response: 02/15/23 at 9:38 AM, 02/15/23 at 10:45 AM, 02/15/23 at 12:30 PM, and 02/17/23 at 1:42 PM. Facility's Final Incident Investigation Report dated (12/24/22) regarding incident which occurred on 12/20/22 between R6 and R7 documents in part: R6 went into R7 room to retrieve R6's jacket which had been taken by R7 from R6's room while R6 was sleeping. R6 stated that R6 went into R7's room and grabbed R6's jacket from R7's hands. At that time both R6 and R7 denied any physical altercation. R7's roommate reported witnessing R6 slap R7, which R7 later confirmed. R6 has diagnosis not limited Cognitive Communication Deficit, Major Depressive Disorder, Epilepsy, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Vitamin D Deficiency, Nicotine Dependence. R6's Brief Mental Status Interview (BIMS) dated 11/25/22 documents that R6's cognition is moderately impaired. R6's care plan documents in part R6 has been physical aggressive toward peers when angry and displays poor impulse control. R6's MDS section G (Functional Status) documents R6 is able to walk in room and corridor with supervision (oversight, encouragement, cueing). R7 has diagnosis not limited to Bipolar Disorder, Anxiety Disorder, Disorder of Adult Personality and Behavior, Schizophrenia, Adult, Chronic Obstructive Pulmonary Disease, Difficulty Walking, Lack of Coordination, Weakness, Type 2 Diabetes Mellitus, Epilepsy, Diastolic (Congestive) Heart Failure, Anemia, Insomnia. R7's Brief Mental Status Interview (BIMS) dated 12/02/22 documents that R7's cognition is moderately impaired. R7's care plan documents in part R7 may be at risk for potential abuse related to mental/emotional challenges, secondary to behaviors displayed as evidenced by going into peers' rooms and not respecting peers' boundaries. R7's MDS section G (Functional Status) documents R7's ability to walk in room and corridor did not occur 100% of the time. R9 has a diagnosis not limited to Schizoaffective Disorder, Morbid Obesity, Weakness, Lack of Coordination, Difficulty Walking, Alcohol Abuse, Osteoarthritis, Adult Failure to Thrive, Need for Assistance with Personal Care. R9's Brief Mental Status Interview (BIMS) dated 01/11/23 documents that R9 is cognitively intact. R7's progress note dated 12/20/22 at 06:16 completed by V32 (11-7 Registered Nurse) documents in part, R6 wandering the hall all night going in peers room taking their belongings. R9's progress note dated 12/20/22 at 06:33, completed by V32 documents in part, R9 complained of R9's roommate (R7) was slapped by a male resident in R9's room. R7's progress note dated 12/20/22 at 06:40 completed by V32 documents in part, R7's roommate informed nurse that R7 had been slapped by a male resident, R7 denied being slapped but later when questioned R7 stated that R7 took R6's coat and gloves looking for money and R6 came into R7's room and snatched R6's coat out of R7's hands and the coat sleeve hit R7. R6's progress note dated 12/20/22 at 06:48, completed by V32 documents in part, R6 stated R6 went to R7's room and snatched R6's coat out of R7's hand that's all, denied striking R7. R6's progress note dated 12/20/22 at 14:33, completed by V1 (Administrator, Former Social Service Director) documents in part R6 hit peer because R6 stated peer (R7) stole R6's jacket and R6 stated, so what. On 02/14/23 at 1:20 PM, surveyor observed R7 in R7's room sitting in a wheelchair. R7 stated that R6 was in R7's room but R7 did not know why. R7 denied taking R6's jacket. R7 stated, he (R6) hit me in the face, here and as R7 made this statement R7 took R7's hand and covered R7's face with R7's hand. R7 stated R6 has not been in R7's room since R6 hit R7. R7 stated, he's a nice guy. On 02/14/23 at 1:24 PM, R9 stated that R6 barged into R7 and R9's room early one morning and asked for R6's jacket back. R9 stated that R7 gave R6 his jacket back and then R6 slapped R7 across the face really hard. R9 stated that R9 told R6 to get out of their room and that R6 left the room at that time. R9 stated that R9 reported what R9 had witnessed to the nurse on duty. On 02/14/23 at 1:32 PM, R6 stated that R7 came into R6's room when R6 was in the washroom and took R6's jacket. R6 stated that one of R6's roommates told R6 that R7 took R6's jacket. R6 stated that R6 went into R7's room to get R6's jacket back. R6 stated that R7 tried to make it like she (R7) didn't have it. But, I saw my jacket on her (R7)'s bed as she (R7) was going through the pockets of my jacket. R6 stated that R6 snatched R6's jacket from R7's bed. R6 stated that R6 did not hit or slap her. R6 stated, I don't hit ladies. Men aren't supposed to hit ladies. R6 stated that R7's roommate told R6 that R6 should not be in the room and told R6 to leave. R6 stated that R6 then left the room with R6's jacket in hand, and said, that was all, I did not touch her. R6 stated that R7 has taken other things from R6's room before but not able to specify what items. On 02/14/22 at 11:15 AM, V1 (Administrator) stated that V1 did not recall or witness the incident between R6 and R7 that occurred on 12/20/22. V1 stated that R7 has a known history of roaming into other resident rooms and taking items from them. V1 stated that initially R7 denied being touched by R6, however later R7 did confirm that R7 was slapped by R6. V1 stated that the facility confirmed abuse had occurred. On 02/14/22 at 1:22 PM, V1 stated to surveyors, residents have the right to be free from abuse. On 02/14/23 at 1:44 PM, V17 (4th Floor Social Worker) stated that R7 constantly goes into other resident's rooms uninvited and takes their things without their permission. V17 stated that R7 took R6's jacket from R6's room and that R6 went into R7's room to get R6's jacket back. V17 denied being aware that R6 hit or slapped R7 when R6 was in R6's room retrieving R6's jacket. V17 stated R6 and R7 continue to reside in the same room on the same unit but that R6 and R7's rooms are on opposite sides of the unit from each other. V17 stated that R6 and R7 don't socialize and that R6 keeps to himself except to participate in smoke breaks and activity functions. V17 stated that staff continue to monitor R7 for roaming behavior as this is an ongoing behavior and try to redirect R7 back to R7's room. On 02/14/23 at 1:54 PM, V18 (Certified Nursing Assistant) stated that V18 has been working at the facility for 6 years. V18 stated that R7 is constantly taking other resident items and selling or trading them to other residents for money or cigarettes. V18 stated that this is R7's long standing behavior and is something R7 is constantly doing including all night and throughout the day. V18 stated that R7 also wanders to the other floors looking for money and cigarettes. V18 stated R6 stays in R6's room and does not wander or roam into other resident's rooms. V18 was not aware of incident between R6 and R7. On 02/15/23 at 11:56 AM, V22 (Former Administrator) reported that on 12/20/22 R7 had taken R6's jacket from R6's room and R6 went into R7's room to retrieve the jacket. V22 stated that R6 grabbed the jacket from R7's hand and that initially, R7 denied being hit by R6 however R7's roommate (R9) reported seeing R6 slap R7 on the face. V22 stated that R7 has a history of denying physical abuse even if it has occurred because R7 would then have to admit to taking items from other residents (for example R6's jacket) which R7 knows R7 is not supposed to do. V22 stated that after facility investigation was conducted the allegation of theft and abuse were both substantiated. On 02/16/23 at 10:21 AM, surveyor spoke with V32 (11-7 Registered Nurse) via phone. V32 stated that V32 has been working at the facility since June 2020 and that V32 works on the 4th floor (11-7 shift). V32 stated that V7 has a long-standing behavior of entering other resident's rooms looking for money, cigarettes or food and taking other resident's belongings. V32 stated that R7 wanders all light long into and out of other resident rooms and that most of the time R7 will respond to redirection provided however sometimes if R7 has drank a lot of soda R7 can get hyped up and in those instances R7 does not respond to redirection. V32 stated that 12/20/22 was one of those nights, R7 was in constant movement all night long, going in and out of other resident's rooms and was not responding to staff redirection. V32 stated that V32 did not see R7 go into R6's room or see R7 take R6's jacket. V32 stated that on 12/20/22 early in the morning, toward the end of V32's shift V32 was passing medications when R7's roommate (V9) approached V32 and told V32 that R6 had entered R7 and R9's room and R9 saw R6 slapped R7 in the face. V32 stated that V32 separated R6 and R7 and went to R7's room to assess R7 for injury. V32 stated R7 had no signs or symptoms of injury and denied pain. V32 state that R7 denied being hit by R6 and that R7 felt safe. V32 notified the nursing supervisor who came to the floor to interview R6 and R7 and the Administrator was notified. On 02/16/23 at 1:06 PM, V21 (Restorative Aide/Certified Nursing Assistant) stated V21 has been working at the facility for 8 years. V21 state that R7 is non-compliant with wandering and stealing behavior and that R7 is constantly wandering around the facility looking for money or cigarettes. V21 stated this is a long-standing behavior. V21 stated that R7 does have the ability to walk however R7 only uses R7's wheelchair when R7 is out of R7's room. On 02/16/23 at 1:10 PM, R9 stated that R7 goes room to room looking for items all day and night and that R7 steals things so R7 can trade them or sell to other residents in the facility. R9 stated that R7's behavior makes the other residents mad and that the residents whose stuff R7 has stolen then come looking for their items in R7 and R9's room and that those residents are very, very angry. R9 stated that R6 burst into their room early one morning when still dark outside and started arguing with R7. R9 stated that R9 got up because of the commotion and that is when R9 saw R7 slap R6 real hard across the face. On 02/16/23 at 3:05 PM, surveyor spoke with V36 (Psychiatric Nurse Practitioner) via phone. V32 stated that V36 provides care to R6 and R7 and that V36 has been covering the facility since the fall of 2022. V36 stated that R6 has a history of being verbally and physically aggressive and that those types of behaviors are usually exhibited when R6 is triggered by something. For example, by the way people talk to R6, or if R6 is told to do something R6 does not want to do. V32 stated that verbal and physical aggression are not new behaviors for R6. V36 stated that R7 displays a lot of aggression and agitation toward staff and other residents. V36 described R7 as being very manipulative, non-compliant with care and roams around R7's unit, and other resident floors within the facility looking for money, or cigarettes constantly. V32 stated that R7's wandering, hoarding, and stealing behaviors are not new behaviors. V36 always sees R7 sitting in R7's wheelchair but has seen R7 transfer herself from R7's wheelchair to the R7's bed when in R7's room. V36 stated that V36 was aware of the altercation between R6 and R7 in terms of R7 stealing R6's jacket but did not realize R6 had slapped R7 on the face when R6 had gone into R7's room to retrieve R6's jacket. V36 stated, that should not be happening at the facility and that physical aggression toward another resident could be triggering for that resident (R7) and for all of the other residents on the unit. V36 stated it is not a safe environment if there is physical aggression between residents. V36 stated that R7 is a high risk of this happening again because of R7's wandering and stealing behaviors are ongoing. V36 stated that the facility needs more people to make sure the residents are safe in their rooms and provide more re-direction as needed to intervene quickly. Surveyor left voice mail messages for V37 on 02/17/23 at 9:40 AM, 10:21 AM, and 12:12 PM with no response. Policy: Abuse Prevention Program - Policy undated, documents in part, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Residents' Rights undated, documents in part, your (residents') rights to safety: you must not be abused, and the facility must ensure that you are free from retaliation. 44314 R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: HYPERLIPIDEMIA, UNSPECIFIED, MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED, SCHIZOAFFECTIVE DISORDER, UNSPECIFIED, MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY, FOURTH [TROCHLEAR] NERVE PALSY, LEFT EYE, DIPLOPIA, ALCOHOL DEPENDENCE, UNCOMPLICATED, HOMONYMOUS BILATERAL FIELD DEFECTS, LEFT SIDE, PRESENCE OF INTRAOCULAR LENS, OTHER VISUAL DISTURBANCES. Final Incident Investigation Report (fated 01/13/2023) documents On 01/13/2023 at approximately 8:15am, AM nurse reported that she witnessed R1 hitting R2 in the back. Both residents were immediately assessed for injuries. No injuries observed. Staffed confirmed that R1 repeatedly asking R2 to leave her room as she was getting dressed. Upon further investigation of this incident, physical abuse was founded. Upon the conclusion of this investigation, it is believed that abuse is substantiated. R1's Care Plan (dated 10/24/2020) documents that R1 presents with verbal/physical act out with peers, easily agitated, poor impulse control. R1's Care Plan (revised on 01/15/2023) documents that R1 may be at risk for potential abuse r/t behavior problem as evidenced by verbally and physically acting out when agitated. R1's Minimum Date Set assignment dated 12/30/2022 indicated R1 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates resident has intact cognitive response. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: OTHER ASTHMA, UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION,IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC), UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, SCHIZOPHRENIA, UNSPECIFIED, INSOMNIA, UNSPECIFIED, DYSPHAGIA, ORAL PHASE, RESIDUAL HEMORRHOIDAL SKIN TAGS. R2's Minimum Date Set assignment dated 11/20/2022 indicated R2 has a Brief Interview for Mental Status (BIMS) score of 11, which indicates resident has moderately impaired cognitive response. R2's Care Plan (dated 06/24/2022) documents that R2 may be at risk for potential abuse r/t behavior problem, communication issues/deficits as well as poor impulse control, secondary to mental and emotional challenges. Abuse Prevention Policy (dated 11/22/2017) states: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. On 02/14/2023 at 9:15am, R1 stated, On 01/13/2023, I was sitting on my bed, and I was getting dressed. Suddenly, R2 just barged into my room and stood there and was staring at me. I asked R2 to leave my room, but he did not leave. R2 just stood there and was looking at me getting dressed. So, after I asked him several times to leave, I pushed him out of my room and hit him on his back to get him out. I don't know why R2 came in here in the first place, maybe R2 was confused because R2 just stood there. R2 did not say anything to me when I asked him to leave. R2 just stood there. Finally, I became agitated and pushed R2 out of my room and hit him on his back so that R2 would leave. I didn't hit R2 hard and R2 did not sustain any injuries. I wasn't trying to hurt R2, I just wanted him to leave. I feel safe here, I just wanted some privacy so that I can get dressed. On 02/14/2023 at 9:23am, R2 stated, I don't remember what happened. I don't remember going into anyone's room. On 02/14/2023 at 1:43pm V15 (licensed practical nurse) stated, R1 is not aggressive. R1 is calm and cooperative and keep to herself. R2 is not aggressive and has not been physically aggressive towards other residents. R2 has periods of confusion and during those periods of confusion, R2 can wonder into other resident rooms. R2 wondered into R1's room because R2 was confused at the time. R1 got upset that R2 entered R1's room. On 02/15/2023 at 12:33pm, V1 (administrator) stated, On 01/13/2023, a nurse reported that R1 hit R2 on the back. Both of the residents were separated. I met with R1 first and R1 said that R2 came into her room while R1 was getting dressed. R1 said that R1 asked R2 to leave and R2 refused to leave and R1 hit R2 on the back because R2 would not leave. R1 admitted that R1 hit R2 on the back. R1 said that R2 did not take anything from the room, it was just that R1 was trying to get dressed and R2 would not leave. I asked R2 what happened and R2 indicated that R2 did not know. R2 did not remember the incident. We did a potential for abuse form for R2. R1 was encouraged to seek staff assistance when she becomes triggered. The incident between R1 and R2 was substantiated, and abuse was founded. The resident has the right to be free from abuse. On 02/16/2023 at 10:05am V21 (certified nursing assistant) stated, On 01/13/2023, I was working on the 4th floor, and I heard someone yelling get out of my room. I recognized the voice to be of R1. I immediately stopped what I was doing, and I went to R1's room. When I walked in to R1's room, I saw R1 screaming at R2 telling him to get out of her room. R2 was just standing there, and I asked R1 to calm down. I asked R2 to leave R1's room. R2 just stood there and was staring at me but he didn't move. When I was talking to R2 telling him to leave R1's room, that's when R1 became more agitated and came from behind and hit R2 in the middle of R2's back. I was in between R1 and R2, and R1 came from behind and punched R2 in the middle of his back. After R1 hit R2 on the back, R2 left R1's room and went to his room. R2 did not appear to be injured. R2 just walked to his room. R2 did not scream from pain or anything like that, R2 just left R1's room and went to his own room. After the incident, the nurses assessed R1 and R2 and both residents were immediately separated. R1's Progress Note (dated 01/13/2023) documents, Staff reported to writer co-resident entered res room while res was dressing. Res asked co-resident to leave room three times. Co-resident res did not leave room so res punched co-resident in back. Residents were immediately separated. NP notified. DON notified. POA notified. No s/s of bruising or pain noted. vitals within normal range. No further behaviors noted at this time. 72 hr behavior charting initiated at this time. Will continue to monitor. R1's Social Service Note (dated 01/13/2023) documents, Wellbeing check/ Behavior monitoring 1/3: Writer was made aware by nursing staff that resident initiated physical aggression towards peer. Resident presents to be aox3 and can verbalize her wants and needs with no issues. Resident stated He was in my room while I was changing my clothes, when I asked him to leave. I punched him because he wouldn't leave my room after I asked 3x. Writer encouraged resident to seek staff assistance when needed. Writer encouraged resident to maintain appropriate boundaries. Writer reassured resident that she resides in a safe place. Psychiatrist made aware. Appropriate departments made aware. Resident was able to be redirected and complaint. No reported aggression. Staff to continue to monitor resident accordingly. R2's Progress Note (dated 01/13/2023) documents, Staff reported to writer res was seen in co-residents' room. co-resident stated res was asked to leave room three times. res did not leave room so co-resident punched res in back. residents were immediately separated. NP [NAME] notified. POA [NAME] notified. no s/s of bruising or pain noted at this time. vitals within normal range. no further behaviors noted at this time. 72 hr behavior charting initiated at this time. will continue to monitor. R7's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: BIPOLAR DISORDER, CURRENT EPISODE MIXED, MODERATE, UNSPECIFIED INJURY OF RIGHT ANKLE, INITIAL ENCOUNTER, GENERALIZED ANXIETY DISORDER, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS, UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED, WEAKNESS, EDEMA, UNSPECIFIED. Final Incident Investigation Report (01/03/2023) states: On 12/30/2023 at approximately 3:40pm, both residents were observed getting off the elevator together on the 4th floor. R7, then suddenly physically hit R13 while at the nurse's station unprovoked. Both residents were immediately assessed for injuries. No injuries observed. Staff confirmed that R7 hit resident in front of the nurse's station. Upon the conclusion of this investigation, it is believed that abuse is substantiated. R7's Minimum Date Set assignment dated 12/02/2022 indicated R7 has a Brief Interview for Mental Status (BIMS) score of 12, which indicates resident has moderately impaired cognitive response. R7's Care Plan (dated 11/15/2021) documents that R7 presents with behavioral concerns as evidenced by being physically aggressive towards peer. R13's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, DYSPHAGIA, OROPHARYNGEAL PHASE, PNEUMONIA, UNSPECIFIED ORGANISM, DEHYDRATION, HYPO-OSMOLALITY AND HYPONATREMIA, ABDOMINAL RIGIDITY, UNSPECIFIED SITE, REPEATED FALLS, LONG TERM (CURRENT) USE OF ASPIRIN, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, DYSPHAGIA, ORAL PHASE. R13's Minimum Date Set assignment dated 01/10/2023 indicated R13 has a Brief Interview for Mental Status (BIMS) score of 10, which indicates resident has moderately impaired cognitive response. R13's Care plan (dated 07/10/2022) documents that R13 may be at risk for potential abuse r/t behavior problem as evidenced by verbally and physically acting out when agitated and R13 was involved in a physical altercation in which R13 received physical aggression. Abuse Prevention Policy (dated 11/22/2017) states: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. On 02/15/2023 at 1:20pm, R7 stated, I don't remember hitting anybody. I don't remember it at all. On 02/15/2023 at 10:49, R13 stated, R7 and I were on the elevator together. We got off the elevator and all of a sudden R7 grabbed my arm and scratched my wrist. I don't know why R7 attacked me this way. I didn't do anything to R7. There was no verbal altercation or any issues and R7 just attacked my arm for no reason and scratched me. On 02/15/2023 at 11:33am V1 (administrator) stated, On 12/30/2023, both residents were getting off the elevator, and that's when R7 suddenly hit R13 without being provoked. R7 hit his arm. R13 did not report any injuries after the incident occurred, but later we learned that R7 scratched R13's arm. R7 was not provoked and hit R13 without any reason. Both residents were separated. We spoke to R7 and R7 did not recall what happened. We spoke to R13 and R13 stated that R7 hit him for no reason, but that he was fine and had no injuries. R7 dos not have a history of aggressive behavior towards other. R7 has a lot of behaviors, however, it is not of norm for R7 to hit other residents without a reason. After the incident, we did an abuse assessment on R13. R7 was encouraged to utilize her positive coping skills in the milieu. R7 was encouraged to refrain from any confrontation with a peer and to refrain from being aggressive towards other. The final investigation of the incident between R7 and R13 was substantiated for abuse. The resident has the right to be free from abuse. R7's Social Service Note (dated 12/30/2022) documents, Writer was made aware that resident was involved in an altercation where she initiated physical aggression towards peer. Resident presents to be aox3 and can verbalize her wants and needs with no issues. When questioned, resident very quiet and stated, I don't remember grabbing on nobody. Resident was verbally redirected to appropriate behavior and encouraged to refrain from being aggressive towards others. Resident was encouraged to continue to utilize her positive coping skills in the milieu and to always refrain f [TRUNCATED]

Based on observation, interviews and record review the facility failed to protect (R1) 1 of 3 residents reviewed for Abuse from a physical assault and failed to follow their policy and procedures for Abuse Prevention. This failure resulted in R1 being knocked out of his wheelchair onto the floor. R1 was transported to the hospital for a CT (Computed Tomography) scan of the head. R1 sustained reddish/purplish discoloration to the left eye with swelling from the assault. Findings Include: R1, [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Symptoms related to R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These behaviors can intermittently be disruptive to staff/peers and may put R1 at risk for misunderstanding boundaries and abuse/neglect. R1 is an identified offender and has a criminal history of Battery and Resisting a Peace Officer. R1 is at the Moderate Risk Level. resident has been deemed not to constitute any risk to staff or resident population. Review of R1's progress noted dated 11/1/22 at 6:55 pm, V6 (Social Services) - Writer was made aware that resident was involved in a physical altercation where he received physical aggression. Writer was made aware that resident was hit by R2 in front of the nurse's station and immediately separated. Writer met with R1 to process his feelings regarding being agitated, and involvement in a peer aggressive behavior. Resident presented with no sign of distress during this wellbeing check. When questioned, resident stated He hit me for no reason, but I'm fine pal. Resident has a history of overstepping boundaries. Resident indicated he was doing well and denied any problem at this time. Writer encouraged Resident to inform the nurses and/or social work staff if he experiences any issues. Writer asked resident if he wanted to call police, resident stated no for what. Resident was compliant and did not have any additional behaviors. Writer reassured resident that he resides in a safe place. Writer asked resident if he felt safe in facility, resident stated yes pal. Psychiatrist made aware. Writer encouraged resident to attend groups and activities. Staff will continue to monitor and follow-up accordingly. Care Plan dated 07/01/22 - Resident may be at risk for potential abuse related to behavior problem as evidenced by verbally and physically acting out when agitated. During a face-face interview with V1 (Administrator) on 11/4/22 at 2:32 pm, V1 stated she spoke with R1 concerning the incident with R2. V1 said R1 did not remember the details of the incident but continues to focus primarily on getting a dollar. R1's behavior is to accuse anyone of stealing his money and then he asks that person for $1.00. On 11/18/22 at 11:49 am via telephone with V3 PSA (Psychosocial Rehabilitative Aide), V3 stated on 11/1/2022; R1 was accusing R2 of stealing his money. R1 was screaming and talking extremely loud the entire day. R2 was coming around the corner and R1 started yelling and accusing R2 of stealing his money. R1 was really yelling and screaming at R2, things happened so fast; R2 pushed R1 while in the wheelchair and R1 hit the floor. R2 felt bad, he had never done anything like this before. R2 is very quiet and to his self. R1 really upset R2. During a phone interview with V5 (nurse) on 11/18/22 at 10:47 am, surveyor asked V5 if she was on the unit when the altercation between R1 and R2 occurred. V5 said yes and R1 was very loud, he was extra loud that day and had been going on for hours. R2 was walking down the hallway towards the elevator and R1 started pointing and yelling that R2 stole his money. It happened so fast, R2 tackled R1 to the floor. Surveyor asked V5 if R2 did anything like this before. V5 said no, he is one who stays to himself, he has no behaviors. R1 agitated him a lot that day. On 11/17/2022 at 10:15 am while waiting to interview R1. I could hear a voice screaming very loudly and using profane language that someone stole their money. R1 entered the doorway and immediately started using vulgar language and accused me of stealing his money. V1 (Administrator) was present and told R1 she has not been by you. I introduced myself to R1 and he was screaming at me and saying what do you want. I introduced myself again and asked him about his money and he was talking very loudly and saying that his roommate stole $12.00 of his money and that everyone owes him money. After I asked R1 the question, he asked me for a dollar. I told R1 I did not have any money, R1 started yelling at me and told V1 I stole his money. V1 said to R1, I am standing right here with her. R1 said oh and asked V1 to give him $1.00. R1 is verbally aggressive and uses profanity while talking with a very loud voice as he accuses anyone passing by of stealing his money. On 11/18/22 at 10:54 am while speaking to V6 (Social Services) via telephone, surveyor asked V6 if she was familiar with R1's behavior of yelling loudly, accusing people of stealing his money and begging for a dollar. V6 said she is very familiar with R1 and his accusatory behaviors. She said R1 did not remember the incident. Surveyor asked what interventions are in place to prevent another altercation of this matter from happening. V6 said R1 has groups but he will not show up unless he gets a reward of some kind. We continue to redirect R1 and talk to him about invading other people space. Surveyor asked V6 about R2 and his behaviors. V6 said R2 is quiet and to self. He has never had a behavior before this altercation. Abuse Policy: Abuse Prevention Policy - not dated, Template # 759.3 Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 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 This will be accompanied by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation and misappropriation of property The Facility prohibits abuse, neglect, exploitation, misappropriation of property and exploitation of its residents, including verbal, mental, sexual or physical abuse, corporal punishment and involuntary seclusion. The facility has a no tolerance philosophy.

Based on observation, interview and record review, the facility failed to ensure that residents remain free from abuse. This affected two(R8 abused by R9). This failure resulted in R8 requiring sutures for a forehead laceration. R9 with known aggressive behaviors; facility failed to ensure R1 was free from abuse by R2. R2, a resident with known aggressive behavior. Findings include: R8's medical record (Face Sheet, Minimum Data Set) notes R8 is a severely cognitively impaired [AGE] year-old admitted to facility on 4/17/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's care plan initiated 07/18/2022, notes in part, R8 may be at risk for potential for abuse related behavior problem as evidenced by wandering in peers' rooms. R8's care plan initiated 08/07/2022, notes in part, R8 has a behavior problem related to (touching staff, residents, the nurse's cart, walls, wheelchairs and objects on the unit) secondary to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R9's medical record (Face Sheet, MDS-Minimum Data Set of 07/29/2022) notes R9 is a severely cognitively impaired [AGE] year-old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Section E Behavior, notes in part, R9 exhibits delusions, physical behavioral symptoms (e.g., hitting, pushing) directed towards others and, verbal behavioral symptoms (threatening/screaming/cursing at others). R9's care plans initiated 01/29/2022 note in part, R9 has a behavior problem related to verbally and physically acting out when agitated and R9 has been physically towards peers and staff due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R9's care plan initiated 07/31/2022 notes in part, R9 may be at risk for potential abuse related to behavior problem as evidenced by: poor impulse control, verbally/physically acts out. R9's care plan initiated 09/16/2022 notes in part, R9 presents with behavioral concerns as evidenced by verbal and physical aggression. On 10/26/2022 at 10:50 AM, R9 was observed standing in hallway between Day Room and Nurses Station. Surveyor approached R9, R9 said, Get the f*** away from me. Facility's final incident report (10/16/2022) notes in part, The resident (R8) was walking on the unit and walked into another resident('s) personal space which resulted with the resident being pushed to the floor. Open area noted to forehead. On call called and order given to send to (Local Hospital) for evaluation and CT scan. (R8) returned to the facility with 3 sutures. V14 (Licensed Practical Nurse-LPN) on 10/26/2022 at 4:58 PM, said V27 (Certified Nursing Assistant-CNA) told me that R8 walked up to R9, tapped R9 on the shoulder. Before V27 could get up to intervene, R9 pushed R8 and R8 fell . R8 had a laceration to her head. R9 has hit staff. I'm not aware of him hitting any residents. R9 has gone to strike (residents) but we were able to intervene before R9 hit the person. R9 is easily agitated, R9's agitation leads to aggressive behavior. V14 said R8 does wander the hallway and is at risk for abuse. On 10/26/2022 at 5:25 PM, V27 (CNA) said, I was monitoring the unit, doing my POCs (Point of Care documentation) at the nurses station. R8 came out of nowhere, R8 went up to R9 and R9 pushed R8. I couldn't get to them in time. V27 said R8 is a wanderer. R8 goes into other resident's rooms. We try to redirect R8 to R8's room. V27 said, I've seen R9 hit others. On 10/27/2022 at 12:00 PM, V3 (Assistant Director of Nursing-ADON) said, Yes, R9 does have a history of aggression. R9's number one trigger is people getting in R9's space. Once R9 gets up and dressed in the morning, R9 has a spot that R9 likes to stand in. We try to re-direct R9 to a different spot. We have given R9 a chair to sit in. The more we try to re-direct R9, the more likely R9 is to become aggressive and attempt to strike out. V3 said R8 doesn't respect the boundaries and personal space of others. R8 is a wanderer. Facility's Abuse Prevention Policy (effective November 22, 2017) notes in part: -Residents have the right to be free from abuse. -Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. -Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. -Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. R1 is a [AGE] year-old individual admitted to the facility on [DATE]. R1 Brief Interview for Mental Status (BIMS) completed on [DATE], document R1 BIMS score as 9/15, indicating R1 has some cognitive disabilities. On 10/26/2022 at 10:20am, R1 was observed in the in the hallway being assisted by staff in combing R1's hair. at 10:32am, R1 was observed in R1's room. R1 said someone pushed R1 but R1 does not remember the name of the person. R1 is alert and oriented to person and place, and R1 has confusion. R2 is a [AGE] year-old individual with initial admitted to the facility on a 4/21/15, readmitted to the facility on [DATE] band discharged from the facility on 10/7/22. R2's Brief Interview for Mental Status (BIMS), completed on [DATE] document R2' BIMS as 10/15, indicating R2 has some cognitive deficits. On 10/26/2022 at 5:34pm, V1(Administrator) said it's the facility expectation is for residents not get physical with each other. V1 said if a resident is physically abused, they can feel unsafe, violated and afraid, and it's the facilities responsibility to keep residents safe. On 10/26/2022 at 12:48PM, V6 (Certified Nurses' Assistant-CNA) V6 said R1 is not aggressive and usually likes to stay in R1's room. V6 said that R2 used to pace and wander a lot, going into other residents' rooms looking for cigarettes and R2 has been involved in altercations with other residents, but no alterations with staff. V6 said in most of the altercations, R2 was the physical aggressor. V6 said residents should not be hitting other residents, and staff do their best to redirect residents. V6 said when a resident is hit by another resident, the resident can feel scared and afraid. On 10/26/2022 at 1:11pm, V5 (Restorative Nurse/LPN (Licensed Practical Nurse) said R1 has psychiatric issues, and likes to sit in the basement on the floor, but R1 is not aggressive at all V5 said that on 10/07/2022, on the fourth floor, between 7:15am and 7:30am, V5 said V5 heard a loud noise while at the nursing station and one of R5's coworker said R1 went flying and hit the floor. V5 said V5 went to R1's room and saw R2 outside R2's room sitting on R1 buttocks. V5 said R1 said he (R2) pushed me (R1). V5 said R2 was standing in the doorway. V5 said V5 asked R2 why R2 pushed R1. V5 said R2 denied pushing R1. R2 said R2 told R1 to get F out of my(R2) room. V5 said R1 said R2 shoved R1 and told R1 to get out of R2 room. V5 said V5 did an assessment on R1 to make sure R1 did not break anything. V5 said (V5) told R1 to go to R1 room, and R1 kept saying He (R2), pushed me(R1) V5 said R1 did not sustain any injuries and R2 went to R1 room. V5 said R2 remained in R2's room until it was time for R2 to get R2 medications and after R2 got his medications, R2 started daily routine. V5 said V5 notified V1(administrator) V5 said residents should not be pushed or hit by another resident. V5 said when a resident is pushed or hit, they can feel unsafe and can be fearful and residents are supposed to feel safe in the facility. On 10/26/2022 at 12:33pm, V24(Certified Nurses' Assistant-CNA) said that R1 was mostly quite and R1 was not aggressive. V24 said that R1 is a little confused sometimes, talks to self, and V24 has not seen R1 go into other resident's room and R1 very compliant with ADL care. V24 said residents should be kept free from harm because they can feel scared and unsafe. V24 said staff try their best to keep residents safe. Facility Final Investigation Report dated 10/10/2022 documents; -Based on the details of this investigation, it is believed R1 did abuse R2 by pushing R2 out of the room and causing R1 to fall onto R1 buttocks. Facility Abuse Prevention Program -Policy, effective November 22, 2017, documents; -Abusee means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. -Physical Abuse is the infliction of injury on a resident that occurs other than by means of accidental means. -Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interviews and record reviews, the facility failed to provide adequate supervision for 2 residents (R7 and R8) of 8 residents reviewed for supervision. This failure resulted in R7 sustaining a 2cm (centimeter) forehead laceration that required three sutures. Findings include: R7's medical diagnoses include but are not limited to unspecified dementia with behavioral disturbance, weakness, unspecified lack of coordination, wandering in diseases classified elsewhere, unspecified bilateral hearing loss, history of falling, other abnormalities of gait and mobility, and vascular dementia. R7's MDS (Minimum Data Set) assessment dated [DATE] documents in part: R7 is rarely/never understood. R7 also has short and long-term memory problems and no memory/recall ability. R7's cognitive skills are severely impaired. R7 has inattention and disorganized thinking that are continuously present. Surveyor reviewed R7's comprehensive care plan. Care plan initiated 04/12/2022 documents in part that R7 has impaired cognitive function/dementia or impaired thought process related to dementia and paranoid [CONDITION(S)] as evidence of inattention, disorganized thought content, confusion, and forgetfulness. Care plan initiated 07/18/2022 documents in part that R7 may be at risk for potential abuse related to behavior of wandering into peers' rooms. Care plan initiated 08/22/2022 documents in part that R7 has potential for falls related to progressive dementia, hard of hearing, impaired cognition, poor safety awareness, history of falls, and history of bending over to pick up invisible objects from the floor. R8's medical diagnoses include but are not limited to unspecified dementia with behavioral disturbance, restlessness and agitation, unspecified hearing loss in bilateral ears, vascular dementia with behavioral disturbance, cognitive communication deficit and Alzheimer's Disease. R8's Quarterly MDS assessment dated [DATE] documents in part: R8 has inattention that fluctuates and disorganized thinking that is continuously present. R8 has delusions and physical, verbal and other behaviors that occurred 1 to 3 days during the look back period. The behaviors significantly intrude on the privacy or activity of others. Surveyor reviewed R8's comprehensive care plan. Care plan initiated 01/29/2022 documents in part that R8 is at risk for altered thought process related to diagnosis of Alzheimer's Disease. Care plan initiated 01/29/2022 documents in part that R8 has a potential to demonstrate verbally abusive behaviors related to dementia. Care plan initiated 01/29/2022 documents in part that R8 has been physically aggressive towards peers and staff due to diagnosis of dementia and poor impulse control. Care plan initiated 01/29/2022 documents in part that R8 has a behavior problem related to verbally and physically acting out when agitated. Facility's Report of Resident Incident/Accident reads [R7] was walking on the unit and walked into [R8's] personal space which resulted with [R7] being pushed to the floor. On 10/04/2022 at 2:19 PM, V13 (Nurse) stated R7's dementia has progressed and gotten worst. V13 cannot make out what R7 says due to R7's disorganized thinking. V13 stated R7 wanders around the unit a lot. On 10/05/2022 at 10:42 AM, V15 (Nurse) stated R7 gets up and wanders a lot. V15 stated R7's gait is steady but R7 is frail. V15 stated R8 stands in the hallway and sometimes tries to grab people. At 11:09 AM, V17 (Nurse) stated [V17] was on break when the incident between R7 and R8 occurred. V17 did not witness the incident but described R7 as someone that likes to touch people or pat people's shoulders. V17 stated R7 needs one-to-one monitoring because R7 is always busy and [R7's] dementia has progressed. V17 stated R7 has poor safety awareness. V17 stated R8 with history of physical and verbal aggression. V17 stated R8 gets easily agitated. R8 gets irritated when someone gets in [R8's] personal space. V17 stated if someone gets too close to R8 then staff need to immediately diffuse the situation. V17 stated it is not safe to have R7 near R8 because R7 doesn't know what [R7] is doing. V17 stated R7 does not know to stay away from R8. R7 just wanders and does own thing. At 11:25 AM, V18 (Certified Nurse Aide) stated R7 wanders a lot and requires one-to-one monitoring. V18 stated the facility cannot accommodate R7's safety because they have multiple residents to look after. V18 stated R7 requires a lot of redirection because R7 is constantly wandering. At 12:26 PM, V19 (Nurse) stated V19 was in a resident's room when the incident between R7 and R8 occurred. V19 did not witness the incident but describes R7 as oriented to self only and is confused. V19 stated R7 needs a lot of monitoring because R7 wanders and sometimes goes into people's rooms. V19 stated R7 does not have safety awareness. V19 stated R8 is territorial of the area that [R8] stands in. V19 stated R7 would not know to avoid R8. V19 stated We shouldn't have let [R7] get that close to [R8]. I don't know how it happened. [R7] doesn't even follow instructions. You have to hold [R7's] arm to guide [R7] into the room. [R7] can't follow verbal instructions. At 3:09 PM, V20 (Certified Nurse Aide) stated R7 is very confused. Staff need to monitor R7 because [R7] is a wanderer. V20 stated R7 requires one-to-one monitoring. V20 stated R8 stands in the hallway most of the time and does a lot of fussing. V20 stated R8 is hard to redirect and bothers people. R8 bothers people when people are walking past. R8 doesn't like people walking too close to [R8.] V20 stated R7 and R8 cannot be in the same area together. R7 does not understand to be clear of R8. V20 stated R7 cannot follow verbal direction. R7 won't understand if you tell [R7] to stay away from R8. V20 stated staff have to physically pull R7 away and redirect. V20 stated during R7 and R8's incident, V20 was sitting at the nurses' desk charting. V20 stated R7 came out of nowhere. My head was down in the computer. R8 started fussing on R7. Before I could get up to remove R7 from R8's personal space, [R8] pushed [R7] and [R7] fell . [R7] fell forward and had a gash on [R7's] forehead that was bleeding. V20 stated I was too busy working on the computer. I didn't see R7 approach [R8]. I heard R8 talk to R7. That's when I looked up. When I started to walk up and redirect R7, that's when R8 pushed R7 and [R7] fell in the floor. V20 stated facility sent R7 to the hospital for evaluation due to gash on the forehead. R7's hospital records dated 09/11/2022 documents in part a diagnosis of facial trauma. R7 sustained a 2cm laceration that required three sutures. Facility's Dementia policy created 05/2022 documents in part: A resident who displays or is diagnoses with Dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Treatment and Services: . 2. Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; Facility's Wandering, Unsafe policy created 05/17/2022 documents in part: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement. Facility's Safety and Supervision of Residents policy created 10/2021 documents in part: Resident supervision is a core component of the systems approach to safety.

Based upon record review and interview the facility failed to follow the abuse prevention policy, failed to ensure that one of six residents (R5), remained free from abuse (resulting in serious injury) and failed to provide 1:1 supervision to R4 immediately following aggressive behavior. These failures resulted in R5 sustaining a laceration (above left eye) on 8/18/22 which required suture repair. Findings include: R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R4's (8/5/22) cognitive assessment determined a score of 15 (cognitively intact). R4's care plan includes (4/6/22) resident presents with behavioral concerns as evidenced by initiating physical aggression towards peers. Intervention: staff to redirect resident when behaviors are present. (6/14/22) Resident may be at risk for potential abuse related to behavior problems as evidenced by combative behavior. Intervention: monitor resident behavior. (6/20/22) Resident has a behavior problem related to displaying verbally aggressive behavior with the potential for physically aggressive behavior related to poor impulse control. Intervention: intervene as necessary to protect the rights and safety of others. Remove from situation and take to alternate location as needed. R4's (8/18/22) progress notes state writer responded to obscene language on unit in hallway and noted resident engaged in altercation with peer. Resident noted standing over peer while delivering blows and kicks to resident head, face and body. Writer able to restrain resident from further aggression at that time, approximately 5 minutes after separation of residents, resident approached peer and initiated another altercation with resident shoving peer to floor and delivering punches to face, head and body. R4 was transferred to the hospital on 8/18/22 at 2:34 pm and did not return to the facility prior to this investigation. R4's documentation excludes 1:1 supervision immediately following 8/18/22 incident. R5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's (7/21/22) cognitive assessment determined a score of 10 (moderately impaired). On 8/29/22 at 2:24pm, surveyor inquired about the 8/18/22 incident R5 was slow to respond, became angry and stated I ain't got a phone man! and refused to answer any other questions. On 8/31/22 at 10:30am, surveyor inquired about the (8/18/22) incident V9 (LPN/Licensed Practical Nurse) stated that R4 and R5 had a physical altercation on the first floor. V9 separated R4 and R5 from the altercation. V9 sent R4 back to the room and took R5 to the nurse's station. R4 came out of the room and started rushing at R5 with another physical altercation. R5 had a cut on the eye, skin was broken, more like a laceration with some bleeding. On 8/31/22 at 11:05am, surveyor inquired about R5's (8/18/22) injury V6 (LPN) stated R5 had blood coming from R5's eye. an abrasion on R5's cheek and inside lip was swollen and bloody. The (8/18/22) final incident investigation states at approximately 4:30am, (R4) stated that (R5) wandered into R4's room and tried to take R4's phone. (R5) admits to hitting (R4). (R5) returned (from the hospital) with sutures to left eyebrow. On 9/1/22 at 10:31am, surveyor inquired if R4 was immediately placed on 1:1 supervision post 8/18/22 incident V10 (Assistant Director of Nursing) stated social service had a 1:1 with him, I (V10) think they (social service) got here like 8:00am or something. The (11/22/17) abuse prevention policy states if the alleged perpetrator is a resident, the resident will be separated from the alleged victim and resident's condition will be evaluated as soon as reasonably possible to determine the most suitable therapy and placement for the resident. This will be done taking in consideration the safety of other residents and employees of the facility.

Based on interviews and record reviews, the facility failed to provide adequate supervision to a severely cognitively impaired resident with unsteady balance while walking who wanders in the unit to prevent her from falling for 1 (R1) of 3 residents reviewed for falls. This failure resulted in R1's having a fall incident on 7/12/22 while wandering in the unit unsupervised and was found lying on left side in the hallway. R1 was transferred to the local hospital. R1's hospital records show left distal radius fracture and left femoral neck fracture status post fall. Findings Include: On 8/02/22 at 10:10 AM, observed R1's emergency call light was going off. Surveyor observed R1 inside R1's room standing on the side of R1's bed with her (R1) incontinence pad on the floor wet and soiled. R1 was confused and unable to verbalize needs. R1 had a low bed. Call light not in place. V3 (Registered Nurse) walked in and stated R1 does not use the call light due to severe impaired cognition. V3 stated R1's roommate probably was the one who pressed the call light. R1 observed with a unsteady and shuffling gait. R1's room was also observed approximately 35 feet away from the nurses' station. R1's electronic health record (EHR) indicates an initial admitted [DATE] with listed diagnoses not limited to [CONDITION(S)], Wandering in Disease Classified Elsewhere, [CONDITION(S)], Bilateral Unspecified Hearing Loss, Paranoid [CONDITION(S)], and History of Falling. R1's Medication Administration (MAR) indicates R1 was receiving antipsychotic medication [MEDICATION(S)] 25 mg in the morning from 7/1/22 to 7/11/22. R1's Annual Minimum Data Set (MDS) with assessment reference date (ARD) of 4/12/22 shows R1 is severely impaired with her (R1) cognitive skills and daily decision making. It also shows that R1 was requiring supervision one staff physical assist with her (R1) transfers, walking in room and walking in corridor. R1's Restorative/Mobility Nursing Screen (Admission/Quarterly) signed by V6 (Fall Nurse) on 4/18/22 shows R1's balance during transitions and walking were not steady and R1 was not utilizing any mobility device. It also shows R1 required supervision with ambulation on/off unit. R1's Fall Risk Screen - V2 dated 7/07/22 at 4:51 PM shows R1 scored with moderate risk. R1's ADL care plan created on 9/07/19 shows R1 has self-care deficit and requires limited one staff assist with ADLs due to diagnosis of dementia with behavioral disturbances. On 8/02/22 at 10:16 AM, an interview conducted with V3 (Registered Nurse). V3 stated R1 is a wanderer and is confused. V3 stated staff needs to supervise R1 when wandering because she (R1) is high risk from falling. V3 stated R1 requires assistance with all her (R1) activities of daily living (ADL's). At 10:34 AM, an interview conducted with V5 (Certified Nursing Assistant). V5 stated R1 is not steady when walking and needs assistance. At 11:42 AM, an interview conducted with V6 (Fall Nurse). V6 stated R1 has advanced dementia and is a wanderer. V6 stated R1 fell three times in the month of July this year. V6 stated the first fall happened in 7/7/22 when R1 was observed in another resident's room lying on the floor. V6 stated R1 needs one physical staff assist supervision for walking. V6 stated R1 fell again on 7/12/22 was observed lying on her (R1) left side in the hallway, and fractured her (R1) left hip and wrist and was hospitalized . V6 stated on 7/29/22 R1 fell the third time and was observed on the floor in her (R1) room. V6 stated all three falls were unwitnessed. At 12:17 PM, a phone interview conducted with V8 (Certified Nursing Assistant/CNA). V8 stated she (V8) was assigned to R1 on 7/12/22 when R1 fell . V8 stated, It was dinner time and all CNAs were passing tray. She (R1) was walking around back and forth. She (R1) was wearing the crocs slippers. She (R1) was walking by herself. Nobody was assisting her (R1) walk. It's normal for her (R1) to walk around by herself (R1) and she (R1) wanders a lot. She's (R1) very confused. She's (R1) pretty steady. She (R1) does not use any assistive device. The nurses were passing meds and the CNAs were passing trays. I (V8) was grabbing the other resident's tray and next thing I (V8) know when I (V8) turned around, she (R1) fell in front of me (R1). There were no staff that saw what exactly happened. At 12:28 PM, a phone interview conducted with V9 (Licensed Practical Nurse). V9 stated she (V9) was the nurse in charge on 7/12/22 when R1 fell the second time. V9 stated, I (V9) was charting at the nurses' station I (V9) heard a noise down the hall. I (V9) got up she (R1) was observed lying on her (R1) left side down the hall. She (R1) was ambulating before the fall. She (R1) has dementia. She (R1) walks by herself for the most part. She (R1) just needed assistance with ADL care changing, dressing. For the most part she (R1) was pretty much able to transfer herself (R1). I (V9) did not see her (R1) falling. At 1:38 PM, a phone interview conducted with V11 (Certified Nursing Assistant). V11 denied witnessing R1 fell on [DATE]. V11 stated she (V11) was at the nurses' station charting. V11 stated R1 was just walking around like she (V11) normally do. V11 stated before R1 fell , R1 was walking by herself (R1) around the unit, and that there was no staff supervising her walking. On 8/03/22 at 9:42 AM, a phone interview conducted with V13 (Licensed Practical Nurse). V13 stated she was not assigned to R1 on 7/12/22. V13 stated she (V13) did not see how R1 fell because V13 was charting at the desk. V13 stated R1 is a busy little lady that cruises around the facility. V13 stated R1 wanders independently. At 10:11 AM, an interview conducted with V15 (Restorative Nurse). V15 stated that in general, if a resident is coded in the MDS with supervision one staff physical assist in walking that means one staff should be on standby cuing and watching the resident at all times while the resident is walking and should be observing the resident's gait. V15 stated, The resident can walk by themselves but the staff is supposed to be watching. Surveyor asked V15 if is it safe for a resident to walk by herself if she was assessed with unsteady gait, poor judgement and requires supervision one staff physical assist. V15 answered No. V15 stated that the resident would be at risk for falling. V15 stated that based on R1's functional ability assessment and annual MDS on 4/12/22, R1 required supervision with one staff assist with walking and transfer. At 11:11 AM, an interview conducted with V19 (Nurse Practitioner). V19 stated that usually, if a resident is cognitively impaired with poor judgement and is assessed to be at risk for falling, also assessed with unsteady gait requiring supervision one staff physical assist, it is not safe for that resident to be ambulating independently. V19 stated, It's different if the gait is stable. If gait is not stable or they if have some balance issues they should not be ambulating by themselves. V19 further stated that if a resident uses an assistive device when walking, the resident can possibly ambulate without assistance from staff; but if no assistive device used with an unsteady gait, the staff should be assisting that resident. V19 stated when R1 fell on [DATE] the staff sent R1 to the hospital, hospital found R1 with left wrist fracture then R1 was sent back to the facility. V19 stated she (V19) noticed R1 was not looking good with her (R1) hip so V19 ordered a stat X-ray on both hips. X-ray result came back with left femoral neck fracture. R1 was sent back to the hospital and had a surgery on R1's hip. On 8/04/22 at 12:16 PM, a phone interview conducted with V12 (Certified Nursing Assistant). V12 stated she (V12) was passing trays with V8 when R1 fell . V12 stated, I did not see her (R1) when she (R1) fell . I just heard the noise when she (R1) fell . V12 stated R1 walked by herself. A record review of the facility's Fall documentation dated 7/7/22 at 4:51 PM shows R1 had an unwitnessed fall and was found in other resident's room lying on the floor with no visible injuries upon V9's (Licensed Practical Nurse) assessment. Fall care plan was updated on 7/8/22 reads in part: S/P Fall 07/07/22: Neuro checks initiated. Staff will continue to monitor resident and anticipate needs. A record review of the facility's Fall documentation dated 7/12/22 at 6:15 PM shows R1 had an unwitnessed fall and was observed lying on left side in hallway after thump sound was heard. R1 was sent to the hospital for evaluation. R1's hospital records dated 7/13/22 reveals R1 obtained left distal radius fracture and left femoral neck fracture status post fall. R1's hospital records also show that on 7/14/22, R1 had a procedure done for Closed management of intra-articular fracture of the left distal radius and closed reduction percutaneous pinning of left femoral neck fracture. A record review of the facility's Fall documentation dated 7/29/22 at 6:30 AM shows R1 fell for the third time unwitnessed and was observed on the floor in R1's room. Reviewed the facility's policy on Falls Management with revision date of 6/21 reads in part: GENERAL: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed and the resident's existing plan of care shall be evaluated and modified as needed.

Based on interview , record review and observation the facility failed to provide supervision to 1 of 3 residents ( R4) in a sample of 9 by failing to prevent the possession of (ETOH) alcohol while inside the facility. This failure resulted in R4 sustaining a hand laceration requiring 6 sutures, due to intoxication and sent out to hospital. Findings include: R4 is a [AGE] year old male with a diagnosis including Diabetes 2 , [CONDITION(S)] , Anxiety Disorder , Alcohol Dependence, and Cocaine Abuse . R4 was first admitted to the facility on [DATE]. R4 s April 2022 Minimum Data Set BIMs score is 14. R4 has care plans including : 12/30/21 care plan - potential for altercation in cognitive status r/t toxic metabolic [CONDITION(S)] 2/2 ETOH and substance abuse and hx of hyperammonemia . 7/1/21 care plan - Has mood problem r/t Disease Process alcohol and drug abuse. 4/13/21 care plan - Has [CONDITION(S)] or an acute confusion episode r/t alcohol and drug abuse. 6/27/22 (recent) care plan - Has potential to demonstrate physical behaviors r/t poor impulse control . 6/27/22 R4 was observed intoxicated , became aggressive and punched out the window. Date initiated 6/27/22. Review of documents show that on 6/27/22 the facility sent Illinois Department Of Public Health an incident report . The report included documentation that the nurse heard a loud yelling and noise coming from the room , upon entering room Patient was observed guarding left hand with a cloth and closer look blood was noted . Patient seen belligerent , unsteady gait , slurred speech , combative , screaming , and aggressive towards staff . Patient refused first aid care and vital signs . The window was broken in the room and glass on floor. Team Health On Call called and Nurse Practitioner called and returned call and made aware . 911 called. 911 in facility and Pt. (patient) care for his left hand . BIMs score 13 . Resident denied being abused or mishandled. Review of hospital record ( 6/27/22 ) shows R4 admitted to hospital with a diagnosis including hand laceration and alcohol intoxication. 6/27/22 progress note/behavior note states - Writer ( V6) 1AM was at the nursing station and heard a loud yell coming from the back of the unit. Writer immediately went to where the noise was coming from and observed patient in his room with an unsteady gait, slinging his left hand with his clothes noted with blood on it. Patient left hand (back of the hand) was also noted with blood which patient refuses for writer to render first aid care to the hand. Patient appears to be intoxicated with alcohol with slurred speech unsteady gait and also combative towards writer. Rapid response was called which staff nurses in the facility arrived on the unit to assist with patient care. Patient now still combative, screaming and calling staff out of their names with threats of bodily harm. Other staff unable to assist patient due to his aggressive behavior. Patient refuses vital signs to be taken by staff nurses and also refuses to change his clothes which has blood on it. 3-11 pm Supervisor also arrived at the unit to also assist with patient first aid which patient became very aggressive towards supervisor attempting to hit supervisor and also throwing items at supervisor. Patient now at the nursing station still refusing care to his laceration site. 911 called for transportation for patient, awaiting for their arrive to unit. Patient still attempting to fight supervisor again refusing first aid care to his left hand. IPC service called and writer spoke to on call NP (nurse pactionier) who was made aware of patient above listed change of condition with order given to transfer patient to s local hospital for evaluation of laceration to the left back of the hand, order noted and carried out. Patient POA (sister) was also called and made aware of patient above behavior with laceration at the back of the left hand. POA inform that patient is been transfer to the hospital for evaluation of the left hand which she verbalized understanding. 911 personal arrived on unit which patient at the nursing station still refuses for the EMT to render care to the his left laceration side. Patient now aggress to be transfer to the hospital for evaluation. Patient was then taken to St. [NAME] hospital with 911 EMT'S. Writer then called hospital ER and gave nursing report to ER nurse of patient above listed change of condition. Facility administrator and DON both made aware of patient above listed change of condition as listed above by 3-11 pm supervisor. Writer will follow up on patient status later on at the hospital. 6/27/22 progress note/ behavior note states resident returned to facility via elite ambulance,with 6 sutures to left hand covered by kerlix dressing. refusing vital signs still s/s of intoxication. 6/27/22 hospital record shows 6 sutures to left hand. 6/30/22 progress note/wound care note states resident is a readmission back into the facility and full body assessment performed today by wound care department. Resident is ambulatory and continent of bowel and bladder. Resident noted with surgical wound to the left hand with 6 intact sutures with no drainage noted following assessment by wound care department. MD is aware of readmission, tx and dietary supplement orders given and carried out. Resident declined assessment on yesterday but allowed for assessment on today. Resident is alert and orient x's 3. Resident resting comfortably following assessment by wound care team. On 7/1/22 11AM V4 ( Maintenance Director ) stated R4 hit the window with his hand and cut his hand. R4 was intoxicated from alcohol . I went to the room after he broke the window and returned from the hospital around 5 AM . He was still very drunk and stumbling all over the room. The nurse in charge on the night shift took a bottle of alcohol from him. R4 had to go to the hospital to get treatment to his hand . R4 is now in another room . This room is kept locked until the window company can replace the glass. I do not know how R4 got the alcohol. On 7/1/22 11:30AM V6 ( Nurse) stated I heard a loud noise. I got to R4s room. R4 was staggaring and combative. Blood was all over the room . I call rapid response for help . The nurse ( Supervisor nurse ) came up . He tried to talk to R4 . R4 was slinging his hand . We called 911. They came in and took him to the hospital. He got 6 stitches . R4 appeared to be intoxicated. He reeked of alcohol . We found a 1 empty bottle and one that was half full . R4 has a community pass to go in community. The policy states that the staff look in the residents bag when they return. On 7/1/22 11:41 AM V5 ( Social Service) stated I was aware of R4 incident. R4 did not have a pass to leave the facility . On 3/7/22 R4 was found to appear to be intoxicated. R4s community pass was revoked . R4 was restricted to the building. I do not know how R4 got the alcohol . My staff have been working with him . Social service met with him today. No concerns no behaviors or aggression . I will be meeting with him today to discuss 1:1 counciling. On 7/1/22 12:35 PM R4 stated I got the 2 bottles of rum from a friend. He talked to me on the phone and asked me if I needed anything . I told him to get me rum . He met me out on the facility patio and handed me the two bottles of rum . I took it up to my room . No one checked me when I came back into the facility . There was no staff out on the patio when I received the rum on the outside patio from my friend . He handed it to me over the fence. I brought it up to my room and drank it. On 7/3/22 9:35AM V5 ( Social Service ) stated I am in charge of the outside patio. The patio is kept locked at all times unless there is a staff person to supervise the residents . All department staff can supervise the outside patio area. Everybody helps with watching the residents when they are out on patio. Yesterday I worked with R4 with his new behavior contract. During this time R4 told me he got the alcohol from and outside visitor outside the building. R4 did not tell me exactly how he did it. R4 does not have unrestricted community pass at this time since the incident. On 7/2/22 10:40AM V1 ( Administrator ) stated our policy on (ETOH) alcohol in the facility is covered by our policy titled Contraband (Room Search) . Alcohol possession by residents is prohibited . Residents out on the patio are supervised . There are PSAs or staff ( CNAs) that supervise the patio when residents are out there. If there is no staff the door to patio is locked . Family members and guest with bring contraband into the facility. There was no report that anyone passed alcohol to R4 over the fence in the patio. No one knows how R4 got the alcohol in the facility. I believe there are cameras out on the patio. Had I known R4 got alcohol from the patio I would have checked the cameras. On 7/1/22 12PM R1s room was observed . The exterior wall lower window was observed broken out . Old blood was observed on the wall directly below the window . This room was observed locked with no resident access. Facility Policy titled Contraband ( Room Search ) 3/20/22 states including Purpose : To provide a process for searching a residents room and / or belongings when residents exhibit behaviors of self- harm or inflection of harm onto others . Definitions: Contraband : Any item that is banned from the facility and/ or is of harm to the resident or others. Items included but are not limited to : guns , knives, ammunition , chemical substances, illegal drugs or drug paraphernalia, Alcohol , Tobacco , lighters , Flammable substances , and other items that pose safety or risk as determined by staff. Facility guideline dated 7/10 states To provide monitoring of residents on the patio in addition to any camera monitoring. All facility staff . 1. The patio will be monitored when residents are on the patio if necessary. 2. Staff will monitor the patio as assigned. This on addition to the current cameras that monitor the patio. 3. If a resident exhibits inappropriate behavior , then the resident will be asked to leave the patio. The PRSC or Social Services will be alerted and will provide appropriate intervention.

Based on interviews, and record reviews the facility failed to ensure one of five sampled residents [R1] was free of sexual abuse and financial exploitation from an employee [V3]. This was identified as an Immediate Jeopardy which began on 05/31/22 when R1 made it known about his personal relationship with V3. On 06/24/22 at 9:42 am the administrator was notified of the immediate jeopardy. The facility presented a final removal plan on 06/24/2022 at 4:49PM. The facility's removal plan was accepted at 2:44 PM on 06/27/2022. The surveyor conducted additional interviews and record reviews on 06/28/2022 to verify the plan was implemented. The immediate jeopardy was removed on 06/24/2022 based on actions from the removal plan. Although the immediacy was removed, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Finding include: R1 was admitted to the facility on [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Date Set [MDS] dated 04/25/22, Section C-brief interview for mental status summary score is (15) indicates R1 is cognitively intact. On 06/07/22 at 10:45 AM, R1 stated, I called the complaint line because I was angry with V3 (Certified Nursing Assistant) for playing with my emotions, making me feel bad about being so nice. Then we made up and got back together. So then, I called the complaint line back and said all the information previously given was a lie. However, it was not a lie, everything I reported was the truth. After I called the IDPH compliant line to say it was a lie, a few days later V3 blocked me from calling her cell phone. I feel like V3 was only nice to me and wanted to get back together so I would not talk about our relationship. Since you are here, I'm going to be honest about everything, V3 and I had started a sexual relationship in March 2022. I paid V3's taxicab fees to and from work so many times I can't count since March 2022. V3 asked me for the taxi money and said they will pay me back on her paydays, which never happened. I also would order V3 food, sometimes when V3 was hungry working here at the facility. Also, sometimes V3 would ask me to order food, and have it delivered to her location. I would say I gave V3 at least $600 since March 2022, which included taxicab fees, food, and money. Here read our last text message excuse all the curse words, we were arguing. On 06/07/22 at 10:50 AM, Surveyor observed the text message from R1's cell phone. V3's text messages with R1 documents in part: R1 cursing at V3 for not responding to his call or text messages. R1 stating that V3 must have been out cheating on R1. V3 responded that she was not out cheating on R1. The messages went back and forth with cursing. On 06/07/22 at 12:11 PM, V3 [Certified Nurse Assistant] stated, I knew R1 from other facilities that I worked at in the past. On Mother's Day (May 8, 2022), R1 was sick with vomiting and diarrhea. R1 called my cell phone while I was working on the second floor (R1 does not reside on the second floor) , to come help him to clean up. I went up to R1's floor to help R1, while providing assistance R1 kept vomiting and it got all over my uniform. I went into R1's bathroom took off the scrubs, but I still had on my underwear, and started to clean myself up. V8 [Certified Nurse Assistant] busted into R1's room, without knocking on the door, then V8 saw me with my underwear on sitting on the bed next to R1. I was sitting on the bed, but R1 was laying down, and R1 was still not feeling well. I tried to explain what happened to V8, but V8 said V7 [Nurse Supervisor] was looking for me, then V8 left out the room. I went to V7, who told me to punch out and go home. I told V7 why, I had on my underwear, but V7 said I will have to talk to V2 [Director of Nursing] tomorrow. I was suspended from 05/8/22 to 5/19/22. V4 [Human Resource] called me to come into the facility. The next day 5/20/22, I met with V4 and explained everything to V4, the reason why I had on my underwear in R1's room. V4 said due to the situation, it was best for me to resign. So, I wrote my resignation on a sheet of paper and that was it. I received abuse training when I was hired. Some types of abuse are, physical, mental, verbal, sexual, and exploitation. R1 and I was not having any type of sex on 05/08/22. We are close friends and call/text each other all the time. R1 did pay for my taxi cabs often, to help me get back and forth to work. The taxicab service would only take cash, so R1 would give me cash to pay for my rides. There was times R1 would buy me food and have the food delivered to the job. R1 gave me approximately $300 over time for my taxicab rides and food. I did not ask R1 for the money or food, R1 offered to help me. Facility's Staff assignment sheet dated 05/08/22, documented V3 was scheduled to work 3PM-11PM on the first floor and 11PM-7AM on the second floor. V3's timecard dated 05/08/22 read; punch in at 2:56 PM and punched on at 12:28 AM. Reviewed R1's progress notes dated: 05/06/22, 05/07/22, 05/09/22, and 5/10/22, no documentation regarding the incident on 05/08/22, nor signs or symptoms of any diarrhea or emesis that R1 was experiencing. On 06/07/22 at 1:29 PM, V8 (Certified Nurse Assistant) stated, V7 [Nurse Supervisor] asked me to go check R1's room to see if R1 was in there. I went to R1's room and saw V3 siting on R1's bed, while R1 was laying in the bed. I told V3 that V7 wanted to talk with them. I told V7 what I saw. On 06/07/22 at 1:40 PM V7 (Nurse Supervisor) stated, V3 worked 3PM-11PM shift and picked up to 11PM-7AM on 05/08/22. Around 12:30 AM, the floor nurse notified me that V3 was not on the assigned floor. I asked V8 (Certified Nurse Assistant) to go look for V3. Little while later, V8 told me that V3 was sitting on R1's bed. I told V3 to punch out, go home and talk to administration in the morning. V3 nor V8 told me that V3 was in R1's room without clothes on. When I saw V3, her uniform was in place and clean. I sent V3 home because, she (V3) was not authorized to be off their assigned floor, and for sitting on a resident's bed. I called V2 (Director of Nursing) and V2 was made aware of the incident. I received abuse training a few times a year. Some types of abuse are sexual, physical, verbal, exploitation and financial. The abuse coordinator is the administrator. On 06/07/22 at 3:10 PM V2 (Director of Nursing) stated, I received a phone call on 05/08/22 around midnight. V7 told me that V8 was making rounds on the unit, and knocked on a door and entered, where V8 observed V3 laying in the bed sleeping. I do not know which room V3 was in, and I did not ask V7. It is not appropriate for staff to be sleep in a bed. If a staff member gets emesis, or bowel movements on their uniform, I expect the staff to get an extra uniform from administration or they will be allowed to go home to clean up and change their uniform. Staff should not accept any money, gifts, or food from residents, that would be considered abuse. I completed an investigation regarding V3 sleeping in a bed. I made mental notes in my mind, I do not have an investigation on paper, because I did not write anything down. I was not made aware of any sexual or financial abuse allegations regarding R1 and V3. I will start an investigation today. On 06/07/22 at 3:40 PM, V1 (Administrator) stated, I interviewed R1, R1 said he called the state, because V3 stop taking his phone calls. R1 did not tell anyone about the sexual encounters between R1 and V3. R1 also said he gave V3 money for food and taxicab services. That was all the questions I asked R1, I did not want to [NAME] R1 with questions today, I have 5 days to investigate. It was not appropriate for V3 to be in R1's room at midnight (since V3 was not assigned to R1), nor for V3 to accept money from R1 if the allegations are true. On 06/09/22 at 10:15 AM, R1 reported to surveyor, not to turn in the statement from 06/07/22, R1 stated, I spoke with V3 and do not want V3 to lose her children. V3 has a child in the system, and V3 is afraid that my statement can hurt the chances of getting her child back out of the system. I enjoyed having those sexual encounters, V3 did not make me do it. I gave V3 all that money, V3 did not ask me for the money. On 06/09/22 at 3:30 PM V6 (Director of Social Service) stated, I spoke with R1 on 06/07/22, to obtain a statement. R1 said, the sexual encounters were consensual and R1 was not violated, in fact R1 said they enjoyed it. R1 said on 05/08/22, V8 caught V3 lying in R1's bed, and they both R1 and V3 was naked. Also, that from March 2022, R1 gave V3 cash money to pay for V3 taxicab service to and from work, and purchased food through R1's cash app. On 06/21/22 surveyor returned to the facility and follow up interviews were obtained. 0n 06/21/22 at 10:54 AM, V1 (Administrator) stated, After I was notified of the allegations on 06/07/22, I called V3 (CNA) a few times, but I could not make contact. I spoke to V7 between 06/07/22-06/08/22. V7 told me he [V7] sent V3 home because she was insubordinate being off her [V3] assigned floor and was sleeping in a resident's bed on the fourth floor. I did not ask V7 who's bed V3 was in. I should have asked, but I did not. I took a basic interview from R1 on 06/07/22. R1 said he was in a relationship with V3 and he [R1] was giving V3 cash for cab fees and sending money through a cash app to pay for food deliveries. R1 said he did engage in oral sex with V3 and did not report it because he[R1] enjoyed it. On 06/09/22 R1 told me that V3 stopped taking his[R1] phone calls and that is what made him mad and phoned the state. Later R1 said he realized V3 did not work here anymore in the facility and that he [R1] did not want to pursue with the complaint, because he does not want to get V3 in trouble. I do not have V7 or V8 written statements. After I was informed about the allegations of abuse, all staff abuse education training was completed. Along with the types of abuse, how, when and who to report abuse to. The policies regarding abuse and employee conduct are documented in the facility abuse policy, resident's rights, and the employee handbook. I believe the employee handbook talks about staff should not accept gifts or money for residents. The resident's rights policy talk about residents should not be sexually exploited. The abuse policy speaks to different types of abuse and what exploitation is. New employee orientation for V3 and for all new staff, receives abuse training first day of orientation and they receive the employee handbook the same day. In regard to R1's allegation final reportable sent, I believe the allegations was unsubstantiated, because R1 engaged in oral sex voluntary and R1 did not feel abused or exploited. R1 called in a complaint to the IDPH, in retaliation for V3 not returning his [R1] phone calls. On 06/21/22 at 11:05 AM, surveyor and V1 observed the final incident investigation report faxed into IDPH on 06/10/22 documents in part: Upon further investigation of this matter, staff reports that on 05/09/22 on 3rd shift (approximately 1am), V3 was observed unclothed and sitting on R1's bed. When asked why she [V3] was there [V3 was not assigned to this unit] V3 response was he [R1] called me and asked for help. V3 further stated that R1 vomited and pooped all over her [V3] and that is why she [V3] removed some of her clothing. V3 and R1 was informed that V3 should not be in R1's room, sitting on the bed and was asked to leave R1's room. The supervisor [V7] on duty asked V3 to punch out and go home. V1 stated, I got this information on the final reportable from V7 and V8 mixed together. I did not write down V7 or V8's statement. On 06/21/22 at 11:39 AM, V2[Director of Nursing] stated, On 05/08/22 after midnight I received a phone call from V7 [Nurse Supervisor] said that he sent V3[Certified Nurse Assistant] home due her missing off her assigned unit and she was found on the fourth floor in one of the resident's rooms. V7 said that V8 [Certified Nurse Assistant] informed him that she [V8] observed V3 in R1's room sitting on R1's bed. V7 sent V3 home because she [V3] was not supposed to be in R1's room and it was inappropriate conduct to be in a resident's room and sitting on R1's bed. I [V2] called V3 on 05/09/22 to meet regarding V3's behavior and proper adequate in a clinical setting and that it was not appropriate to sit on a resident's bed, but V3 did not show up for the meeting. V5[Nurse Scheduler] called V3 on 05/09/22 to meet with me, but V3 did not show up at 10:00 AM. I called V3 and she [V3] said she will come that Tuesday, but she never showed up on 05/10/22. I[V2] was out of the office a few days, upon my return I met with V3 on 05/20/22. V3 said, she [V3] was just assisting R1, but I [V2] explained to V3 it is not appropriate even with helping a resident to sit or use resident's belongings. At that time V3 felt I was making a big deal out of nothing and did not want to discuss the situation any further. V3 never acknowledged she [V3] was sitting on R1's bed, gave her [V3] resignation and left the facility. No investigation was done, I only spoke to the staff members, and nothing came from it. I was only informed V3 was sitting on R1's bed, no reportable was done on 05/08/22, because R1 did not allege abuse. V3 was sent home. When staff is disciplined, normally a write up is done with the reason the staff member was sent home, what the incident was about, and the results of the investigation. An employee discipline investigation is a collaboration between human resources and that employee's manager. On 05/08/22, I did not complete a write up on V3. She [V3] was sent home due to her behavior, being sent home and suspended is the same thing and it is pending investigation if a resident is alleging abuse. V3 was sent home and suspended on 05/08/22, and never returned to the facility to work. Anytime there is a discipline, an investigation and report will follow, and it placed in the staff member's personnel file. On 06/21/22 at 12:17 PM, V2 looked thru V3's personnel file for the discipline documentation from 05/08/22 and she could not find the discipline form in V3's personnel file. V2 stated, A discipline form for V3 is not in her[V3] personnel file. Usually V4[ Human Resource] will complete the discipline form. I Spoke to R1 on 05/09/22 and made R1 aware it is inappropriate for staff to sit on his [R1] bed. R1 did not allege any abuse. I do not have any written statements from V7 or V8. On 06/21/22 at 12:42 PM V4 [Human Resource] stated, If an employee is disciplined or sent home, that employee's supervisor will let me know what happened. When an employee is suspended or disciplined, I get involved to make sure the union and the employee handbook guidelines are followed. Typically, the employee's supervisor investigates the situation and then the final investigation is forward to me, to make sure we are following the rules that are set forth. On Monday 05/09/22 or Tuesday 05/10/22, I was informed by V5 [ Nurse Scheduler] that V3 was sent home for inappropriate behavior and was removed off the schedule. I did not get the specifics from V5 why V3 was sent home and removed off the schedule. V3 kept calling the facility trying to talk to V2 and staff would send the calls to me. I told V3 that V2 was unavailable. On 05/20/22, V3 came in and spoked with V2 regarding her[V3] being in a resident's room and I did not know which room V3 was in. V3 then spoke to me and kept saying she [V3] did nothing wrong. V3 was asking me did she have a job and kept looking at her[V3] cell phone, saying I got to go. V3 said I will just quit, and I told her [V3] to put it in writing. V3 wrote out her resignation letter. I never received any discipline documentation or write up from V3's supervisor [V2] for 05/08/22 discipline. The supervisor completes the discipline paperwork. Since V3 was set home, and removed from the schedule, a discipline form should have been completed by V2. Once V3 was taken off the schedule, there should have been a discipline written by V2 and V3 should have received a copy of the discipline for being taken off the schedule. On 06/21/22 at 1:22 PM V1 (Administrator) stated, Any staff member in a resident's room late at night, sitting on their bed is in appropriate behavior. Yes, we should have reported the incident, and should have investigated and sent a reportable to IDPH. I started working here at this facility on May 23, 2022. There was no administrator on site, the allegation was not clear it was abuse, the story changed and evolved along the way. I was not the administrator 05/8/22, I started to work here on 05/23/22. V11 [Previous Administrator] last day of work was 04/26/22, when V11 left the facility, it was a gap in between. On 06/22/22 at 9:31 AM V7 [Nurse Supervisor] stated, On 05/08/22 around midnight the second-floor nurse called me and said that V3 was missing since the start of the shift at 11PM. I called up the fourth floor and V8 [Certified Nurse Assistant] answered the phone. I asked V8 to go to R1's room and check to see if V3 [Certified Nurse assistant] was in R1's room. I asked V8 to check R1's room because, when V3 is missing off her assignment, she [V3] has the tendency to be in R1's room. Sometime in April 2022, I found V3 in R1's room several times. V3 would be standing in R1's room talking with R1 with the door open. Sometimes when I found V3 in R1's room, V3 and R1 stated he[R1] was ordering food delivery for V3. Other times V3 said she would be in R1's room eating, taking her[V3] lunch break. Each time I would explain to V3 it was not appropriate for her to be in R1's room. That she [V3] needs to be on her assigned floor taking care of those residents. R1's room was not the employees break room, and she [V3] was not allowed to be in R1's for any reason. I did not report the incidents to anyone, because I did not see a reason to report anything, V3 was just visiting with R1. A little while later, V8 called me and said, she [V8] found V3 in R1's room with the door closed and V3 was sitting on R1's bed, while R1 was lying on the bed. V8 said she told V3 to come see me[V7]. V3 told me[V7] that she was in R1's room taking a lunch break eating her food. I explained to V3 that I told her [V3] before not to be in R1's room for any reason. Also, I told V3 she had been missing since 11PM over an hour and her [V3] lunch break is only for 30 minutes. It is not appropriate to be in R1's room taking your lunch break. Then I called V8 down, to repeat what she saw. V8 stated, she found V3 in R1's room with the door closed and V3 was sitting on R1's bed, while R1 was lying on the bed. I asked V8 was V3 eating, and V8 said no, V3 was not eating. V8 went back to her assignment. I told V3 to punch out and leave the facility. Because I have warned her several times in the past to stay out of R1's room, not to leave her[V3] assignment, and it was inappropriate for her[V3] to be sitting on R1's bed. I also told V3 I was going to report the incident to V2, and to follow up with V2 tomorrow. I did not ask V3 if she had on clothes, because I had no reason to think V3 was naked. V3 uniform was clean, and dry. I immediately called V2 and made her aware of the incident. V2 did not asked me to write a statement. A couple of weeks later in May the new administrator, V1 asked me what happened on 05/08/22. I told V1 everything, that happened with V3 and R1. V1 did not ask me to write a statement or sign a statement. I did not hear anything else about 05/08/22 incident with V3 and R1, until you (surveyor) came into the facility 06/07/22. On 06/22/22 at 10:17 AM, During a telephone conversation requesting abuse training information for V7, V1 stated, I told you yesterday that V8 [Certified Nurse Assistant] and V7 [Nurse Supervisor] gave me the information documented on the final investigation report dated 06/10/22 faxed in to IDPH. Documents in part that: [Upon further investigation of this matter, staff reports that on 05/09/22 on 3rd shift approximately 1am, V3 was observed unclothed and sitting on R1's bed. When asked why she was there, she was not assigned to this unit, V3 response was R1 called me and asked for help. She [V3] further stated that he vomited and pooped all over her and this is why she removed some of her clothing]. [V1] stated, I was confused with another reportable, V8 did not tell me any of that information. On 06/22/22 at 10:29 AM V8 [Certified Nurse Assistant] stated, V7 called the nursing station [fourth floor] and asked me to let him [V7] know if I see V3 on the floor and to send her [V3] to see me[V7]. During making rounds, I knocked on R1's door and entered, the main light was off just the night light was on. I saw V3 sitting on R1's bed fully clothed and looked very surprised, while R1 was lying down on the bed covered up. I told V3 that V7 was looking for her [V3] and to go see V7. I went back to the nursing station and called V7, made him [V7] aware that I found V3 in R1's room with the door closed, the main light was off and V3 was sitting on R1's bed, while R1 was lying in the bed. Around 15 minutes later V7 called the nursing station and asked me to come down to speak to him [V7]. I entered the room and V3 and V7 was present. V7 asked me to repeat what I witnessed in R1's room. I said, during making rounds, I knocked on R1's door and entered, the main light was off. I saw V3 sitting on R1's bed fully clothed and looked very surprised, while R1 was lying in the bed covered up. V7 asked me was V3 eating, I said no, V3 was not eating. At that time V7 told me I can go back to my floor. I received abuse training when I was hired 06/2021. Some types of abuse are physical, and sexual. I'm not sure who the abuse coordinator is. If I witness abuse I would report it to my nurse, then maybe the nurse would tell me what to do. R1's Social Service Progress note documents in part 06/07/22 at 16:11(4:11PM): Writer asked R1 has they ever had any relationships with V3 at this facility, R1 stated yes. Writer asked resident has they ever been involved in a sexual relationship with V3, resident stated yes. Writer asked R1 what their sexual relationship was, R1 stated oral sex, I was going down on V3. Writer asked R1 if the relationship with V3 was consensual, R1 stated yes. Writer asked R1 if they felt violated, R1 stated hell no, I did that because I wanted to do. R1 reported that this sexual relationship with R1 and V3 started in March. R1 could not confirm date. R1 reported buying V3 food when V3 needed on cash app card. R1 also reported spending cash money in the amount of approximately $400 in cab service money. Writer asked R1 if they told any other than today, R1 stated no, why would I tell anyone anything. Writer asked R1 if they think they resides a safe environment, R1 stated yes. R1 stated Honestly, I'm going to be honest with you, I called state because V3 blocked my number from V3 phone, and I was mad. R1 admitted to calling IDPH to get back at V3. Writer asked R1 if they wanted to call police, R1 stated no. R1 did not have any additional issues, questions or concerns. Writer provided R1 with emotional support. Writer encouraged R1 to seek staff assistance when needed. Writer encouraged R1 to attend psychosocial groups. Staff to continue to monitor resident accordingly. R1's (06/07/22 at 17:18 (5:18PM) Social Service note documents: Writer met with R1 to discuss interview and to obtain signature for statement that they provided. R1 refused to sign paper as evidenced by saying yeah I called state but I'm not going to sign that because I don't want to incriminate V3 or get V3 in trouble, I just called to get back at V3. I lied about everything, everything I said is a lie now because I don't want to get V3 or their kids in trouble. Writer provided R1 with emotional support. Writer asked R1 was they forced to say this allegation was a lie R1 frowned and said NO I just don't want to get V3 in trouble, nobody is forcing me to do anything. Writer ensured R1 that they reside in a safe environment. Writer to continue to follow-up accordingly. Facility's Abuse Prevention Program Policy(undated) documents in part: -Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. -Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. Facility's Employee Handbook dated (04/2018) documents in part: page 12 Titled: Rules of Conduct and Other Expectation: All employees have an ethical and professional responsibility to support and promote the highest standards of conduct. It is the policy of the facility to comply with all applicable federal, state, local laws and regulations. Every employee will voluntarily assume the obligations of self -discipline, honor, and integrity as set forth by the facility. We will not accept conduct, which limits, restricts or interferes with our ability to respond to the needs of our facility, residents or vendors. The facility has a zero-tolerance policy for abuse and neglect. It is imperative that every employee commit to maintaining the dignity of each resident at all times. -The facility shall take all appropriate actions to ensure that the responsibility of that employee do not affect the quality of care rendered to any patient or resident, or the accuracy of any claims submitted to any Federal or State health care program. Page 13- As part of the compliance and Integrity Commitment, employees must be aware that the acceptance of gifts is strictly prohibited. There are times when residents, resident family members or vendors want to show appreciation by giving gifts or money. It is strictly prohibited to accept any gifts from any resident, resident family member, or vendor. If a resident or family member is insistent on giving a gift, please refer them to the administrator or department head. The surveyor confirmed on 06/28/22 through observation, interview, record review, that the facility took the following actions to remove the Immediate Jeopardy: The facility implemented all measures on the removal plan. [1] R1 received wellness checks daily from 06/24/22 thru 06/27/22 by Social Services. Order dated 06/24/22 Starting on 06/28/22 and the wellness checks will be completed weekly. R1 received abuse training. -R1 was notified that all staff are being educated on all types of abuse and are to avoid engaging with residents on any type of personal level. Completed 06/24/22 -R1 understands that he is to report immediately to Administrator or supervisor on duty if he ever feels abused, neglected or otherwise violated. Completed 06/24/22 -R1 agreed to refrain from offering staff members gifts, money or tokens of appreciation. Completed 06/24/22 -R1 understands that he is not to engage in any type of sexual relations with staff. Completed 06/24/22c -R1 received an order from primary physician to see Psych Services for counseling services. Completed 06/24/22 [2] V3 is no longer works in the facility. Last day of work was 05/08/22. [3] Facility RN's, LPN's, Nursing Managers, Housekeeping staff, Laundry staff, Dietary staff, Social Service staff, Reception staff, and Human Resource staff were educated on Abuse reporting, investigating and prohibition. (Discuss the guidelines and the measures the facility takes to prevent the staff from developing an inappropriate sexual relationship with any resident. Included will be misappropriation. Types of Abuse (Financial, Sexual, Mental, Verbal, Physical, Misappropriation of funds or property and Involuntary seclusion). Additional Staff education including Abuse Fact Sheet and Abuse, Neglect and Exploitation Quiz to be completed by all staff. Staff will not be allowed to work unless they complete the education. This staff education has been initiated as of 6/24/2022 and will continue until all staff receive the education. [4] The facility has a zero-tolerance policy on any form of abuse and once identified staff member will be immediately suspended pending investigation. If found to be substantiated, staff member would be terminated. Completed 06/24/22 [5] Resident interviews will be conducted by department managers to ensure that no other resident has been affected by the same deficient practice. Initiated as of 6/24/2022 - Residents who are unable to be interviewed (vulnerable) will have a Potential for Abuse and Neglect Assessment completed and care planned accordingly. Initiated as of 6/24/2022 [6] The administrator will monitor continued compliance via the following Quality Improvement Programs: - Quality Assurance Tool- Abuse, Neglect and Injury of Unknown Origin Investigation, Reporting and Documentation -Type of Abuse Physical Mental Verbal Sexual (Prevent any staff from developing an inappropriate relationship with any resident). Financial/Theft Neglect Injury of unknown Origin Involuntary Seclusion - Abuse Officer (Administrator or designee) immediately made aware of the allegation and an investigation initiated immediately. Y/N - Date when the Initial Report faxed to IDPH. Provide a copy of the transmission report in the QA Binder. - 3-day wellness checks post incident done and documented in the medical record. (Social Services Department) Y/N- Indicate immediate actions taken to keep the resident(s) safe. - Abuse Assessment completed, and Care Plan updated. (Social Services Department) Y/N - Date when the Final Report faxed to IDPH. (Within 5 days) Provide a copy of the transmission report in the QA Binder.

Based on record review and interviews the facility failed to ensure administration of [CONDITION(S)] medication was documented as given to 1 (R1) out of 3 residents (R1, R2 and R3) reviewed for fall safety. This failure has the potential of contributing the cause of R1's fall due to [CONDITION(S)] on 9/8/21, and as a result R1 sustained a laceration to left side of eyebrow. Findings include: R1 resident in the facility with medical diagnosis of [CONDITION(S)] and Seizures. On 9/23/21 at 11:05 AM. R1 was seen in his room walking and was able to be interviewed upon sitting on his chair. R1 was alert and able to express his needs very well. R1 stated that his fall recently was due to a [CONDITION(S)], and that he has had seizures for a long time. R1 stated that he takes [CONDITION(S)] medication when staff give it to him, but he still has seizures from time to time. R1's fall risk assessments and notes documents R1 had a fall on the following days: On 3/23/21 related to [CONDITION(S)] activity, 4/5/21 related to [CONDITION(S)] activity and 9/8/21 related to [CONDITION(S)] activity. On 9/8/21 R1 suffered left eye wound injury with sutures due to the fall. R1 Medication Administration Record shows that on 9/7/21, two (2) medications [MEDICATION(S)] tablet 1000 MG and [MEDICATION(S)] ([MEDICATION(S)]) Extended Capsule 200 MG for seizures that were scheduled for 9:00 AM were not signed as given. Hospital laboratory result dated 9/8/21 where R1 was sent after the fall reads that [MEDICATION(S)] level was low with result of 6.8 ug / ml (reference level between 10 - 20 ug / ml). Progress noted dated 9/8/2021 10:30 reads: Resident observed lying on left side face down on floor in room. Resident observed in lethargic confused state experiencing [CONDITION(S)] activity, duration 3 min at this time. Upon assessment, laceration noted on left side of eyebrow 3 steri strips applied cleansed with normal saline and dry dressing applied tolerated procedure well. Facility Incident final report sent to Illinois Department of Public Health documents the incident happened on 09/08/21 at 10:30 am says R1 was observed on the floor in a lateral laying position with [CONDITION(S)] like activities [MEDICATION(S)] 3 minutes. Open area noted to left eyebrow. And documents, R1 returned to facility at 17:20 pm with 2 sutures to left eyebrow and subtherapeutic [MEDICATION(S)] level. On 9/24/21 at 11:06 AM V2 (Assistant Director of Nursing) stated he was not aware that R1's [CONDITION(S)] medication was not signed as given because he did not check. And further stated that, when medication is administered it should be signed in the Medication Administration Record as given. V2 also stated that he does not know why R2 [MEDICATION(S)] level was low in the hospital. According to V2 the facility has a Management Risk report that details all fall investigation. And as a policy this report cannot be shared either by looking at it electronically or by printing into a hard copy. Facility also does not give names of staff that are included in the investigation. On 9/24/21 at 12:53 PM V12 (Clinical Nurse Practitioner) stated that R1 has a medical condition of [CONDITION(S)] and currently taking medication for [CONDITION(S)]. And by missing a single dose of two (2) medications ([MEDICATION(S)] tablet 1000 MG and [MEDICATION(S)] ([MEDICATION(S)]) Extended Capsule 200 MG) can be considered as contributory cause of [CONDITION(S)]. R1 having low [MEDICATION(S)] result can cause seizures. When [CONDITION(S)] medication result is low or high compared to its normal values [CONDITION(S)] can occur. Facility Falls Management with review date 6/21 reads: Facility Guidelines following a fall incident: Complete a fall event. This event includes the circumstances surrounding the fall, device in use, full body observation for injury, pain, range of motion and neuro checks as needed. All incident and accident with serious physical injury will be initially reported as required to the Health Department. A final written investigation report is required by the Department of Public Health within seven (7) days of the incident.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred to the appropriate medical asssitive equipment (wheelchair)and supervised. The facility also failed to identify and remove the risk of injury when a resident was transferred to the incorrect medical assistive equipment (wheelchair). This failure resulted in a fall with right lens dislocation, facial bruising and a laceration for 1 resident R92 in a sample of 37. Findings Include: R92 has diagnosis not limited to [CONDITION(S)], Low Back Pain, Dementia, [CONDITION(S)], Major Depressive Disorder, Unspecified Cataract, and [CONDITION(S)]. R92 fell out of a wheelchair on 04/07/21 sustaining facial bruising, and a laceration requiring sutures. R92 was transferred to the emergency room for evaluation/treatment, and returned to the facility 04/08/21 with discharge diagnosis of lens dislocation, and laceration. On 04/13/21 at 10:41 AM R92 was observed sitting in a recliner wheel chair. Bruising was observed to both eyes, right side of face, forehead, bridge of nose and a dark bruised area was observed under the right eye. R92 was observed looking over head with the neck hyperextended. On 04/14/21 at 09:42 AM V3 (Assistant Director of Nursing) ADON stated R92 fell on [DATE]. On 04/13/21 at 10:45 AM V6 (Licensed Practical Nurse) LPN stated R92 had a fall on 04/07/21. She had a laceration to her right eyebrow. On 04/14/21 at 12:36 PM V6 (Licensed Practical Nurse) LPN stated R92 did not have any bruising to the face on 04/05/21. 04/07/21 was the first time that she had fallen since I have been working here. On 04/14/21 at 04:23 PM V7 (Licensed Practical Nurse) LPN stated I did not see any bruising on R92 face on the morning of 04/07/21. She usually sit up in the Broda Chair from hospice and had it the entire time that she was on hospice. I never experience her sitting in a regular wheelchair. On 04/14/21 at 11:13 AM V17 (Licensed Practical Nurse) LPN stated R92 is impulsive, has poor safety awareness and is alert to self. R92 had just gotten discharged from hospice and we were not aware the vendors were here to get the bed that was leased. We was rushing and in a hurry to get the process completed. I do not think anyone was in the room with her when she fell . She was in a regular wheelchair. She did not have bruising to her face prior to the fall. I think one of her roommates may have pulled the call light when she fell . I found her lying face down on the floor. Once we got her up she had a laceration, and we administered first aid to stop the bleeding. On 04/14/21 at 12:33 PM V22 (Psych Social Aide) stated R92 did not have any bruising to her face prior to the fall. When the fall happen they had put her in a regular wheelchair. She had not been in a regular wheelchair. On 04/15/21 at 12:26 PM V30 (Director of Therapy) stated currently R92 ADL's (Activities of Daily Living) are extensive to dependent. She has impaired vision and need help with everything. She is non ambulatory and is not independent with her trunk. Her neck tone is spastic and she is in extension with her head tilted backwards. She has poor trunk control and it is not adequate. I do not think that a wheel chair is appropriate for her. I feel that a reclining wheel chair is appropriate but the Broda chair has more appropriate padding and reclines. If she was in a wheel chair there is more of a potential of her falling. We are unable to reposition the wheel chair and she would require some reclining. She should not be in a wheel chair unattended and someone would need to be next to her so she does not fall out of the wheel chair. On 04/15/21 at 03:26 PM V31 (Restorative Nurse) stated R92 is extensive with hygiene, transfers and feeding. She has [CONDITION(S)] with low vision and can move about in a squirming restless manner. She is in a reclining wheel chair but she was in a broader chair which is padded and comfortable where they can recline the back. When the tech came to get the bed and Broda chair the Certified Nurse Assistant's put her in a wheelchair. She is not capable of sitting in a wheelchair because her trunk is weak. I would not have recommended that she be in a regular wheel chair at any time. R92 had not been in a regular wheel chair in a while. Based on my investigation R92 had bilateral bruising across her eyes and bridge of nose. Based on the note the lens dislocation happen with the fall. They found her on the floor face down. On 04/15/21 at 10:29 AM V32 (Certified Nurse Assistant) stated R92 has behaviors of being confused most of the time and is a little aggressive. She move about in the reclining wheel chair and have been in the reclining wheel chair since she was on hospice. The day she fell hospice came to take the chair and bed. We had to put her in another chair. Everyone was in a rush because they were taking the bed. She fell around 4 pm. She was in her room in the Broda chair. They asked me to transfer her to another chair because they were taking the bed and chair. We transferred her to a normal wheelchair. I had never seen R92 sit in a normal wheel chair. It was in the hallway and we asked the V33 (Second Floor Manager) could we use that chair to transfer R92. V33 said to use that chair because they were going to bring the new bed right away. We put her in that wheel chair because it was available and I asked the nurse. I believe I should have used another reclining wheel chair. That day she was moving a lot and I had to leave the room to get ice water for the other roommate. The Hospice guy came out of the room running and he was the one that told me R92 fell . We got her off of the floor and transfer her to the reclining wheel chair. I do not know where the reclining wheel chair came from. Her bed was not ready yet. There was no bruising to face before she fell . Definitely I would have brought her a reclining wheel chair. On 04/15/21 at 11:18 AM V33 (Registered Nurse/2nd Floor Unit Manager) stated R92 is alert and oriented to self, combative, supervision with feeding and total care. She normally stay in bed and was just discharged from hospice. The supply company said they came for her bed and assistive devices. While I was finishing medication orders the Certified Nurse Assistant said R92 fell . She went in and saw her on the floor. When she became hospice she was in a reclining wheel chair. I assessed the patient, she was face down on the floor, her face was bleeding and I started first aide. She was fighting and combative. The staff was definitely rushed and it was around 4 pm. The rushing could be part of the cause she had fallen. It could have been avoided if we had known they were coming and if we had ample time. It was a big issue. On 04/15/21 at 12:05 PM V34 (Nurse Practitioner) stated R92 was advance dementia. She was having a decline on hospice until the end of March. She was discharged because she is not appropriate at this time. I was called and told she R92 had a fall from the wheel chair. She was face down and had a laceration based on the fall. She went to the emergency department and received sutures to the right side of her head. The CT scan of the head showed her right lens was dislodged. The lens in the eye was not in the right place it had moved. I believe the fall contributed to the dislodging of the lens. She usually use the Broda chair and she is not able to sit up independently and has poor trunk control. It is better for her to be in the reclining wheel chair to decrease the risk of falls. Based on the 2 day frame to follow up with the ophthalmologist that could be something serious with the lens dislodging. On 04/15/21 at 12:58 PM V35 (Ophthalmologist) stated the lens is the part of the eye that does the focusing. It can get displaced and is a major injury depending on how it happen. If there was a follow up for 2 days and they are unable to get an appointment they should be sent to the emergency room . If possible one should not wait until next week to see the ophthalmologist. To be on the safe side she can be seen before next week. That is [MEDICATION(S)] head trauma. If it is a lens dislocation it may need to be relocated, removed and replaced with intraocular surgery. On 04/15/21 at 02:37 PM V37 (Certified Nurse Assistant) C.N.A. stated I was not in the room when R92 fell . I was the one that helped put her in a wheel chair after the fall. They were not able to find the reclining wheel chair so they put her in a regular wheel chair. She need a reclining wheel chair. She has poor trunk control and need to be supervised. I would have put her in a reclining wheel chair. She had no bruising to her face prior to the fall. On 04/15/21 at 04:41 PM V38 (Certified Nurse Assistant) C. N.A. stated R92 has always been total care. She is a little aggressive and will scratch you. V32 (Certified Nurse Assistant) C.N.A. asked me to assist when R92 bed was being switched out. We transferred her to a regular wheelchair. She should have been in a reclining wheelchair but we could not find one on the second floor. We let V33 (Second Floor Unit Manager) know we checked on one side or the hall for a reclining wheel chair and she said there were no reclining wheelchairs, just transfer her to a regular wheelchair since it is going to be a quick transfer. She would always use a reclining wheelchair. R92 had no facial bruising prior to the fall. Record review of Hospice Physician's Orders/Plan of Care from 03/29/21 - 05/27/21 document in part DME (Durable Medical Equipment)/Supplies Bed with bolsters Broda chair for safety. Safety Measures: Fall precautions. Functional: Complete bed bound. Requires Broda chair for mobility. Total assistance with ADL's (Activities of Daily Living) and feeding. C right side. Clinical Update Progress Note document in part Patient received in Geri, poor trunk control and posture noted, head and neck kept tilted towards her back Record review of Hospice documents indicate R92 was discharged from Hospice 03/29/21 related to no longer appropriate, No longer terminal. Record review of Care Plan indicate R92 is a fall risk and is non-compliant with fall precautions, gets out of chair and bed without staff assistance, potentially resulting in injury and has impaired vision related to [CONDITION(S)] date initiated 07/31/20. Interdisciplinary Resident Screen dated 01/29/21 indicate Dependent with Broda chair, non-ambulatory. Record Review of Progress Note dated 04/07/21 document in part staff responded to room's call light. Noted resident on floor lying face down. Upon observation, noted with laceration with scant of amount of bleeding to face and bruising/[CONDITION(S)] to nasal septum. Pressure dressing applied to laceration. Record Review of Progress Note dated 04/08/21 document in part Patient seen and examined. Follow up post fall was sent out for imaging, and evaluation due to extensive evidence of head trauma related to fall. Facial laceration sutured and recommended for follow up with ophthalmologist for lens dislocation. Skin- extensive facial bruising, orbital swelling, laceration approximated with sutures. Accidental fall from wheelchair - patient sent out to ED (Emergency Department) for imaging, and evaluation due to extensive evidence of facial trauma related to fall. Record review of hospital records dated 04/07/21 document in part R92 Procedures Performed: Simple repair, superficial wounds, Face/Ears/Eyelids/Nose/Lips/ Mucous Membranes; 2.5 CM or less Laceration-Single repair. Hospital CT Brain without Contrast Clinical indication status post fall at Nursing Home Bruising to forehead, orbits, nose. There is a scalp hematoma over the right frontal bone. The lens of the right eye has been dislodged and is in the dependent portion of the right eyeball. Final Diagnosis: Lens Dislocation Additional Diagnosis: Laceration Policy: Abuse Prevention Program dated 02/07/17 document the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Neglect means failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish.

Based on interview and record review the facility failed to notify and consult with the physician regarding self-injurious behavior of one of three residents (R12) reviewed with tracheostomies, in a sample of 12. This failure resulted in R12 not being transferred to the hospital when he was exhibiting self-injurious behaviors, R12 removing his [MEDICAL CONDITION] and being found unresponsive by staff with subsequent transport to the hospital where R12 died . Findings include R12 was admitted on [DATE] from a local hospital with [DIAGNOSES REDACTED]. R12 was [AGE] years old. R12 was discharged on [DATE] to a local hospital and expired on [DATE] at the hospital. Nurse's Notes dated [DATE] (,[DATE]) indicate R12 mitts on but [MEDICAL CONDITION] (trach) out, put back in. Staff notified R12's physician and received orders for psychiatric evaluation, mitts to both hands and if R12 [MEDICAL CONDITION] to send to a local hospital emergency room . On [DATE] at approximately 3:30pm E13, Licensed Practical Nurse/LPN stated "R12 was constantly taking [MEDICAL CONDITION] out, taking his oxygen off, and removing his mitt restraints. R12 could get them off very quickly (E13 snapped her fingers to indicate how quickly R12 could remove his restraints). I notified R12's physician however I did forget to put it on the 24 hour report sheet. I did report it to the oncoming nurse. " E13 also stated that on [DATE], the day that she spoke to R12's physician, he wanted R12 sent out to the hospital if R12 pulled out [MEDICAL CONDITION] again for a psychiatric evaluation because of R12's continued behavior of attempting to pull [MEDICAL CONDITION]. POS dated [DATE] indicates Mitts to both hands, if resident [MEDICAL CONDITION] send to local hospital ER. On [DATE] at 11:40am E2, Director of Nursing/DON stated she had no knowledge that R12 was supposed to be transferred out if he pulled [MEDICAL CONDITION] again. E2 stated the order should've been placed on the 24 hour report and verbally passed to herself, the Assistant Director of Nursing/ADON and the unit manager. E2 went on to state "there has been an identified issue with communication with the nurses, myself and managers." On [DATE] at 12:15pm E11, ADON stated "I only received information once that R12 had pulled out [MEDICAL CONDITION]. I thought it was a one-time incident. I didn't know about the order to send R12 to the hospital if he pulled his tube." On [DATE] at 4:30pm E14, LPN/Supervisor stated "I was not aware of the order to send R12 to the hospital, but I did hear from other staff around [DATE] that R12 was still pulling [MEDICAL CONDITION]." On [DATE] at 1:20pm via phone Z2, Physician stated "Technically the staff is supposed to call me every time a resident pulls out their [MEDICAL CONDITION]. If I were notified I would send the resident out at the first hint of instability. Medically, a person can only last about a half hour without [MEDICAL CONDITION] and then they're in trouble, and if R12 was continuing to take out his tube he also would need a psychiatric evaluation. I think this resident knew what he was doing. He had been doing it for a long time. If mitt restraints aren't working he would need 24 hour sitter to prevent resident from pulling the tube or be sent out of the facility." R12 was not sent out to the hospital per physician's order [REDACTED]. On [DATE] at 4:05pm E2, DON stated (via telephone interview) "We don't have any policy regarding following physicians orders. It's understood that when a physician's order [REDACTED]."

Based on interview and record review the facility neglected to assess for self-harm, to adequately assess and monitor restraint usage, to follow physicians orders and to monitor and provide adequate supervision for one (R12) of three residents reviewed with a [MEDICAL CONDITION]. This failure and neglect resulted in R12 removing his mitt restraints resulting in the self-injurious action of pulling his [MEDICAL CONDITION] out, being found unresponsive by staff and transport to the hospital where R12 died . Findings include: R12 was admitted on [DATE] from a local hospital with [DIAGNOSES REDACTED]. R12 was [AGE] years old. R12 was discharged on [DATE] to a local hospital and expired on [DATE] at the hospital. Nursing Admission and Assessment Sheet dated [DATE] indicates Other Chronic Illness as Suicidal Ideation and Psychosocial/ Restraints used: hand restraints with Reason: history of suicidal ideation. Assessment indicates R12 was alert and oriented to person, place and time. Nurse's Notes dated [DATE] at 6:30pm indicate R12 had soft hand mitten restraints. Physicians Order Sheet/POS dated [DATE] indicate soft hand restraints bilateral were ordered on admission. Also ordered on admission POS were [MEDICAL CONDITION] care, size and continuous oxygen via [MEDICAL CONDITION]. On [DATE] at 4:30pm E14, Licensed Practical Nurse/PM shift Supervisor stated he admitted R12 on [DATE] and was unsure if he took a phone report from the hospital or if the admit report was previously written on R12. E14 further stated he had received no other specifics regarding the [DIAGNOSES REDACTED]. R12 yet and I was being cautious due to R12 requiring bilateral mitts to prevent him from pulling out his [MEDICAL CONDITION] (trach) tube." E14 stated at that time that he did not include the bilateral mitt restraints or R12's documented behavior of pulling [MEDICAL CONDITION] out on R12's Initial Care Plan as he didn't believe it was "an active problem" despite R12 being received at the facility with bilateral mitt restraints and an admission physicians order to continue restraints at the facility. On [DATE] at 1pm E2, Director of Nursing/DON stated " The mitt restraints and the behavior requiring the restraints should've been on the initial care plan. The initial care plan should be reviewed by each department within ,[DATE] hours of admit and updated as necessary." The initial care plan for R12 completed on [DATE] by E14 did not contain the problem mitt restraints or the behavior R12 exhibited requiring the use of the restraints. Hospital referral records dated [DATE] indicate History of Present Illness: R12 was transferred from another hospital where he was admitted with a dislodged [MEDICAL CONDITION]/status [REDACTED]. Hospital referral records dated [DATE] indicate Restraints: Non-emergent restraint: Hand mitten restraint and monitoring, bilateral hands. On [DATE] at 1:00pm E2, DON stated "The facility's expectation when reviewing the admissions referral is to go through every page and every line and to place all pertinent information on top of the referral so everyone is aware. We don't like to take residents from the hospital with restraints. We would have asked the hospital not to send the resident with restraints without a trial of any restraints for ,[DATE] hours." Social Service Progress Notes/Admission Note dated [DATE] (4 days after R12 was admitted ), indicates R12 has attempted to remove tubes multiple times since admission. On [DATE] at 12:50pm E16, Psych Rehabilitation Services Coordinator/PRSC stated "Today is the first I saw R12's admission records. It wasn't presented to me when he was admitted and I didn't see it, but I am ultimately responsible for reviewing it on admission. It would have triggered a self-harm assessment given R12's history." E16 also stated she did not complete some of the initial assessments on R12 due to his inability to speak and was waiting to talk with his family. E16 stated she spoke with R12's family member on [DATE] and documented that conversation in a progress note however did not request information to complete assessments or discuss R12's behavior of [MEDICAL CONDITION]. On [DATE] E16 further stated that on [DATE] a nurse (unable to recall staff's name), let her know about R12's attempts to remove his [MEDICAL CONDITION] and that it was becoming a behavior. E16 went on to state that she even went into R12's room and R12 was in the process of attempting to remove a mitt on one hand with his teeth and then attempted to remove the other mitt with his free hand. E16 stated that she and the nurse discussed the repeated behavior of R12 removing his mittens and attempting to pull [MEDICAL CONDITION]. E16 went on to state " I told the nurse the only thing I could imagine was to have someone with him all the time to stop him from doing it. The nurse agreed. I thought nursing was handling it after that." On [DATE] at 10:40am E17 Assistant Social Services Director stated "E16 got a report from a nurse that R12 pulled or attempted to pull [MEDICAL CONDITION] and I asked her if she let the nurse know and E16 stated 'yes the nurse was aware.' I told E16 to be sure to care plan it." E17 went on to state that the expectation would be to make a note, document the discussion and observation of residents behavior in the chart. That would have been the action that needed to take place to communicate concerns." No documentation was found or presented to indicate E16's observations and/or conversations with staff were documented or communicated verbally to other staff. R12's care plan did not include revisions, updates or a plan to address R12's behavior of removing mitten restraints or attempts to pull [MEDICAL CONDITION] by nursing or social services. On [DATE] at 10:21 E7 Psych Rehabilitation Services Director/PRSD stated "A Self Harm/Suicide Risk Assessment should've been done for this resident (R12) due to the triggers. E16 should have reviewed the hospital transfer records prior to interviewing the resident. E16 never spoke to me regarding R12 or his behaviors." On [DATE] at 1:00pm E2 DON stated "I agree initial investigation into R12's history of suicide attempt and suicide ideation and his behaviors and restraints should have been done." Facility policy Screening for Evaluating Self-Harm/Suicide Risk Protocol/Assessment Objective indicates: It is the facilities policy to assess, evaluate and investigate statements voiced by residents or otherwise communicated (via behavior symptoms) that may be threatening to themselves or others and pose a risk to safety. The facility will provide appropriate follow-up interventions based upon the individual ' s needs. Procedure: It is advisable to screen new admissions using this tool, especially when: B. There is a history of self-directed aggression. E. The person is an older adult who has experienced multiple personal and physical losses/multiple medical issues. Nurse's Notes dated [DATE],7am indicates R12 was received awake with right soft mitten to hand, trying to pull on [MEDICAL CONDITION] collar. Resident reminded not to pull tubing. Nurse's Notes dated [DATE],7pm indicates while staff was 'rounding' observed R12 [MEDICAL CONDITION] cannula, staff reinserted tube. Staff reeducated importance of not removing tube. Nurse's Notes dated [DATE],9pm indicates while staff 'rounding' staff observed R12 [MEDICAL CONDITION] in hand. New inner cannula inserted will continue to monitor. Nurse's Notes dated [DATE] (,[DATE]) indicate R12 mitts on [MEDICAL CONDITION], put back in. Staff notified R12's physician and received orders for psychiatric evaluation, mitts to both hands and if R12 [MEDICAL CONDITION] to send to a local hospital emergency room . Nurse's Notes dated [DATE], 12:30am indicates R12 pulling out trach, reinserted, mittens in place.' Resident biting Velcro ties and remove mitten left hand and pull trach.' Staff explained to resident he will become short of breath if he [MEDICAL CONDITION] out and told R12 he would have to go to the hospital. Note indicates R12 communicated "No hospital" with staff ' closely monitoring with Certified Nursing Assistant/CNA provided.' Nurse's Notes dated [DATE],7am indicates 'Please monitor resident. Resident try (tries) to pull out trach. Mittens to hand bilaterally." Nurse's Notes dated [DATE],3pm indicates R12 'occasionally tries to pull trach, monitored frequently and re-directed. Nurse's Notes dated [DATE], 12(noon) indicates 'R12 requires constant redirection to stop pulling out trach. R12 also removes bilateral hand mitts with his teeth. Resident redirected and monitored closely at all times. Nurse's Notes dated [DATE], 9:40pm "Upon rounding writer observed residents mittens on floor [MEDICAL CONDITION] between legs. R12 was unresponsive, code blue called and Cardio [MEDICAL CONDITION] Resuscitation initiated. R12 left the facility at 10:10pm with Emergency Services transport. Notes further indicate R12 was transferred to the Intensive Care Unit at a local hospital and was admitted with [DIAGNOSES REDACTED]. Admit/Discharge Report dated [DATE] to [DATE] indicates R12 expired at the local hospital on [DATE]. On [DATE] at approximately 3:30pm E13, Licensed Practical Nurse/LPN stated "R12 was constantly taking [MEDICAL CONDITION] out, taking his oxygen off and taking his mitt restraints off. He could get them off very quickly (E13 snapped her fingers to indicate how quickly R12 could remove his restraints). I notified R12's physician however I did forget to put it on the 24 hour report sheet. I did report it to the oncoming nurse. " E13 also stated that on the day [DATE] that she spoke to R12's physician, he wanted R12 sent out to the hospital if R12 pulled out [MEDICAL CONDITION] again for a psychiatric evaluation because of R12's continued behavior of attempting to pull [MEDICAL CONDITION]. POS dated [DATE] indicates Mitts to both hands, if resident [MEDICAL CONDITION] send to local hospital ER. On [DATE] at 11:40am E2, DON stated she had no knowledge that R12 was supposed to be transferred out if he pulled [MEDICAL CONDITION] again. E2 stated the order should've been placed on the 24 hour report and verbally passed to herself, the ADON and the unit manager. E2 went on to state "there has been an identified issue with communication with the nurses, myself and managers." On [DATE] at 12:15pm E11 ADON stated "I only received information once that R12 had pulled out [MEDICAL CONDITION]. I thought it was a one-time incident. I didn't know about the order to send R12 to the hospital if he pulled his tube." On [DATE] at 4:30pm E14 LPN/Supervisor stated "I was not aware of the order to send R12 to the hospital, but I did hear from other staff around [DATE] that R12 was still pulling [MEDICAL CONDITION]." R12 was not sent out to the hospital per physician's order [REDACTED]. On [DATE] at 4:05pm E2 DON stated (via telephone interview) "We don't have any policy regarding following physicians orders. It's understood that when a physician's order [REDACTED]." On [DATE] at 11:45am E2 DON stated "Staff was to monitor R12 more frequently than every 2 hours - but no specific time was designated." On [DATE] at 9:40am E2 stated "We don't have any close monitoring policy. If something happens and a resident needs special precautions or monitoring then it gets passed on in the 24 hour shift report and care planned." On [DATE] at 2:00pm E2 stated that in general the supervisor of the shift makes rounds and a directive for special monitoring gets determined shift to shift. E2 went on to state that there is no specific documentation other than an hourly monitoring sheet that the CNA's could use but those sheets are just a worksheet and are not kept unless there is an incident that occurs on a shift and then the sheet is reviewed at the end of the shift. E2 also stated "We were never able to locate any hourly or special monitoring sheet for R12 for the incident that occurred on [DATE]. Each time R12 was removing or attempting to remove [MEDICAL CONDITION] new goals and approaches should have been added. Usually once it's identified on the care plan an hourly monitoring sheet gets generated." On [DATE] at 3:00pm E12 Licensed Practical Nurse/LPN stated "The supervisors put 30 minute checks in place for R12. That's what we were doing, sometimes even more frequent. I don't know if the CNA was documenting the checks. The last rounds were done at 9:00pm for R12. I made the next rounds and saw R12's mitts on the floor at each side of R12's bed and [MEDICAL CONDITION] R12's legs. R12 was unresponsive to shaking and rubbing. I put [MEDICAL CONDITION] in and started CPR." On [DATE] at 4:40pm E14 LPN/Supervisor stated "R12 was on hourly monitoring, the 24 hour report indicates R12 was on hourly monitoring. " On [DATE] at 3:10pm E18, Certified Nursing Assistant/CNA stated she was assigned to R12 only once and that R12 had standard monitoring of every 2 hours - no special monitoring or precautions. On [DATE] at 5:20pm E19, CNA stated "I was told by the nurse that R12 was on 30 minute checks the night R12 coded. I thought the CNA assigned to R12 was doing an hourly monitoring sheet. I checked on R12 for the nurse at 9pm on that night because she was busy. The nurse seemed very worried and cautious about R12 pulling out [MEDICAL CONDITION]. R12 was lying in bed at 9pm watching television. R12 made eye contact with me and I left the room. Shortly later I heard the code called to R12's room." O[DATE] at 3:45pm E20 CNA stated she was assigned to R12 only once on the night of [DATE], the night R12 coded. E20 stated she was unaware that night that R12 had a behavior of taking off his mitts or pulling [MEDICAL CONDITION] out and that R12 did not make any previous attempts that night prior to pulling out [MEDICAL CONDITION] after 9pm. E20 recalled R12 getting checked on by staff every 30 minutes to 1 hour however could not recall if R12 had an hourly monitoring sheet that night. E20 also stated she received no formal report from the previous shift CNA regarding R12's care needs. 24 Hour Report [DATE] indicates ,[DATE] shift note: monitor R12, keeps taking out the mask and playing with the trach, check on R12 often ,[DATE] shift notes: monitor for behavior, [MEDICAL CONDITION] today; will remove mittens. Needs continuous monitoring 24 Hour Report [DATE] [MEDICAL CONDITION] place, please monitor, R12 has pulled [MEDICAL CONDITION] two occasions, mittens were placed on hands, needs continuous monitoring. None of the 24Hour reports reviewed dated [DATE] thru [DATE] indicate hourly,30 minute monitoring or any type of scheduled monitoring in place for R12, only that R12 required continuous monitoring due to his behavior. There is no documentation to support any type or frequency of monitoring for R12. On [DATE] at 1:20pm via phone Z2, Physician stated "Technically the staff members are supposed to call me every time a resident pulls out their [MEDICAL CONDITION]. If I were notified I would send the resident out at the first hint of instability. Medically, a person can only last about a half hour without [MEDICAL CONDITION] and then they're in trouble, and if R12 was continuing to take out his tube he also would need a psychiatric evaluation. I think this resident knew what he was doing. He had been doing it for a long time. If mitt restraints aren't working he would need 24 hour sitter to prevent resident from pulling the tube." ON [DATE] at 1:50pm E21, Licensed Practical Nurse/LPN/ Falls and Restraint Nurse stated "It's unusual for a resident to come in with a restraint. I try to get assessment done within 24 - 72 hours of admission. I don't remember anyone telling me R12 could remove the mitts. I would have done a reassessment if I were told that R12 was removing the mitts." Physical Restraint assessment dated [DATE] (4 days after R12 was admitted ) for R12 indicates no other alternatives were attempted and resident currently was removing oxygen and removing trach. Facility Policy: Facility Procedure for the Use of Physical Restraints (undated) indicates: Prior to the implementation of a physical restraint, the facility must: 1. Complete an assessment of the resident's overall needs 2. Complete the 4-page Physical Restraint RAP Assessment of the resident's need for physical restraints and possible less restrictive alternatives. Facility Policy: Facility Procedure For The Use of Physical Restraints: Exceptions for Emergency Situations I. Identification of Emergency After less restrictive interventions to prevent the resident from doing serious harm have been proven ineffective, determine the need for an emergency physical restraint. This determination may be made by a nurse. On [DATE] at 3:10pm E2 DON stated "Yes, it would be considered an emergency if a resident pulled [MEDICAL CONDITION] out."

Based on interview and record review the facility failed to assess for self-harm, to adequately monitor restraint usage, and to monitor and provide adequate supervision for one of three residents (R12) reviewed with a tracheostomy, in a sample of 12. The failure resulted in R12 removing his tracheostomy tube and being found unresponsive by staff with subsequent transport to the hospital where R12 died . Findings include: R12 was admitted on [DATE] from a local hospital with [DIAGNOSES REDACTED]. R12 was [AGE] years old. R12 was discharged on [DATE] to a local hospital and expired on [DATE] at the hospital. Nursing Admission and Assessment Sheet dated [DATE] indicates Other Chronic Illness as Suicidal Ideation and Psychosocial/ Restraints used: hand restraints with Reason: history of suicidal ideation. Assessment indicates R12 was alert and oriented to person, place and time. Nurse's Notes dated [DATE] at 6:30pm indicates R12 had soft hand mitten restraints. Physicians Order Sheet/POS dated [DATE] indicate soft hand restraints bilateral were ordered on admission. Also ordered on admission POS were Tracheostomy care, size and continuous oxygen via tracheostomy tube. 1. On [DATE] at 4:30pm E14, Licensed Practical Nurse/PM shift Supervisor stated he admitted R12 on [DATE] and was unsure if he took a phone report from the hospital or if the admit report was previously written on R12. E14 further stated he had received no other specifics regarding the [DIAGNOSES REDACTED]. R12 yet and I was being cautious due to R12 requiring bilateral mitts to prevent him from pulling out his tracheostomy (trach) tube." E14 stated at that time that he did not include the bilateral mitt restraints or R12's documented behavior of pulling his trach tube out on R12's Initial Care Plan as he didn't believe it was "an active problem" despite R12 being received at the facility with bilateral mitt restraints and an admission physicians order to continue restraints at the facility. On [DATE] at 1pm E2, Director of Nursing/DON stated " The mitt restraints and the behavior requiring the restraints should've been on the initial care plan. The initial care plan should be reviewed by each department within ,[DATE] hours of admit and updated as necessary." The initial care plan for R12 completed on [DATE] by E14 did not contain the problem mitt restraints or the behavior R12 exhibited requiring the use of the restraints. On [DATE] at 10:00 am E15; Admissions Director stated " Before a resident is admitted , the initial referral gets a clinical review by nursing." On [DATE] at 12:15pm E11, Assistant Director of Nursing ADON stated "I reviewed the referral for R12 before he was admitted to the facility. We review the information to make sure we're medically equipped to take care of the resident. We generally look at [DIAGNOSES REDACTED]. that he was coming with restraints. I do remember reading something about R12 trying to pull his trach tube out." E11 went on to state that usually if a resident still has restraints on in the hospital, we have the hospital do a 24 hour trial without the restraints prior to coming to the facility. E11 further stated " I really don't remember seeing the restraints for R12 when I reviewed the referral. I would have put some sort of provision in place if I knew he was coming with restraints. I wasn't aware of the mitt restraints until a couple of days after R12 was admitted ." Nursing Admission Alert for R12 dated ,[DATE] indicates E11's signature and "OK"and that facility received the admission referral information via facsimile on [DATE]. Hospital referral records dated [DATE] indicate History of Present Illness: R12 was transferred from another hospital where he was admitted with a dislodged tracheostomy tube/status [REDACTED]. Hospital referral records dated [DATE] indicate Restraints: Non-emergent restraint: Hand mitten restraint and monitoring, bilateral hands. On [DATE] at 1:00pm E2, DON stated "The facility's expectation when reviewing the admissions referral is to go through every page and every line and to place all pertinent information on top of the referral so everyone is aware. We don't like to take residents from the hospital with restraints. We would have asked the hospital not to send the resident with restraints without a trial of any restraints for ,[DATE] hours." 2. Social Service Progress Notes/Admission Note dated [DATE] (4 days after R12 was admitted ), indicates R12 has attempted to remove tubes multiple times since admission. On [DATE] at 12:50pm E16, Psych Rehabilitation Services Coordinator/PRSC stated "Today is the first I saw R12's admission records. It wasn't presented to me when he was admitted and I didn't see it, but I am ultimately responsible for reviewing it on admission. It would have triggered a self-harm assessment given R12's history." E16 also stated she did not complete some of the initial assessments on R12 due to his inability to speak and was waiting to talk with his family. E16 stated she spoke with R12's family member on [DATE] and documented that conversation in a progress note however did not request information to complete assessments or discuss R12's behavior of pulling trach tube. On [DATE] E16 further stated that on [DATE] a nurse (unable to recall staff's name), let her know about R12's attempts to remove his tracheostomy tube and that it was becoming a behavior. E16 went on to state that she even went into R12's room and R12 was in the process of attempting to remove a mitt on one hand with his teeth and then attempted to remove the other mitt with his free hand. E16 stated that she and the nurse discussed the repeated behavior of R12 removing his mittens and attempting to pull his trach tube. E16 went on to state " I told the nurse the only thing I could imagine was to have someone with him all the time to stop him from doing it. The nurse agreed. I thought nursing was handling it after that." On [DATE] at 10:40am E17 Assistant Social Services Director stated "E16 got a report from a nurse that R12 pulled or attempted to pull his trach tube and I asked her if she let the nurse know and E16 stated 'yes the nurse was aware.' I told E16 to be sure to care plan it." E17 went on to state that the expectation would be to make a note, document the discussion and observation of residents behavior in the chart. That would have been the action that needed to take place to communicate concerns." No documentation was found or presented to indicate E16's observations and/or conversations with staff were documented or communicated verbally to other staff. R12's care plan did not include revisions, updates or a plan to address R12's behavior of removing mitten restraints or attempts to pull his trach tube by nursing or social services. On [DATE] at 10:21 E7 Psych Rehabilitation Services Director/PRSD stated "A Self Harm/Suicide Risk Assessment should've been done for this resident (R12) due to the triggers. E16 should have reviewed the hospital transfer records prior to interviewing the resident. E16 never spoke to me regarding R12 or his behaviors." On [DATE] at 1:00pm E2 DON stated "I agree initial investigation into R12's history of suicide attempt and suicide ideation and his behaviors and restraints should have been done." Facility policy Screening For Evaluating Self-Harm/Suicide Risk Protocol/Assessment Objective indicates: It is the facilities policy to assess, evaluate and investigate statements voiced by residents or otherwise communicated (via behavior symptoms) that may be threatening to themselves or others and pose a risk to safety. The facility will provide appropriate follow-up interventions based upon the individual ' s needs. Procedure: It is advisable to screen new admissions using this tool, especially when: B. There is a history of self-directed aggression. E. The person is an older adult who has experienced multiple personal and physical losses/multiple medical issues. 3. Nurse's Notes dated [DATE],7am indicate R12 was received awake with right soft mitten to hand, trying to pull on tracheostomy collar. Resident reminded not to pull tubing. Nurse's Notes dated [DATE],7pm indicate while staff were 'rounding' observed R12 removed trach inner cannula, staff reinserted tube. Staff reeducated importance of not removing tube. Nurse's Notes dated [DATE],9pm indicate while staff 'rounding' staff observed R12 holding trach tube in hand. New inner cannula inserted will continue to monitor. Nurse's Notes dated [DATE] (,[DATE]) indicates R12 mitts on but trach out, put back in. Staff notified R12's physician and received orders for psychiatric evaluation, mitts to both hands and if R12 pulls trach again to send to a local hospital emergency room . Nurse's Notes dated [DATE], 12:30am indicates R12 pulling out trach, reinserted, mittens in place.' Resident biting Velcro tie and remove mitten left hand and pull trach.' Staff explained to resident he will become short of breath if he pulls trach tube out and told R12 he would have to go to the hospital. Note indicates R12 communicated "No hospital" with staff ' closely monitoring with Certified Nursing Assistant/CNA provided.' Nurse's Notes dated [DATE],7am indicates 'Please monitor resident. Resident try to pull out trach. Mittens to hand bilaterally.' Nurse's Notes dated [DATE],3pm indicates R12 'occasionally tries to pull trach, monitored frequently and re-directed. Nurse's Notes dated [DATE], 12(noon) indicates 'R12 requires constant redirection to stop pulling out trach. R12 also removes bilateral hand mitts with his teeth. Resident redirected and monitored closely at all times. Nurse's Notes dated [DATE], 9:40pm "Upon rounding writer observed residents mittens on floor and trach noted between legs. R12 was unresponsive, code blue called and Cardio Pulmonary Resuscitation initiated. R12 left the facility at 10:10pm with Emergency Services transport. Notes further indicate R12 was transferred to the Intensive Care Unit at a local hospital and was admitted with [DIAGNOSES REDACTED]. Admit/Discharge Report dated [DATE] to [DATE] indicates R12 expired at the local hospital on [DATE]. , taking his oxygen off and taking his mitt restraints off. He On [DATE] at approximately 3:30pm E13, Licensed Practical Nurse/LPN stated "R12 was constantly taking his trach tube out could get them off very quickly (E13 snapped her fingers to indicate how quickly R12 could remove his restraints). I notified R12's physician however I did forget to put it on the 24 hour report sheet. I did report it to the oncoming nurse. " E13 also stated that on the day [DATE] that she spoke to R12's physician, he wanted R12 sent out to the hospital if R12 pulled out his trach tube again for a psychiatric evaluation because of R12's continued behavior of attempting to pull his trach tube. POS dated [DATE] indicates Mitts to both hands, If resident removes trach tube send to local hospital ER. On [DATE] at 11:40am E2, DON stated she had no knowledge that R12 was supposed to be transferred out if he pulled his trach tube again. E2 stated the order should've been placed on the 24 hour report and verbally passed to herself, the ADON and the unit manager. E2 went on to state "there has been an identified issue with communication with the nurses, myself and managers." On [DATE] at 12:15pm E11 ADON stated "I only received information once that R12 had pulled out his trach tube. I thought it was a one-time incident. I didn't know about the order to send R12 to the hospital if he pulled his tube." On [DATE] at 4:30pm E14 LPN/Supervisor stated "I was not aware of the order to send R12 to the hospital, but I did hear from other staff around [DATE] that R12 was still pulling his trach tube." R12 was not sent out to the hospital per physician's order [REDACTED]. On [DATE] at 4:05pm E2 DON stated (via telephone interview) "We don't have any policy regarding following physicians orders. It's understood that when a physician's order [REDACTED]." 4. On [DATE] at 11:45am E2 DON stated "Staff were to monitor R12 more frequently than every 2 hours - but no specific time was designated." On [DATE] at 9:40am E2 stated "We don't have any close monitoring policy. If something happens and a resident needs special precautions or monitoring then it gets passed on in the 24 hour shift report and care planned." On [DATE] at 2:00pm E2 stated that in general the supervisor of the shift makes rounds and a directive for special monitoring gets determined shift to shift. E2 went on to state that there is no specific documentation other than an hourly monitoring sheet that the CNA's could use but those sheets are just a worksheet and are not kept unless there is an incident that occurs on a shift and then the sheet is reviewed at the end of the shift. E2 also stated "We were never able to locate any hourly or special monitoring sheet for R12 for the incident that occurred on [DATE]. Each time R12 was removing or attempting to remove his trach tube new goals and approaches should have been added. Usually once it's identified on the care plan an hourly monitoring sheet gets generated." On [DATE] at 3:00pm E12 Licensed Practical Nurse/LPN stated "The supervisors put 30 minute checks in place for R12. That's what we were doing, sometimes even more frequent. I don't know if the CNA was documenting the checks. The last rounds were done at 9:00pm for R12. I made the next rounds and saw R12's mitts on the floor at each side of R12's bed and the trach between R12's legs. R12 was unresponsive to shaking and rubbing. I put the trach back in and started CPR." On [DATE] at 4:40pm E14 LPN/Supervisor stated "R12 was on hourly monitoring, the 24 hour report indicates R12 was on hourly monitoring. " On [DATE] at 3:10pm E18, Certified Nursing Assistant/CNA stated she was assigned to R12 only once and that R12 had standard monitoring of every 2 hours - no special monitoring or precautions. On [DATE] at 5:20pm E19, CNA stated "I was told by the nurse that R12 was on 30 minute checks the night R12 coded. I thought the CNA assigned to R12 was doing an hourly monitoring sheet. I checked on R12 for the nurse at 9pm on that night because she was busy. The nurse seemed very worried and cautious about R12 pulling out his trach tube. R12 was lying in bed at 9pm watching television. R12 made eye contact with me and I left the room. Shortly later I heard the code called to R12's room." O[DATE] at 3:45pm E20 CNA stated she was assigned to R12 only once on the night of [DATE], the night R12 coded. E20 stated she was unaware that night that R12 had a behavior of taking off his mitts or pulling his trach tube out and that R12 did not make any previous attempts that night prior to pulling out the trach tube after 9pm. E20 recalled R12 getting checked on by staff every 30 minutes to 1 hour however could not recall if R12 had an hourly monitoring sheet that night. E20 also stated she received no formal report from the previous shift CNA regarding R12's care needs. 24 Hour Report [DATE] indicates ,[DATE] shift note: monitor R12, keeps taking out the mask and playing with the trach, check on R12 often ,[DATE] shift notes: monitor for behavior, removed trach once today; will remove mittens. Needs continuous monitoring 24 Hour Report [DATE] indicates Trach in place, please monitor, R12 has pulled out trach on two occasions, mittens were placed on hands, needs continuous monitoring. None of the 24Hour reports reviewed dated [DATE] thru [DATE] indicate hourly,30 minute monitoring or any type of scheduled monitoring in place for R12, only that R12 required continuous monitoring due to his behavior. There is no documentation to support any type or frequency of monitoring for R12. 5. On [DATE] at 1:20pm via phone Z2, Physician stated "Technically the staff are supposed to call me every time a resident pulls out their tracheostomy tube. If I were notified I would send the resident out at the first hint of instability. Medically, a person can only last about a half hour without their trach tube and then they're in trouble, and if R12 was continuing to take out his tube he also would need a psychiatric evaluation. I think this resident knew what he was doing. He had been doing it for a long time. If mitt restraints aren't working he would need 24 hour sitter to prevent resident from pulling the tube." ON [DATE] at 1:50pm E21, Licensed Practical Nurse/LPN/ Falls and Restraint Nurse stated "It's unusual for a resident to come in with a restraint. I try to get assessment done within 24 - 72 hours of admission. I don't remember anyone telling me R12 could remove the mitts. I would have done a reassessment if I were told that R12 was removing the mitts." Physical Restraint assessment dated [DATE] (4 days after R12 was admitted ) for R12 indicates no other alternatives were attempted and resident currently was removing oxygen and removing trach. Facility Policy: Facility Procedure For The Use of Physical Restraints (undated) indicates: Prior to the implementation of a physical restraint, the facility must: 1. Complete an assessment of the resident's overall needs 2. Complete the 4-page Physical Restraint RAP Assessment of the resident's need for physical restraints and possible less restrictive alternatives. Facility Policy: Facility Procedure For The Use of Physical Restraints: Exceptions for Emergency Situations I. Identification of Emergency After less restrictive interventions to prevent the resident from doing serious harm have been proven ineffective, determine the need for an emergency physical restraint. This determination may be made by a nurse. On [DATE] at 3:10pm E2 DON stated "Yes, it would be considered an emergency if a resident pulled his trach tube out."