Every finding on record at Central Nursing Home

Based on interview and record review, the facility failed to ensure a resident's personal privacy was maintained during bathing for one resident (R5) resulting in R5 being observed unclothed when a Housekeeper entered the shower room without knocking causing R5 to feel violated, traumatized and ongoing fear of using the first floor north shower room. This failure affected one of five residents reviewed for privacy.Findings include:R5's Brief Interview for Mental Status (BIMS) dated 7/5/26 shows a score of 15 which indicated that R5 is cognitively intact. R5's has a diagnoses which include but not limited to cellulitis of left upper limb, type 2 diabetes mellitus, follicular cyst of the skin and subcutaneous tissue, synovitis and tenosynovitis left forearm, hyperglycemia, surgical aftercare following surgery on the skin and subcutaneous tissue. The facility's initial reportable dated 07/27/26 at 2:26 pm, documents, in part: Resident stated that while he was in the shower room today employee (Housekeeper) walked in without knocking and he felt violated.The facility's final reportable dated 08/3/26 at 4:31 pm, documents, in part: Resident stated that he was I the shower roman he had his music playing and he had just finished taking a shower. Resident stated he had the occupied in use sign on the door to the shower room. He said all of the sudden the door opened and the housekeeper walked in and looked at him and then turned around and walked out. He stated he did not apologize or anything and it made me uncomfortable. I was traumatized I assured resident that employees would be disciplined and I apologized on behalf of the facility . Although resident privacy was violated there was no abuse.On 8/24/26 at 1:23 pm, R5 stated that a few weeks ago he was naked in the first-floor shower room north stall (that did not have a curtain attached to the shower stall) when V3 entered the shower room unannounced and starred at R5 while R5 was naked causing R5 to feel violated and traumatized. R5 explained that he had the shower water running, as well as playing music on his cellular phone while he was showering and did not hear anyone knocking at the door. R5 also explained that due to the shower water running and music playing indicating that it was obvious that a resident was utilizing the shower room, that V3 had no reason to enter the shower room while R5 was naked and utilizing the shower. R5 also stated that V1 (Administrator) informed R5 that V3 was suspended due to V3 entering the shower room while R5 was showering and R5 has not seen V3 at the facility since that day. R5 reported feeling safe in the facility at this time. On 8/25/26 at 10:53 am, V14 (Housekeeper Supervisor/ Human Resources, HR) stated she was made aware of the incident involving R5 and V3 on 7/27/26. V14 stated that she was informed that V3 entered the shower room on the first-floor unit while R5 was showering without knocking. V14 explained when she questioned V3 regarding the incident that V3 stated he knocked prior to entering the shower room. V14 explained that the incident with R5 and V3 was reported by a previous state surveyor on 07/27/26 witnessing V3 not knocking on the shower room door prior to entering and that the surveyor reported the concern to V1 (Administrator). V14 also explained that V3's behavior was consistent with his previous employee history when an allegation in April 2026 was reported regarding V3 entering a resident's room without knocking while staff was providing care to a resident as well as a report of V3 being inappropriate with the staff member when V3 entered the room with the staff who was providing care to the resident. V14 explained that everyone including housekeeping staff should knock prior to entering a resident's room and the resident should grant permission for staff to enter before staff enter a resident's room. V14 stated that the facility is the resident's home and if staff do not knock prior to entering a resident's room it is a dignity and privacy concern for the residents. V14 further explained if a resident is showering the housekeeper staff should not attempt to clean the area while the resident is showering. V14 stated if a housekeeper sees a resident who is exposed naked while shower it can make the resident feel embarrassed, cause the resident trauma, make the resident feel violated amongst other emotions. V14 finally explained that V3 was terminated due to the incident with V3 entering the shower room without knocking while R5 was showering on 07/27/26.On 8/25/26 at 12:15 pm, Surveyor attempted to contact V3 (Housekeeper) and was unsuccessful. V1 (Administrator) stated that V3 no longer works at the facility and did not have any other contact phone number for V3. On 8/25/26 at 12:41 pm, V16 (R5's Nurse Practitioner) stated she is familiar with R5 at the facility, that R5 is a resident who has anxiety and that she last saw R5 on 8/18/26. V16 explained that she was informed regarding the incident with R5 and V3 a few days ago and explained that it was reported to V16 that a staff member accidentally entered the shower room while R5 was showering. V16 explained she was not aware of the incident when she last saw R on 08/18/26 so she did not ask R5 regarding the incident or how it made R5 feel. V16 then explained if a housekeeper enters the shower room and observes a resident showering naked it can make the resident feel upset and uncomfortable. V16 also explained that the resident feeling traumatized and violated are also responses that can occur after resident is seen naked by an unauthorized staff member at the facility while showering. V16 further stated that staff at the facility should ensure the resident feels comfortable and that staff should be knocking on the residents doors and checking that everything is clear before entering or if they are non-clinical the staff should ensure that a clinical person checks to make sure the area is clear before attempting to clean the area.On 8/25/26 at 1:55 pm, V1 (Administrator) stated that she is the abuse coordinator. V1 stated that staff should report abuse immediately to the department head and managers on duty and the staff or manager on duty should also inform V1 regarding any allegations of abuse. V1 stated if abuse involves an employee the staff member is immediately removed from contact with the facility and residents as well as the staff is placed on suspension pending the investigation. V1 then explained that housekeepers should be knocking and announcing themselves before entering the residents' rooms or shower room. V1 further explained if a resident is showering in the shower room the housekeeper should not try to clean the shower room area. V1 then stated if a housekeeper hears water running in the resident shower room, that is an indication that the resident is showering. V1 further stated if a housekeeper enters the shower room while the resident is showering, without knocking and/or awaiting the resident to let the staff know that it is okay to enter, and the housekeeper enters the shower room and sees the resident exposed naked the residents' privacy is not being respected, and the resident can become upset because they are seen naked. V1 stated that she was informed regarding V3 entering the shower room and seeing R5 playing music, naked, and showering a few weeks ago. V1 stated that during her investigation, R5 reported feeling traumatized and that V3 did not apologize before leaving the shower room after V3 saw R5 naked. On 8/26/26 at 1:24 pm, V2 (Director of Nursing, DON) stated on 07/27/26 she was approached by a surveyor who stated to V2 that R5 informed her that the housekeeper opened the shower door while R5 was in the shower without knocking on the door and that R5 was not comfortable. V2 then stated that she spoke with housekeeper who stated that he knocked at the door. V2 further explained that V3 was sent home and told that an investigation would be conducted. V2 also stated that she then went to speak with R5 who stated that the housekeeper opened the door while R5 was showering and that he felt the housekeeper knew he was in the shower because he (R5) was playing music. V2 stated that R5 denied being touched and stated that he told V3 to close the door and V3 then closed the shower room door. V2 then stated that V1 (Administrator) conducted an investigation regarding R5 allegation towards V3. Facility untitled document dated 07/27/26 authored by V2 (DON) documents in part: It was reported that resident complained that a staff member opens the bathroom while he is in the shower without knocking at the door.The facility's undated and untitled document, in part: Dated 07/272/26 at 1:15 pm, Resident: R5: Incident location: Common Bathroom, Person Preparing Report: V2 (Director of Nursing, DON), Nursing description: It was reported that the resident complained that a staff member open the bathroom while he is in the shower without knocking at the door.The facility policy dated 9/1/24 and titled Residents Rights documents, in part: employees shall treat all residents with kindness, respect, and dignity. Policy interpretation and implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident rights to a. A dignified existence: b. To be treated with respect, kindness, and dignity; t. Privacy and confidentiality.The facility policy dated 9/1/24 and titled Dignity documents, in part: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Interpretation and implementation: 1. Residents are treated with dignity and respect at all times . 5. When assisting with care, residents are supported and exercising their rights. For example, residents are e. Provided with a dignified experience. 7. Staff are expected to knock and request permission before entering residence rooms. 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The facility job description titled Housekeeper Job Description documents, in part: Housekeeper is responsible to keep the facility clean, safe in accordance with the current federal and state standards and comfortable manner. Essential duties and responsibilities: maintain the confidentiality of resident information and honor his/her personal and property rights.

Based on interview and record review the facility failed to ensure that one resident (R2) was free from physical abuse when R1 struck R2 in the face during an altercation. This failure affected one of six residents reviewed for abuse.Findings include: R1 has a diagnoses which includes but not limited to chronic obstructive pulmonary disease, chronic gingivitis plaque induced, major depressive disorder recurrent moderate, opioid abuse, acquired absence of right leg below knee, hyperlipidemia, local infection the skin and subcutaneous skin and subcutaneous, essential hypertension, gangrene, epigastric pain. R1's Brief Interview for Mental Status (BIMS) dated 6/15/26 shows a score of 15 which indicated that R1 is cognitively intact.R2 has a diagnoses which include but not limited to type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, major depression, chronic kidney disease stage 5, end stage renal disease, anemia, chest pain and nicotine dependence.R2's Brief Interview for Mental Status (BIMS) dated 7/7/26 shows a score of 15 which indicated that R2 is cognitively intact.The facility initial reportable to the local stage agency dated 07/27/26 at 12:36 pm documents in part Resident R1 and R2 were having a verbal argument and R2 put his finger in R1 face, and she tried to hit him with her phone charger cord.The facility final reportable to the local state agency dated 08/3/26 at 4:31 pm, R1 and R2 (usually friends) got into an argument, according to both residents they were just having a disagreement when R1 swung her phone cord charger and it hit R2 in his upper lip, no injury. We provided counseling and discussed appropriate behavior in the facility and the importance of treating each other with respect.On 8/24/26 at 1:50 pm, R1 stated that a few weeks ago R1 was by R2's room and R1 was trying to talk with R2's roommate when R2 place his right-hand index finger and second finger on the side of R1's face, pressing firmly and stating to R1 that he was going to Whoop R1's A***. R1 then explained she then pulled out her phone charging cord and swung it at R2 in attempt for R2 to remove his fingers from R1's head. R1 then explained that the nurse (she does not recall the nurse present) came into the middle of R1 and R2 and that R1 continued to swing the phone charger cord and hit staff while the staff was in the middle of R1 and R2 because she thought the staff was trying to help R2 until she saw the nurse take R2 to the nurse's station. R1 explained that she refused to go to the local hospital and informed the staff that she and R2 would not speak to each other again as a means of peace between R1 and R2. R1 stated, We nipped it in the bud. R1 also reported that she feels safe in the facility. On 8/25/26 at 1:55 pm, V1 (Administrator) stated that she is the facility's abuse coordinator and that abuse is reported to V1 by staff immediately. V1 then explained that if a resident hits another resident with the intent to harm the resident that it is considered abuse. V1 explained that a few weeks ago it was reported that R1 and R2 had a physical altercation on the third-floor unit. V1 further explained that R2 did not want R1 to go inside his room to see his roommate, both residents got into a heated argument where they both became upset and R2 then attempted to stop R1 from entering his room, and R1 pulled out a phone charger from her purse that she whipped around hitting the staff and R2 in his lower lip causing R2 to have a laceration. V1 then explained that the staff separated and counseled both residents and both residents were placed on a one-to-one monitoring with no further physical contact observed. On 08/25/26 and 08/25/26 surveyor made several attempts to speak with R2. On 8/25/26 at 3:50 pm, Surveyor attempted to interview R2 and R2 stated, I don't have nothing to say and refused to answer surveyors questions during this interview and survey. On 8/26/26 at 10:39 am, V17 (Licensed Practical Nurse, LPN) stated that she was the nurse for R1 and R2 on 7/25/26 in the evening and on the morning of 07/26/26. V17 explained that on 7/25/26 around 9:00 pm, V17 was at the nurses station and heard R2 yell down the hallway and then informed V17 to come to his room to ask R1 to leave his room because he was tired and did not want her in his room or by his door. V17 then denied recalling any other staff member present and explained that she observed R1 outside of R2's room and asked R1 to go to her room and she did. V17 denied witnessing any physical altercation occurring between R1 and R2 on 07/25/26. V17 further explained that she was R1 and R2's nurse during the 7:00 am to 3:00 pm shift the next day on 07/26/26 and V5 (Social Service Director) informed V17 that R2 reported to her that R1 hit R2 in the lip with a phone charging cord the night before on 07/25/26. V17 then explained that R2 came to the nurse's station, reported R2's allegation against R1 to V17 that R1 hit him with a phone charging cord in the mouth the night before and then R2 showed V17 his lip. V17 stated that she does not recall observing R2's having an injury to his lip when she assessed R2's lip and that she recalls R2's lip looking normal. V17 then explained that R1 came to the nurse's station with her phone charging cord, showed V17 the phone charging cord and admitted to hitting R2 in the mouth with her phone charging cord. V17 explained that she requested R1 to give her the phone charging cord and R1 refused stating No, I need this to charge my phone. V17 then explained that R1 was placed on a one-to-one supervision with staff and the police was called however R2 refused to speak to the police when they arrive and R2 stated that he was fine. On 08/26/26 at 11:32 am, V5 (Social Service Director) stated in the afternoon of 7/26/26 she recalls being the weekend manager on duty at was at the third floor nursing station when she heard commotion coming from R2 and R12's room. V5 stated that V17 (Licensed Practical Nurse, LPN) was the nurse for the third-floor unit and asked V5 if she could go and see what the commotion was coming from R2's room. V5 then explained she went to R2 and R12's room and observed them both lying in their beds with a bowl of soup spilled on the floor near R12's bed that they both stated R1 had done. R2 and R12 both stated that R1 kept coming into their rooms uninvited and that she came into their room the night before (07/25/26) uninvited and refusing to leave. V5 further explained that R2 stated when R1 came to R2's room the night before (07/25/26) refusing to leave he (R2) pointed his finger at R1 and asked her to please leave and to stop coming in his room. V5 further explained that R2 stated that R1 proceeded to take her phone charging cord out and swung the phone cord toward R2's face and hit R2's lip. R2 denied making any physical contact with R1 when pointing his finger and then showed V5 that his lip was injured. V5 explained when she observed R2's lip it was red, irritated with skin broken and that she asked R2 if he notified the nurse of his injury and the incident however R2 reported that he did not inform the nurse. V5 then stated that she sent a text to V1 (Administrator) informing her of R2's alleged allegation with R1 and then instructed R2 to go to see the nurse. V5 then stated that R2 went to see the nurse and explained that she then went to inform V17 of R2's report of R1 hitting him with her phone charging cord in the face. V5 stated while she was informing V17 of the altercation with R1 and R2, R1 came to the nurse's station and V5 asked R1 to go to her room so that she could speak with her. V5 explained that she asked R1 if she struck R2 in the face with her phone charging cord and R1 admitted that she struck R2 with her phone charging cord but did not indicate where R1's phone charger cord hit R2. V5 stated that R1 began to explain that the night before R2 invited her into the room and then told her to leave so she became upset. V5 stated that R1 further explained that she was still feeling angry towards R2, left her room, went to the third-floor nurses station, and started yelling at R2 at the third-floor nurses station while V5 was still questioning R1 regarding the incident. V5 then explained that R1 was placed on a one-to-one monitoring with V5 and that V5 completed an involuntary petition for R1 to be sent to the local hospital. V5 further explained when the ambulance arrived R1 refused to go and the ambulance called a crisis emergency team who refused to take her because they were afraid that R1 would hurt them due to R1 had then removed a pedal from her wheelchair and had the pedal to her wheelchair as a weapon and the crisis team reported being afraid of getting hurt by R1. V5 explained that it was then decided to move R1 to a room on the first floor overnight and R1 was agreeable to sleeping in a room on the first floor for one night and the next morning V1 (Administrator) spoke with R1 and R2 and further investigated the event. V5 stated if a resident hits another resident with a phone charging cord with the intent to hurt them and causes injury to the resident it is considered physical abuse and could even be mental abuse if it traumatizes the resident.On 8/26/26 at 1:15 pm, V2 (Director of Nursing, DON ) stated she was not present during the time of incident and that the incident occurred on a weekend. V2 that staff called V2 when R2 reported the incident between R1 and R2 on 7/26/26 and V2 then spoke with R1 over the phone on 07/26/26. V2 explained during her conversation with R1 over the phone, R1 admitted to swinging her phone charger cord at R2 due to R2 putting his fingers in her face and that she (R1) did not realize that she hit R2. V2 stated that she did not speak with R2 and that V5 (Social Service Director) and V1 (Administrator) conducted the investigation regarding the incident with R1 and R2. During this survey, surveyor made several attempts to speak with R1regarding the incident with R1 and R2 on 7/25/26 and R1 refused to speak with the surveyors. R1's progress note dated 07/26/26 at 4:28 pm, resident was place 1:1 observed on 7/26/26 for alleged physical altercation with another resident on 07/25/26 R2's progress note dated 07/26/26 at 4:36 pm, authored by V5 (Social Service Director) Writer met with resident n 07/26/26 for wellness check. R2 reported being the recipient of an alleged physical altercation with another resident. Resident reported feeling safe. Facility untitled document dated 07/26/26 authored by V17 (LPN) documents in part: Resident reported that another resident hit him with a wire/cord, assessed immediately, no injuries noted. Vital signs within normal range. Resident description: resident stated, she hit me with a cord in my mouth.Facility untitled document dated 07/26/26 authored by V17 (LPN) documents in part: It was reported that the resident hit another resident with a charger cord. Separated immediately, was put on 1:1 staff supervision. No injury noted. No complaint any pain. Residents stated that resident that she swung her charger core to the resident because he was pointing his finger on his face.R1's care plan dated 07/1/26 documents in part: Abuse and Neglect Factors: His abuse and/or neglect my comprehensive assessment reveals a history of suspected abuse, neglect, exploitation and/additional factors that may increase my susceptibility to abuse/neglect related to domestic violence.R2's care plan dated 07/10/26 documents in part: HX (history of) aggressive impulsive behaviors: R2 is challenged by mental illness and have a history of demonstrating aggressive behavior towards others. Symptoms are manifested by verbal aggression (example: using profanity, making threatening statements, using derogatory language) and combativeness . Abuse and Neglect Factors: His abuse and/or neglect my comprehensive assessment reveals a history of suspected abuse, neglect, exploitation and/additional factors that may increase my susceptibility to abuse/neglect related to comorbidities.The facility policy dated 9/1/24 and titled Abuse and Neglect-Clinical Protocol documents, in part: Defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.The facility policy dated 9/1/24 and titled Abuse Prevention Program documents, in part: Policy Statement: our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to free from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.The facility's documents dated 9/1/24 and titled Residents Rights documents, in part: Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: c. Be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse. This failure affects two (R1, R5) residents out of five residents reviewed for abuse in a sample of five. As a result of this failure, R2 verbally threatened R1 and R5 on separate occasions, and R2 physically hit R1 on 06/28/2026 resulting in R1 sustaining a head laceration, multiple contusions, and closed fracture of nasal bone.Findings include:On 07/01/2026 at 10:45 AM, R1 stated I feel 100% safe now that he (R2) is not here. R1 stated this happened this past Sunday June 28th, 2026. The harassment started in May 2026, I (R1) was at the counter at the nurse's station, he (R2) was standing by the nurse's station, next to me, talking verbally abusive oh you want it, you think you run it here, you are a b****. I (R1) told him to get away from me. He came towards me, I lost balance, and he grabbed me around my buttocks, and he said, oh I don't care what happens to you, I want to see what you have and then I screamed. On 07/01/2026 at 10:53 AM, V4 (Activity Aide) walked into R1's room to post an activity document. R1 stated V4 was there, V4 can you tell her (this surveyor/writer) when I (R1) was by the nurse's station and V2 was verbally abusive. V4 stated, this was about a month and a half ago, the part I saw and heard was there was tension between both (R1 & R2). V5 (Licensed Practical Nurse) was the nurse, they (R1 & R2) were arguing, and I was trying to get R2. R1 went the other way, because he (R2) ran after R1. At first, I (V4) thought R2 was arguing with a man, I didn't know he was going to the microwave area behind the nurse's station. V4 stated I didn't know R1 went in there, she was by the microwave, and it happened so fast. I (V4) saw R2 was all on R1's face with his cane. V5 called the code grey. I tried to keep them separated and I (V4) let R2 know that was not happening, you (R2) are not about to hit a woman. I (V4) can't remember what he said, but basically, he was threatening her. I (V4) wouldn't have called a code, at that moment, you must break it up immediately. He could have beaten R1 with the stick. He was still angry, I (V4) went to talk to R2, since there are always two sides R2 said I got a stick for a reason. I can use it for a weapon. R2 still wanted to come at her (R1). I took him for a walk to get a cigarette and calm down. He had cursed out nurses before.On 07/01/2026 at 11:02 AM, R1 stated that on Sunday June 28th, 2026, R2 threatened to beat and kill R1 earlier in the day. R1 stated I was sitting outside on Sunday afternoon with R5, smoking a cigarette, and R2 came out the doors, and he bent over a little and yelled at my (R1's) face and told me I am going to get you b****. I am going to kill you; I am going to beat you. That is word for word. R1 stated I (R1) sat up quickly attempting to run in the building. The first door opens and the second door, you need to be buzzed in, and I started knocking and screaming for the door to get buzzed. He ran in to come behind me. R1 stated that V9 (Receptionist) was working at the desk, she stood up and told him (R2) to get away and leave me (R1) alone. I (R1) was by the wall, and I stepped back. He (R2) got in my face, and V9 saw it. R1 stated that I screamed for someone to call 911 because of the threats that R2 said to R1. R1 stated I ran in by the nurse's station on the 1st floor, and nurses came running, I (R1) don't know their names, I (R1) think V9 called a code grey which means when people are fighting. A male staff and maybe three staff nurses came to the area, and they told him get away from me (R1). R1 denied that R2 hit her during the first altercation on Sunday. R1 stated but he had his stick up ready to do it and R2 kept repeating I am going to get you b****. R1 denied that any staff called 911 and R1 went to R1's room and R1 called 911 herself. R1 stated that when the police officers came, R1 told them that she wanted R2 arrested because R2 was verbally threatening R1 and R1 was scared. R1 stated that the police officers told R1 that they spoke to V6 (Social Services Director) and were informed that the facility will take care of it. R1 stated that maybe twenty minutes after the police left, R1 went to V6's office to talk to V6 but R1 heard R2's voice. I (R1) waited until he left her office. She (V6) had one person before me, so she took that person and it didn't take long at all. I went to my room. The door was halfway open, and he stood inside the room by the door, and yelled b**** I am going to get you holding his cane with his right hand. He had the cane shortened as a weapon, threatening me and coming towards me (R1). I took my two arms to cover myself, and I yelled help as loud as I could. He (R2) jumped on the bed and pushed me (R1) back and was on top of me beating me with his cane. The first hit was on top of my right arm, and then on top of my head a few times. R1 stated, I suffered three wounds. I (R1) continued to scream for help, the blood was dripping, and I (R1) was scared for my life. R1 stated that V7 (Licensed Practical Nurse) came running in. She bent over, because as I was trying to get away. I fell on the floor. She came in and placed a pulse ox on my finger, and I kept nodding out, I was gasping. I don't believe I was coming to death, but I was weak. This surveyor observed discoloration/bruise noted to her right upper arm, on the top of her right and left hand, and red bruising abrasion noted to right side of neck/below my ear. My head feels sore. A cut is noted on top of my head. That's the one that hurts too. No signs or symptoms of infection noted. On 07/01/2026, at 11:25 AM, R5 stated I (R5) was outside smoking with R1, he (R2) told her (R1) b**** I (R2) am going to get you, I am going to beat your a**, and some other words. She went inside really fast. R5 stated he (R2) threatened me before. R2 told me (R5) I am going to kick your a**. R5 was asked when this happened and why did R2 say that to R5. R5 stated, I told him to quit cutting everyone in line. Then he said that, and this was about a month ago. The staff heard it and told him to quit it. R5 didn't remember the names of the staff that heard R2. On 07/01/2026 at 11:29 AM, V7 (Licensed Practical Nurse) stated that R1 and R2 did have one altercation prior to this past Sunday. V7 stated that V7 was not working when it happened, but I (V7) don't remember details, it had to do with R2 was close to her (R1) which she didn't like, or she felt like that person was too close to her. V7 stated that she was the nurse on duty for both R1 and R2 on June 28th, 2026. V7 stated that she was working a double shift that day. I (V7) don't know what time they called code grey on the first floor, because the floor must be covered. I did not respond to the call because I was the only nurse on this floor. But other staff responded that I found out about it later. She (R1) came from down there crying. R1 stated I am going to call the police, and the police were called. I believe she called the police by herself. They came, interviewed her and him. The police spoke to V6 (Social Services Director). Then the police left. During the afternoon, I did my rounds around 3:30pm, during dinner time. Staff were organizing for dinner. I knew she was in the room, I (V7) checked on her, she was ok, sitting on the bed. Then at one point, I (V7) saw him (R2) walking this way, towards her room. I told him dinner was the opposite way. I saw R2's walking cane. It was folded in a smaller size. I saw him walking past nursing stations walking towards her room. He was anxious and he didn't want to talk to me (V7). V7 stated I am sixty-two and I couldn't catch up to him. I followed him and then he went into R1's room. I went in there. I don't know how many times he hit her (R1). I (V7) grabbed him from the back of R2's shirt; I separated them. I pulled R2 away from the bed, and he tried to go back. V7 stated that's when V7 was close to R1's room. V7 heard R1's yell for help. V7 stated that R2 is alert and oriented x4 (person, place, time, situation), likes to listen to his music on his phone. V7 stated sometimes I have to tell him to lower it, walks around, is compliant with medications, has no behaviors, and can be redirected.On 07/01/2026 12:53 PM, V6 (Social Services Director) stated if there is a resident-to-resident verbal altercation, those residents are separated immediately, and the person who initiated is placed on one-to-one supervision, depending on the content of the verbal aggression. V6 stated, this is in our abuse policy. V6 stated that on Sunday June 28th, 2026, there was a code grey (for behavior). V6 was on the 4th floor because that is where V6's office is located. V6 stated, the receptionist called the first code grey. V6 stated that R1 verbalized to me (V6) that R2 had threatened her (R1) and called her a b****. I (V6) observed that R1 was shaking, and she said I don't know, I just need to call the police and press charges. V6 stated that R2 was not placed on 1:1 prior to R2 striking R1 because the first time R1 reported events that there was no evidence of her (R1) shirt being pulled off and other interventions were done (police came and R2 was redirected). V6 stated that the first time R1 alleged that R2 called R1 a b*** and threatened R1, I (V6) was in immediate contact with the administrator, and I (V6) also included the director of nursing via text message. V6 stated I believe b**** it is a derogatory term which can be an example of verbal abuse. V6 stated to my knowledge, unless he is a danger to himself or others, that is when we place them 1:1. V6 stated that it is important to place a resident on 1:1 to de-escalate a situation, according to CPI (Crisis Prevention Intervention) training and make a situation safe. V6 stated that placing the residents in 1:1 could be an intervention to prevent resident abuse. V6 stated that V6 wouldn't consider R5 as manipulative.On 07/01/2026 at 3:19 PM, V9 (Receptionist) stated that she worked on June 28th, 2026, this last Sunday. V9 stated R1 went out first to the front porch to smoke, and then R2 came out about 2-3 minutes after her (R1). V9 stated, like 30 seconds later, I saw her on the camera. She came in quick. She said I (R1) would like to call the police; he (R2) is threatening me. R2 was coming right after her, the door was still open. V9 stated he (R2) got in her face, and she (V9) heard R2 tell R1 keep my name out of your mouth, it all happened so quickly. I (V9) called code grey which means behavior issues like arguments, escalated situations, things like that. V9 stated that R5 was outside when this happened because it was smoking time.On 07/02/2026 at 9:48 AM, V5 (Licensed Practical Nurse) stated that on May 22nd, 2026, I (V5) was giving the residents medications, it wasn't really an altercation, it was verbal aggression. V5 stated that R1 called V5 a b***. R2 was mad and R1 was like don't call her like that, he (R2) wanted to fight R1, he went towards R2. V5 stated I quickly moved and called a code grey because I wouldn't be able to handle it by myself. When R2 is mad, R2 would be aggressive and say something about R1. R2 didn't like R1. V5 stated everybody came up to the code grey. V6 (Social Services Director) was there. V5 denied that she saw R2 touch R1 in any way. V5 stated that R2 said something like he is going to beat her up. V5 stated that the R2's psych doctor ordered for R2 to be sent out due to his aggressive behavior. V5 stated that what R2 said to R1 is a type of abuse (him threatening her to beat her up), V5 stated that it is verbal abuse.On 07/02/2026 at 10:25 AM, V2 (Director of Nursing) stated that R2 was getting sent out on 05/22/2026, because R2 was getting paranoid. I know they (R1 &R2) had a disagreement that day, but I did not hear, honestly, that R2 was verbally threatening R1. V2 stated but if there is abuse allegation, they must call the abuse coordinator, who is V1 (Administrator). V2 stated that on Sunday, June 28, 2026, V6 (Social Services Director) texted V2 and V1 in a group text. R1 called the police for R2, because there was an incident with the receptionist. I asked did they touch each other. V6 said they had disagreement and V6 did not report that any threats were made. V2 stated that V2 reached out to V7 (Licensed Practical Nurse) to ask where the residents were located, V2 stated that V7 informed her that R1 was in her room and R2 was in his room. V2 stated that R2 shouldn't have 1:1 yet, because there was no physical or anything. V2 stated if there was a threat, he should have been placed on 1:1.On 07/02/2026 at 10:57 AM, V6 (Social Services Director) stated I reported what R1 had told me about R2 calling her a b**** to V1 (Administrator) via text message. I don't recall that there was a response. It was on Sunday June 28th at 3:15 pm, she tried looking in her text message. I found it, it was at 3:22 PM. This surveyor observed the group message. It read R1 stated that R2 called R1 a b****. The messages from V6 to V1 also read R5 said that R2 threatened R5 to kick his butt, the day before, because R5 told him (R2) not to go into another resident's room. V6 stated that V6 found this out that same day regarding R5 and R2. Regarding the incident between R1 and R2 on June 28th, V6 stated I (V6) can't state if I did or didn't say that I was going to take care of it.On 07/02/2026 at 11:14 AM, for the Sunday, June 28th incident, V1 (Administrator) stated that she was notified via group text, that R1 and R2 had words, in the lobby and R2 got in her face, where he got really close to her. The nurse took R2 outside and staff redirected R1 to her room. V1 stated we were going back and forth, and I (V1) asked them did he (R2) threaten her. V6 (Social Service Director) said no because she R1 told the police no. V1 stated that a resident calling another resident b****, could be a verbal allegation of abuse. I was not informed of this. I (V1) didn't report anything until he hit her because nothing else what reported to me. V1 stated that she has past noncompliance to present to this surveyor. V1 stated I (V1) started working on it on Monday. We did in-services already. V1 stated if a resident is threatening another resident that they are going to beat them up, that is a reportable and an investigation should be conducted.On 07/02/2026 at 12:07 PM, R1 approached this surveyor and stated I (R1) am so sorry about yesterday, I didn't mean to talk to you that way. R1 stated I was supposed to get my buspirone every 6 hours and V5 (Licensed Practical Nurse) only gave me one tablet of buspirone at 11:00am instead of 9:00 am last week. I was receiving the buspirone at 6am because I would be in pain, so I wanted it at that time. R1 stated that V10 (Certified Nursing Assistant/CNA) is the staff that closed the door on R1 when R1 was waiting to go in the dining room. R1 stated that she denied that V10 has abused R1 but R1 did report it to V1.R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R1 has intact cognition function (with no or very little impairment).R1's face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: bipolar disorder, chronic pain, not elsewhere classified. R1's nurse note dated 6/28/2026 4:20 PM documents in part, resident (R1) was involved in physical altercation with another resident. Residents separated immediately; noted resident bleeding from her head, first aid applied. Called 911 and transferred for evaluation per MD (Doctor of Medicine) order.R1's nurse note dated 6/29/2026, 7:17 AM documents in part, resident back to facility. Discharge Diagnoses: injury of head, initial encounter, multiple contusions, and closed fracture of nasal bone, initial encounter. Order to schedule appointment with doctor.R1's hospital after visit summary document dated 06/28/2026, documents in part, reason for visit, head laceration. Diagnoses injury of head, initial encounter, multiple contusions, closed fracture of nasal bone, initial encounter.Facility reported incident initial report dated 06/28/2026, at 5:34 PM, documents in part, incident date of 06/28/2026. R1 stated that she was hit by R2. Residents were immediately separated.R2's face sheet documents R2 is a [AGE] year-old individual admitted to the facility on [DATE] and discharged on 06/29/2026 has diagnoses not limited to: schizophrenia, bipolar disorder. R2's nurse note dated 5/22/2026, at 2:22 pm documents in part, resident had an altercation with another resident, NOD (nurse on duty) called hospital intakes, resident information given to the intakes, all requested documents faxed. NOD/nurse on duty is waiting for approval of the resident.R2's MDS/Minimum Data Set, dated [DATE], documents that R2 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R2 has intact cognition function (with no or very little impairment).R2's nurse note dated 6/28/2026, at 11:35 PM documents in part, resident restless, pacing, verbal and physically aggressive with threatening behaviors.R2's nurse note dated 6/29/2026, at 5:00 am documents in part, verified status at hospital. admitted with DX (diagnosis): aggressive behavior.R2's notice of involuntary transfer or discharge form dated 06/29/2026, documents in part this facility seeks to transfer or discharge you. As recorded in your clinical record in accordance with section 483.15 of the federal regulations, the reason for this proposed transfer or discharge is the safety of individuals in this facility is endangered.R2's Notice of Pre-admission Screening and Resident Review/PASRR Level II Outcome documents in part, Short Term Approval without Specialized Services. Date Short Term Approval Ends: March 13, 2026.R5's face sheet documents R5 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to seizures, unsteadiness on feet, schizophrenia, anxiety disorder.R5's MDS/Minimum Data Set, dated [DATE], documents that R5 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R5 has intact cognition function (with no or very little impairment).R5's active care plan documents in part, abuse neglect potential, my (R5) comprehensive assessment reveals factors that may increase my susceptibility to abuse/neglect related to mental illness and medical complexities. I will be treated with respect, dignity, and resident in the facility free of mistreatment (abuse/neglect).Facility concerns form dated 05/22/2026 documents in part, R1 was person sharing the concern, resident involved R2. On May 22, 2026, documentation was reviewed regarding a resident who was noted to have had a verbal disagreement with another resident after R1 stated the resident hit her leg with his cane when walking by. After viewing cameras there was no physical contact.Facility provided document dated 09/01/24 titled abuse and neglect- clinical protocol, documents in part, Abuse is defined at S483.5 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. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on interview and record review, the facility failed to report and investigate abuse allegations for two (R1, R5) of five residents reviewed for abuse in a sample of five. As a result of this failure, R2 verbally threatened R1 and R5 on separate occasions, and R2 physically hit R1 on 06/28/2026 resulting in R1 sustaining a head laceration, multiple contusions, and closed fracture of nasal bone.Findings include:On 07/01/2026 at 10:45 AM, R1 stated I feel 100% safe now that he (R2) is not here. R1 stated this happened this past Sunday June 28th, 2026. The harassment started in May 2026, I (R1) was at the counter at the nurse's station, he (R2) was standing by the nurse's station, next to me, talking verbally abusive oh you want it, you think you run it here, you are a b****. I (R1) told him to get away from me. He came towards me, I lost balance, and he grabbed me around my buttocks, and he said, oh I don't care what happens to you, I want to see what you have and then I screamed. On 07/01/2026 at 10:53 AM, V4 (Activity Aide) walked into R1's room to post an activity document. R1 stated V4 was there, V4 can you tell her (this surveyor/writer) when I (R1) was by the nurse's station and V2 was verbally abusive. V4 stated, this was about a month and a half ago, the part I saw and heard was there was tension between both (R1 & R2). V5 (Licensed Practical Nurse) was the nurse, they (R1 & R2) were arguing, and I was trying to get R2. R1 went the other way, because he (R2) ran after R1. At first, I (V4) thought R2 was arguing with a man, I didn't know he was going to the microwave area behind the nurse's station. V4 stated I didn't know R1 went in there, she was by the microwave, and it happened so fast. I (V4) saw R2 was all on R1's face with his cane. V5 called the code grey. I tried to keep them separated and I (V4) let R2 know that was not happening, you (R2) are not about to hit a woman. I (V4) can't remember what he said, but basically, he was threatening her. I (V4) wouldn't have called a code, at that moment, you must break it up immediately. He could have beaten R1 with the stick. He was still angry, I (V4) went to talk to R2, since there are always two sides R2 said I got a stick for a reason. I can use it for a weapon. R2 still wanted to come at her (R1). I took him for a walk to get a cigarette and calm down. He had cursed out nurses before.On 07/01/2026 at 11:02 AM, R1 stated that on Sunday June 28th, 2026, R2 threatened to beat and kill R1 earlier in the day. R1 stated I was sitting outside on Sunday afternoon with R5, smoking a cigarette, and R2 came out the doors, and he bent over a little and yelled at my (R1's) face and told me I am going to get you b****. I am going to kill you; I am going to beat you. That is word for word. R1 stated I (R1) sat up quickly attempting to run in the building. The first door opens and the second door, you need to be buzzed in, and I started knocking and screaming for the door to get buzzed. He ran in to come behind me. R1 stated that V9 (Receptionist) was working at the desk, she stood up and told him (R2) to get away and leave me (R1) alone. I (R1) was by the wall, and I stepped back. He (R2) got in my face, and V9 saw it. R1 stated that I screamed for someone to call 911 because of the threats that R2 said to R1. R1 stated I ran in by the nurse's station on the 1st floor, and nurses came running, I (R1) don't know their names, I (R1) think V9 called a code grey which means when people are fighting. A male staff and maybe three staff nurses came to the area, and they told him get away from me (R1). R1 denied that R2 hit her during the first altercation on Sunday. R1 stated but he had his stick up ready to do it and R2 kept repeating I am going to get you b****. R1 denied that any staff called 911 and R1 went to R1's room and R1 called 911 herself. R1 stated that when the police officers came, R1 told them that she wanted R2 arrested because R2 was verbally threatening R1 and R1 was scared. R1 stated that the police officers told R1 that they spoke to V6 (Social Services Director) and were informed that the facility will take care of it. R1 stated that maybe twenty minutes after the police left, R1 went to V6's office to talk to V6 but R1 heard R2's voice. I (R1) waited until he left her office. She (V6) had one person before me, so she took that person and it didn't take long at all. I went to my room. The door was halfway open, and he stood inside the room by the door, and yelled b**** I am going to get you holding his cane with his right hand. He had the cane shortened as a weapon, threatening me and coming towards me (R1). I took my two arms to cover myself, and I yelled help as loud as I could. He (R2) jumped on the bed and pushed me (R1) back and was on top of me beating me with his cane. The first hit was on top of my right arm, and then on top of my head a few times. R1 stated, I suffered three wounds. I (R1) continued to scream for help, the blood was dripping, and I (R1) was scared for my life. R1 stated that V7 (Licensed Practical Nurse) came running in. She bent over, because as I was trying to get away. I fell on the floor. She came in and placed a pulse ox on my finger, and I kept nodding out, I was gasping. I don't believe I was coming to death, but I was weak. This surveyor observed discoloration/bruise noted to her right upper arm, on the top of her right and left hand, and red bruising abrasion noted to right side of neck/below my ear. My head feels sore. A cut is noted on top of my head. That's the one that hurts too. No signs or symptoms of infection noted. On 07/01/2026, at 11:25 AM, R5 stated I (R5) was outside smoking with R1, he (R2) told her (R1) b**** I (R2) am going to get you, I am going to beat your a**, and some other words. She went inside really fast. R5 stated he (R2) threatened me before. R2 told me (R5) I am going to kick your a**. R5 was asked when this happened and why did R2 say that to R5. R5 stated, I told him to quit cutting everyone in line. Then he said that, and this was about a month ago. The staff heard it and told him to quit it. R5 didn't remember the names of the staff that heard R2. On 07/01/2026 at 11:29 AM, V7 (Licensed Practical Nurse) stated that R1 and R2 did have one altercation prior to this past Sunday. V7 stated that V7 was not working when it happened, but I (V7) don't remember details, it had to do with R2 was close to her (R1) which she didn't like, or she felt like that person was too close to her. V7 stated that she was the nurse on duty for both R1 and R2 on June 28th, 2026. V7 stated that she was working a double shift that day. I (V7) don't know what time they called code grey on the first floor, because the floor must be covered. I did not respond to the call because I was the only nurse on this floor. But other staff responded that I found out about it later. She (R1) came from down there crying. R1 stated I am going to call the police, and the police were called. I believe she called the police by herself. They came, interviewed her and him. The police spoke to V6 (Social Services Director). Then the police left. During the afternoon, I did my rounds around 3:30pm, during dinner time. Staff were organizing for dinner. I knew she was in the room, I (V7) checked on her, she was ok, sitting on the bed. Then at one point, I (V7) saw him (R2) walking this way, towards her room. I told him dinner was the opposite way. I saw R2's walking cane. It was folded in a smaller size. I saw him walking past nursing stations walking towards her room. He was anxious and he didn't want to talk to me (V7). V7 stated I am sixty-two and I couldn't catch up to him. I followed him and then he went into R1's room. I went in there. I don't know how many times he hit her (R1). I (V7) grabbed him from the back of R2's shirt; I separated them. I pulled R2 away from the bed, and he tried to go back. V7 stated that's when V7 was close to R1's room. V7 heard R1's yell for help. V7 stated that R2 is alert and oriented x4 (person, place, time, situation), likes to listen to his music on his phone. V7 stated sometimes I have to tell him to lower it, walks around, is compliant with medications, has no behaviors, and can be redirected.On 07/01/2026 12:53 PM, V6 (Social Services Director) stated if there is a resident-to-resident verbal altercation, those residents are separated immediately, and the person who initiated is placed on one-to-one supervision, depending on the content of the verbal aggression. V6 stated, this is in our abuse policy. V6 stated that on Sunday June 28th, 2026, there was a code grey (for behavior). V6 was on the 4th floor because that is where V6's office is located. V6 stated, the receptionist called the first code grey. V6 stated that R1 verbalized to me (V6) that R2 had threatened her (R1) and called her a b****. I (V6) observed that R1 was shaking, and she said I don't know, I just need to call the police and press charges. V6 stated that R2 was not placed on 1:1 prior to R2 striking R1 because the first time R1 reported events that there was no evidence of her (R1) shirt being pulled off and other interventions were done (police came and R2 was redirected). V6 stated that the first time R1 alleged that R2 called R1 a b*** and threatened R1, I (V6) was in immediate contact with the administrator, and I (V6) also included the director of nursing via text message. V6 stated I believe b**** it is a derogatory term which can be an example of verbal abuse. V6 stated to my knowledge, unless he is a danger to himself or others, that is when we place them 1:1. V6 stated that it is important to place a resident on 1:1 to de-escalate a situation, according to CPI (Crisis Prevention Intervention) training and make a situation safe. V6 stated that placing the residents in 1:1 could be an intervention to prevent resident abuse. V6 stated that V6 wouldn't consider R5 as manipulative.On 07/01/2026 at 3:19 PM, V9 (Receptionist) stated that she worked on June 28th, 2026, this last Sunday. V9 stated R1 went out first to the front porch to smoke, and then R2 came out about 2-3 minutes after her (R1). V9 stated, like 30 seconds later, I saw her on the camera. She came in quick. She said I (R1) would like to call the police; he (R2) is threatening me. R2 was coming right after her, the door was still open. V9 stated he (R2) got in her face, and she (V9) heard R2 tell R1 keep my name out of your mouth, it all happened so quickly. I (V9) called code grey which means behavior issues like arguments, escalated situations, things like that. V9 stated that R5 was outside when this happened because it was smoking time.On 07/02/2026 at 9:48 AM, V5 (Licensed Practical Nurse) stated that on May 22nd, 2026, I (V5) was giving the residents medications, it wasn't really an altercation, it was verbal aggression. V5 stated that R1 called V5 a b***. R2 was mad and R1 was like don't call her like that, he (R2) wanted to fight R1, he went towards R2. V5 stated I quickly moved and called a code grey because I wouldn't be able to handle it by myself. When R2 is mad, R2 would be aggressive and say something about R1. R2 didn't like R1. V5 stated everybody came up to the code grey. V6 (Social Services Director) was there. V5 denied that she saw R2 touch R1 in any way. V5 stated that R2 said something like he is going to beat her up. V5 stated that the R2's psych doctor ordered for R2 to be sent out due to his aggressive behavior. V5 stated that what R2 said to R1 is a type of abuse (him threatening her to beat her up), V5 stated that it is verbal abuse.On 07/02/2026 at 10:25 AM, V2 (Director of Nursing) stated that R2 was getting sent out on 05/22/2026, because R2 was getting paranoid. I know they (R1 &R2) had a disagreement that day, but I did not hear, honestly, that R2 was verbally threatening R1. V2 stated but if there is abuse allegation, they must call the abuse coordinator, who is V1 (Administrator). V2 stated that on Sunday, June 28, 2026, V6 (Social Services Director) texted V2 and V1 in a group text. R1 called the police for R2, because there was an incident with the receptionist. I asked did they touch each other. V6 said they had disagreement and V6 did not report that any threats were made. V2 stated that V2 reached out to V7 (Licensed Practical Nurse) to ask where the residents were located, V2 stated that V7 informed her that R1 was in her room and R2 was in his room. V2 stated that R2 shouldn't have 1:1 yet, because there was no physical or anything. V2 stated if there was a threat, he should have been placed on 1:1.On 07/02/2026 at 10:57 AM, V6 (Social Services Director) stated I reported what R1 had told me about R2 calling her a b**** to V1 (Administrator) via text message. I don't recall that there was a response. It was on Sunday June 28th at 3:15 pm, she tried looking in her text message. I found it, it was at 3:22 PM. This surveyor observed the group message. It read R1 stated that R2 called R1 a b****. The messages from V6 to V1 also read R5 said that R2 threatened R5 to kick his butt, the day before, because R5 told him (R2) not to go into another resident's room. V6 stated that V6 found this out that same day regarding R5 and R2. Regarding the incident between R1 and R2 on June 28th, V6 stated I (V6) can't state if I did or didn't say that I was going to take care of it.On 07/02/2026 at 11:14 AM, for the Sunday, June 28th incident, V1 (Administrator) stated that she was notified via group text, that R1 and R2 had words, in the lobby and R2 got in her face, where he got really close to her. The nurse took R2 outside and staff redirected R1 to her room. V1 stated we were going back and forth, and I (V1) asked them did he (R2) threaten her. V6 (Social Service Director) said no because she R1 told the police no. V1 stated that a resident calling another resident b****, could be a verbal allegation of abuse. I was not informed of this. I (V1) didn't report anything until he hit her because nothing else what reported to me. V1 stated that she has past noncompliance to present to this surveyor. V1 stated I (V1) started working on it on Monday. We did in-services already. V1 stated if a resident is threatening another resident that they are going to beat them up, that is a reportable and an investigation should be conducted.On 07/02/2026 at 12:07 PM, R1 approached this surveyor and stated I (R1) am so sorry about yesterday, I didn't mean to talk to you that way. R1 stated I was supposed to get my buspirone every 6 hours and V5 (Licensed Practical Nurse) only gave me one tablet of buspirone at 11:00am instead of 9:00 am last week. I was receiving the buspirone at 6am because I would be in pain, so I wanted it at that time. R1 stated that V10 (Certified Nursing Assistant/CNA) is the staff that closed the door on R1 when R1 was waiting to go in the dining room. R1 stated that she denied that V10 has abused R1 but R1 did report it to V1.R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R1 has intact cognition function (with no or very little impairment).R1's face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: bipolar disorder, chronic pain, not elsewhere classified. R1's nurse note dated 6/28/2026 4:20 PM documents in part, resident (R1) was involved in physical altercation with another resident. Residents separated immediately; noted resident bleeding from her head, first aid applied. Called 911 and transferred for evaluation per MD (Doctor of Medicine) order.R1's nurse note dated 6/29/2026, 7:17 AM documents in part, resident back to facility. Discharge Diagnoses: injury of head, initial encounter, multiple contusions, and closed fracture of nasal bone, initial encounter. Order to schedule appointment with doctor.R1's hospital after visit summary document dated 06/28/2026, documents in part, reason for visit, head laceration. Diagnoses injury of head, initial encounter, multiple contusions, closed fracture of nasal bone, initial encounter.Facility reported incident initial report dated 06/28/2026, at 5:34 PM, documents in part, incident date of 06/28/2026. R1 stated that she was hit by R2. Residents were immediately separated.R2's face sheet documents R2 is a [AGE] year-old individual admitted to the facility on [DATE] and discharged on 06/29/2026 has diagnoses not limited to: schizophrenia, bipolar disorder. R2's nurse note dated 5/22/2026, at 2:22 pm documents in part, resident had an altercation with another resident, NOD (nurse on duty) called hospital intakes, resident information given to the intakes, all requested documents faxed. NOD/nurse on duty is waiting for approval of the resident.R2's MDS/Minimum Data Set, dated [DATE], documents that R2 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R2 has intact cognition function (with no or very little impairment).R2's nurse note dated 6/28/2026, at 11:35 PM documents in part, resident restless, pacing, verbal and physically aggressive with threatening behaviors.R2's nurse note dated 6/29/2026, at 5:00 am documents in part, verified status at hospital. admitted with DX (diagnosis): aggressive behavior.R2's notice of involuntary transfer or discharge form dated 06/29/2026, documents in part this facility seeks to transfer or discharge you. As recorded in your clinical record in accordance with section 483.15 of the federal regulations, the reason for this proposed transfer or discharge is the safety of individuals in this facility is endangered.R2's Notice of Pre-admission Screening and Resident Review/PASRR Level II Outcome documents in part, Short Term Approval without Specialized Services. Date Short Term Approval Ends: March 13, 2026.R5's face sheet documents R5 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to seizures, unsteadiness on feet, schizophrenia, anxiety disorder.R5's MDS/Minimum Data Set, dated [DATE], documents that R5 has a BIMS/Brief Interview for Mental Status score of 13/15, indicating that R5 has intact cognition function (with no or very little impairment).R5's active care plan documents in part, abuse neglect potential, my (R5) comprehensive assessment reveals factors that may increase my susceptibility to abuse/neglect related to mental illness and medical complexities. I will be treated with respect, dignity, and resident in the facility free of mistreatment (abuse/neglect).Facility concerns form dated 05/22/2026 documents in part, R1 was person sharing the concern, resident involved R2. On May 22, 2026, documentation was reviewed regarding a resident who was noted to have had a verbal disagreement with another resident after R1 stated the resident hit her leg with his cane when walking by. After viewing cameras there was no physical contact.Facility provided document dated 09/01/24 titled abuse and neglect- clinical protocol, documents in part, Abuse is defined at S483.5 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. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on observation, interview and record review, the facility failed to (a) ensure one resident (R16) was free from abuse from a staff member; (b) failed to ensure that a resident (R2) was free from abuse from another resident. This failure resulted in R16 enduring psychosocial abuse and harm; R2 being confronted by another resident (R14) who had a box cutter in their possession, resulting in R2 leaving the facility against medical advice (A.M.A). Findings include: a. On 5/26/26 at 12:18 PM, R16, said this Saturday I got a visitor, my sister. We were going out on pass. I got it approved with V2 (Director of Nursing). My sister talked to someone about going out. I'm on red pass because I was late coming back from out on pass. So, I can't go out by myself until tomorrow when my red pass is over. I can go out with family. My sister is my #1 emergency contact. I was at the front desk doing paperwork to go out. I was leaving the building. V39 (Social Service Coordinator) comes in saying They aren't leaving the building. I'm getting it (the pass) unapproved. My sister came inside. V39 said I don't need to be here, take them home with you we don't want them here. V39 started yelling at other residents to get out of their way. When V39 was yelling at V23 (Receptionist) and other residents I said to stop yelling at them if you have a problem with me. V39 said to shut up b**** to me. My sister was saying stop talking to me like that. Stop being rude to these residents. You are unprofessional. V2 came and said to go on visit. My sister and I left. I am here for brain aneurysm. I have been here since September 2025. On 5/27/26 at 12:57 PM, V23 (Receptionist) stated I was at the receptionist's desk. I document every resident that comes and goes. An incident took place that should not have taken place. The incident occurred on a Saturday after 2 PM. R16 came to me excited to be going out with their sister and nephew. I called V2 (Director of Nursing) to verify that R16 was going out. I got the release form for the person picking up R16 to complete. V39 (Social Service Coordinator) walks in and starts yelling that R16 is on red pass. V39 comes behind the reception desk, gets on my computer, and starts yelling at R16. That R16 can't go out. R16's sister, who is also an emergency contact, comes into the building. V39 was yelling at the emergency contact. I called a code gray which means an incident/altercation that's happening. Staff showed up. V39 was still yelling at R16 and then started yelling at R16's sister. R16 started crying. V39 was telling R16's sister that when R16 goes out they come back with something insinuating contraband. I called another code gray so another team would come. The current team was in shock wondering what was going on because it was a staff person not the resident that I called for. When I called for the second code grey I inadvertently turned on the intercom, so part of the incident was heard throughout the facility. Residents were lined up to get me to write their names down to go out at the same time. V39 yelled at the other residents What are you waiting on. One resident told V39 they were waiting for a cigarette. V39 was focused on R16. That incident should not have happened. It was heartbreaking. It was sad. I told V39 they were unprofessional and V39 told me I was unprofessional. V39 told me I'm not supposed to be there for the residents. Staff should not be yelling at residents. This is the resident's home. It was inhumane. R16 was being hurt and attacked for no reason. It is a form of abuse. I was upset by the incident. V39 disrespected everybody including myself and the resident. I did not hear mention of a gun from V39. R16 was red pass which means the resident cannot go out by themself. The resident can go out with an escort. I have to know who the resident is going with, and I notify management. On 5/28/26 at 10:10 AM, V2 (Director of Nursing) stated I was here on the Saturday of the incident. R16 came to my office happy to go out on pass with their sister. R16 is on a red pass so I confirmed with V32 (Social Worker) and with V1 (Administrator) that R16 could go out with their sister. V1 and V32 both gave the okay for R16 to go out on pass. I notified V23 (Receptionist) that R16 could go out. I told V23 as long as R16's sister signed them out it is no problem. R16 came to my office and told me that they were waiting at the front desk to go out when V39 (Social Service Coordinator) came into the facility and said they could not go because they were on red pass. I went into the hallway, and I told V39 that as long as R16's sister will sign them out they could go. I went back to my office and then heard a code gray called, which means a behavior with a patient. I went to the lobby and R16's sister was yelling at V39. V39 was explaining that they were verifying that they are the sister and on the face sheet. I think R16's sister was upset because there was a kid in the car, so they were in a hurry. V39 told me that they were checking the face sheet to verify the sister's identity. V39 is new to the facility. V39 has been here for about a month. V39 works in the afternoon, 3 PM-11 PM, and handles the whole building. R16 and their sister left. I told V39 to leave the building for the day because I wanted to investigate what happened. I called V1 (Administrator), the Abuse Coordinator. I was told that V39 was yelling at R16's sister. When I got to the front it was V39 and R16's sister exchanging words and it was loud, voices were raised. I did not hear V39 cussing. R16 was visibly upset, mad and shaking and had a red complexion. R16 was so happy to be going out. V39 is suspended. We do abuse in-services with all staff after an incident and at least every three months. We educate new hires on abuse. On 5/28/26 at 3:30 PM, V1 (Administrator) stated I am the Abuse Coordinator. I offer abuse training and in-services to all staff usually every three to six months and upon hire. R16 was on red pass. R16 had made arrangements for their sister to pick them up. R16 was at the front desk when V39 (Social Service Coordinator) came in. V39 was saying R16 could not go out because R16 was on red pass so R16 was getting upset. V39 text V3 (Assistant Director of Nursing) and was informed to get a copy of the family members' identification. R16's sister admits they were swearing and were loud. They said it was loud. R16's sister didn't feel that V39 was professional. It was a heated argument. R16 and their sister left. During this time the code gray was called due to the argument and inadvertently the intercom was turned on so the whole facility heard the commotion. There were residents in line at the front waiting to get cigarettes. According to R16's face sheet, R16 is a [AGE] year-old resident of the facility. R16 has diagnoses that include but are not limited to aneurysm of other precerebral arteries; type 2 diabetes mellitus; generalized anxiety disorder. According to R16's physician order summary report, R16 has an active order that reads: May go out on pass supervised, order date 5/18/2026. According to R16's MDS (Minimum Data Set) 3/20/2026, R16 has a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. Facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, no date, documents in part: Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff. b. Facility Reported Incident (dated 03/08/2026) documents in part: It was reported that residents, R14 and R2, were in a verbal altercation and started to threaten each other. Separated immediately. Both residents were assessed, no injuries noted on both residents. Both residents were separated immediately by staff. Assessment done to both residents no injury noted. Notifications made. Police notified. MD notified. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Urinary tract infection, intestinal obstruction, other neoplasms of uncertain behavior of lymphoid, generalized anxiety disorder. Minimum Data Set Section (MDS) section C (dated 12/14/2025) documents that R2 has an Interview for Mental Status (BIMS) score of 15, indicating that R2's cognition is intact. A care plan (dated 12/09/2025) showed that R2 has a history of alcohol abuse. This appears related to maladaptive coping skills and ambiguity toward recovery. R2 has been educated on facility policy prohibiting the use of non-prescribed substances. R14's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic obstructive pulmonary disease, schizophrenia. Minimum Data Set Section (MDS) section C (dated 05/05/2025) documents that R14 has an Interview for Mental Status (BIMS) score of 14, indicating that R14's cognition is intact. Care plan (dated 03/19/2026) documents that R14 is challenged by mental illness and/or dementia and experience psychosis: Hallucinations -Command - Auditory and/or Delusions. R14 is noted to respond and react to internal stimuli and present with disorganized/chaotic thinking which distorts my perception of reality. On 05/27/2026 at 9:53AM, V10 (certified nursing assistant) stated, Both R2 and R14 said that they were in line to smoke. They were on the first floor. And then I don't know what R14 thought that he heard R2 say to him. That's when R14 pulled out a knife and said that he was going to kill R2. That's when R2 started screaming that R14 has a knife and that he's trying to kill R2. That's when V11 (activities director) came out to see what's going on. And after that I am not sure. I don't know if he hid the blade and said that R14 did not do anything. I heard about the incident from V11 (activities director). After that happened, they both went outside to smoke. And then they went upstairs and that's when V11 let the nurse and me know what happened. I think the nurse was V12 (licensed practical nurse). V12 works every Sunday. That' s when R2 called the police and said that R2 feels unsafe. On 05/27/2026 at 6:55PM, V12 (licensed practical nurse) stated, I was informed that whatever happened, happened on the first floor, when R2 and R14 were waiting for the smoke break. Some people say that they were waiting in line to smoke, and some people say that it happened on the patio. The police were called. I really don't know what exactly happened. R2 said that he was threatened by R14. I don't know who threatened who exactly. I can't remember if I was the nurse on that day. I don't remember who reported this incident to me, I really don't recall. On 05/27/2026 at 7:10PM, V9 (licensed practical nurse) stated, Pertaining to the incident on 03/08/2026, I am not aware of what happened, I came in towards the end of the incident, after the code was called. This was on the actual smoking patio. R14 had a box cutter. R14 was already upset because he had a red pass, and he could not go outside to smoke in front. The code was called, and I responded to the code. The box cutter was taken when I went to search R14's room. There were no injuries. R14 was leaving the patio when the code was called, and he went to his room. We went up to his room and took the box cutter away. R14 did not try to fight, R14 gave the box cutter willingly. R2 and R14 were separated immediately. R2 felt threatened. R2 has a very paranoid demeanor. R14 goes out into the community independently. The police were called. R14 was taken away by the police, and R14 was later brought back to the facility. R14 goes out into the community and that is how he was able to get a box cutter. R2 and R14 were separated on different floors. R14's room was searched to make sure that he does not have any other weapons, and R14 was placed on the red pass. On 05/28/2026 at 9:02AM, V2 (director of nursing) stated, I think the incident between R2 and R14 happened at night. I think that they notified V1 (administrator) about it. I can't remember the details. There was a misunderstanding on the patio. As far as I can remember, the residents live on different floors. One of them was talking to themselves, and the other resident thought that the other resident was talking to him. I think that R2 was the one that called the police. There was nothing physical. R2 thinks that he was threatened, and he called the police, and the police picked up R14. I did not see a knife, it's like a letter opener. R2 was insisting that he was threatened. I'm not sure but R2 called the police because he was threatened. It's a box cutter. R14 goes out and he has a green pass. I think that R14 is on green pass. A green pass is a privilege for the residents. They know that they cannot have anything on them. R14 was re-admitted to the facility on [DATE] from the police station. After that incident there were no other behaviors from R14. R14 is still insisting that he did not do anything. R14 has auditory hallucinations. When R14 came back to the facility, the doctor ordered to increase Seroquel to 400mg. Since then, R14 has not exhibited any other behaviors. R14 was not supposed to have this box cutter. We discourage the residents from having any sharp objects such as scissors. R14 did not try to stab R2 with the box cutter. R14 is appropriate for this facility. R14 gets along with other residents. R14 was expressing that it's not a weapon, that he did not do anything wrong. After the incident, R2 expressed that he does not feel safe. R2 lives on another floor. I think that R2 wanted to leave the facility. If we placed R2 in a room with another resident, he wanted another room. I accommodated R2 many times with a room change. R2 wanted to change rooms as soon as he got a roommate. R2 did not feel comfortable with having roommates. According to the psych doctor, he documented that R2 has generalized anxiety disorder, and aggressive behavior. R2's BIMS score is 15, and has a green pass. R2 left against medical advice (AMA) on 03/12/2026. R14 has COPD, schizophrenia, schizo-affective disorder, bipolar type. R14's BIMS score is 14. R14 was sent out to the hospital for behaviors on 09/16/2026, and at that time he was new to the facility, and maybe he was still adjusting. R14 was gone for a week that time, and since that time, he has not been sent out to the hospital. During the incident, R14 didn't really know what happened, because he wasn't trying to fight with R2 at all because R14 was talking to himself. We perform random room searches for R14, especially because R14 does out into the community. No other residents expressed having concern for their safety. We have not found any sharp objects on R14 since then. We even remove On 05/28/2026 at 11:45AM, V1 (administrator) stated, On 03/08/2026, R2 and R14 were in the smoke like. R2 was talking to himself constantly. R14 thought that R2 was talking to him. It was standard for R2 to talk to himself. They started arguing because R14 thought that R2 was talking to him. They were arguing with each other. We looked at the cameras and there was no physical contact between R2 and R14. We separated them and it turned out that R14 had a box cutter in his pocket. R14 had a box cutter because he was getting a lot of packages. R14 said that he bought the box cutter at Walgreens. R14 was arrested. When I reviewed the video, I did not see R14 taking out his box cutter. The box cutter remained in his pocket. The police were called, and they searched R14 and found the box cutter in his pocket, and he was arrested. R14 had the box cutter because he gets a lot of packages, and that's why he had the box cutter, that's what he bought it for. R14 never intended for the box cutter to be a weapon. The police did not inform us, and they brought him back to the facility. It was a few days later. R2 had come to me and told me that he was unhappy that R14 was back. R2 and R14 were living on separate floors, but obviously, they smoke outside and they can run into each other on the smoking patio. I informed R2 that they were on separate units. R2 was screaming at me. I asked R2 if he wanted to go to another facility, and he said no. R2 said that he wanted to sign out against medical advice (A.M.A). To ensure the safety of other residents, R14 was having room checks for a while. R14 still receives random room checks. The only thing that we found was a cigarette. R14 does not believe that he has mental illness. There have been no behaviors seen since then. I am the abuse coordinator. All employees receive abuse prevention training. When there is a report of a resident having a sharp object, we perform a room search right away. There have not been any issues with residents having sharp objects. We also search the residents with their consent. Surveyor interviewed R4. On 05/28/2026 at 12:10PM, R4 stated, R14 stated that he was done smoking and as he was walking back inside, R2 was cursing. R14 said that he asked R2 who he's talking to and R2 responded that he was talking to R14. R14 stated that R14 and R2 started to argue and R14 took out a box cutter that he had in his pocket. R14 stated that he did not attempt to stab R2 and he kept the box cutter on his side at all times. R14 stated that R14 has good vision in one eye, and he cannot afford to get hit and lose sight in that good eye. R14 stated that there was no contact made between R2 and R14. R14 stated that he went up to his room and staff arrived and asked him for the box cutter which R14 gave willingly. R14 stated that police arrived and arrested R14 and R14 spent the night in jail. R14 stated that he does not have any sharp objects on him. R14 stated that R2 was always talking to himself and cursing and R14 never started problems with R2. R14 stated that he took the box cutter out from his pocket in case R14 would get attacked. R14 stated that he had the box cutter on him just because it's a tough neighborhood and R14 goes out. R2's Progress Note (dated 03/12/2026) documents, Writer was notified by staff that the resident called the police. Writer observed three officers in the lobby area. According to the officer, the resident called to express his concern about safety and desire to sign an AMA. Social Service present at the time. R2's Progress Note (dated 03/12/2026) documents, Resident verbalized desire to leave the facility against medical advice (AMA). Resident stated he did not feel safe remaining in the facility and contacted local police independently to report this concern. Police responded to the facility and spoke with the resident. Resident assessed and found to be alert and oriented ×3 (person, place, and time). Resident able to communicate needs clearly and demonstrated understanding of the situation and potential risks associated with leaving the facility. Resident was informed of the risks of leaving the facility AMA and was educated regarding the benefits of continuing care and supervision. Resident verbalized understanding of the information provided and continued to request discharge. Resident was offered the option to transfer to an alternative facility if he did not feel comfortable remaining at the current location. Resident declined this option and continued to request to leave. Director of nursing and administration notified. Resident provided with AMA documentation and discharge information. Resident elected to proceed with leaving the facility. Resident discharged from facility per his request. R14's Progress Note (Dated 03/10/2026) documents, During the shift the resident was readmitted to the facility at 12:43pm, he was transported by a uber. A full head toe assessment was completed. There were no injuries, trauma, abrasions, scratches, bruises or wounds visible. The residents VS WNL there were no signs of discomfort observed, he was able to verbalize his needs, all his needs were met. His call light was placed Within reach. Nursing staff to continue to monitor. Director of nursing was notified. R14's Progress Note (dated 03/11/2026) documents, Upon resident's permission, a search of resident's belongings and living area was conducted on 3/10/2026. There were no prohibited/unauthorized items found. The facility prohibited/unauthorized items policy was reviewed again with resident and copy given so that resident is fully aware of all obligations. Resident was re-educated on matters of safety and what steps are taken to minimize risk. The resident verbalized an understanding. Abuse, Neglect, Exploitation and Misappropriation Program Policy (undated) states in part: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Protect residents from any further harm during investigations.

Based on observation, interview, and record review, the facility failed to provide adequate and clean linen for residents in the facility. This failure has the potential to affect all 209 residents residing in the facility. Findings include: On 05/27/2026 at 10:04AM, surveyor located on the fourth floor of the facility observes one linen cart in the hallway. The following items were observed on the linen cart: 0 wash cloths, 0 bath towels. V10 (Certified Nursing Assistant/CNA) states there is only one linen cart on the fourth floor. V10 states there is a drawer at the nurses' station where she keeps extra towels and linen for residents because the linen cart is not always fully stocked. Surveyor now located at the fourth-floor nurses' station with V10 and observes inside of a drawer the following items: 9 towels with 4 ripped/torn towels with frayed and tattered edges. Towels appear to be make-shift towels that were torn into smaller pieces to make more/extra towels. On 05/27/2026 at 10:26AM, R17 states sometimes when he asks the nursing staff for towels, he is told that there are none available. On 05/27/2026 at 10:41AM, surveyor located on the third floor of the facility and observes one linen cart in the hallway. The following items were observed on the linen cart: 0 wash cloths, 0 bath towels. V26 (Certified Nursing Assistant/CNA) states there is only one linen cart on the third floor. V16 (Laundry Aide) observed delivering linen to the third-floor linen cart. V16 observed placing towels onto the linen cart and then removing them and taking them to the third-floor nurses' station and placing them in a drawer. V26 states there is a drawer at the nurses' station where she keeps extra towels and linen for residents because there is a lack of towels in the facility. V26 states there are no clean linen storage closets on either floor in the facility. Surveyor now located at the third-floor nurses' station with V26 and observes inside of a drawer the following items: 16 towels with 14 ripped/torn towels with frayed and tattered edges. Towels appear to be make-shift towels that were torn into smaller pieces to make more/extra towels. Surveyor observes that the 3 towels are heavily stained. V26 then takes the 3 towels from the pile and states the towels are heavily stained and should not be in circulation for resident use. V26 states she will now put the towels to the side and give them to the housekeeping staff to use for cleaning. V26 states the stained towels should not have been stored in the linen cart or the drawer to be intended for resident use. On 05/27/2026 at 10:58AM, surveyor located on the second floor of the facility and observes four linen carts in the hallway. V29 (CNA) states there are a total of 5 linen carts on the second floor and one linen cart was taken down to the laundry room in the basement to be restocked. The following items were observed on linen cart #1: 6 heavily stained towels with ripped/torn, frayed and tattered edges. Towels appear to be make-shift towels that were torn into smaller pieces to make more/extra towels. The following items were observed on linen cart #2: 5 towels with ripped/torn, frayed and tattered edges. Towels appear to be make-shift towels that were torn into smaller pieces to make more/extra towels. The following items were observed on linen cart #3: 0 towels. The following items were observed on linen cart #4: 3 towels with ripped/torn, frayed and tattered edges. Towels appear to be make-shift towels that were torn into smaller pieces to make more/extra towels. On 05/27/2026 at 11:14AM, surveyor located on the first floor of the facility and observes five linen carts in the hallway. The following items were observed on linen cart #1: 0 towels. The following items were observed on linen cart #2: 0 towels. The following items were observed on linen cart #3: 0 towels. The following items were observed on linen cart #4: 0 towels. The following were observed on linen cart #5: 3 towels with ripped/torn, frayed and tattered edges. Towels appear to be make-shift towels that were torn into smaller pieces to make more/extra towels. V33 (Registered Nurse/RN) states the towels were probably cut to make more towels for the residents because the facility is low on towels. On 05/27/2026 at 11:49AM, V16 (Laundry Aide) states he has heard from staff that there are a lack of towels in the facility. V16 states he has also noticed that there are a lack of towels during washing and recirculating the linen. On 05/27/2026 at surveyor tours a linen storage room with V16 located in the basement. Surveyor observes the following inside the storage room: 5 washcloths and 7 body towels with 3 towel having ripped/torn, frayed and tattered edges. Towels appear to be make-shift towels that were torn into smaller pieces to make more/extra towels. On 05/27/2026 at 11:53AM, V17 (Assistant Administrator) states V1 (Administrator) is responsible for ordering linen for the residents in the facility. On 05/28/2026 at 11:41AM, V1 (Administrator) states there is a warehouse that is attached to the facility's corporate office, and she has sometimes got linen from there for residents to use. V1 states she is unable to provide proof of this since she did not order the linen directly.On 05/28/2026 at 12:30PM, surveyor tours another linen storage room with V3 (Assistant Director of Nursing/ADON) located in the basement. V3 uses a key to gain access to this storage room. Surveyor observes the following inside of the storage room: 3 packs of new washcloths. V3 states 50 wash cloths are in each pack, which totals 150 wash cloths. V3 states she is aware of the quality of towels that are in circulation for residents' use and the facility is constantly ordering towels.Facility census dated 05/26/2026 documents that a total of 209 residents reside in the facility.Ombudsman Resident's Rights for People in Long-Term Care dated 11/2018 documents in part, Your facility must be safe, clean, comfortable and homelike.

Based on observation, interview, and record review, the facility failed to a.) ensure a resident (R5) freedom of movement outside the facility by placing the resident on restricted pass privilege for no legitimate reason, b.) ensure Social Services department met regularly with one resident (R4), and c.) ensure proper staff, resident, and representative communication by not ensuring that all facility staff wear an identification badge. This failure has the potential to affect all 159 residents residing in the facility.Findings include: a. 5/27/26 at 9:57 AM, R5 said I have been at the facility for a year and eight weeks. R5 said the facility confused the whole situation regarding the red pass privilege. They confused me with another client. V32 (Social Worker) told me I was confused with another client with the same first name and I was taken off of red pass. I had to stay inside for two days. I felt my civil rights had been taken away. 5/28/26 at 12:07 PM, V13 (Social Services Director) stated in morning meeting, I heard R5 was put on red pass by the receptionist. I don't remember what receptionist. Receptionists do not have the authority to place residents on red pass. There is no documentation regarding the red pass situation. I apologized to R5 and explained it was an error in communication. The error was that the receptionist put R5 on red pass and R5 could not go out. This happened over the weekend and when I came in on Monday I was informed at my meeting and then I rectified it. I went to R5 that Monday and I told R5 they were not on red pass and that they were on green pass. Red pass means residents have broken a facility policy and are unable to go out without supervision. [NAME] pass can go out with or without supervision. I am not able to tell you why the receptionist put R5 on red pass. There is no documentation about this. It happened a month or two months ago. An order is needed from the physician to place on red or green pass. All residents have a standing order for supervised or unsupervised pass privilege. To my knowledge there was no order to place R5 on red pass because it was done by the receptionist who does not have authority. As far as I know the receptionist told R5 verbally they were on red pass. 5/28/26 at 1:45 PM, R5 said on 12/25/25, they came down to go outside to the store and the gym. The receptionist told them they could not go because they were on red pass. The receptionist did not know why. R5 went to V13 (Social Services Director), and they knew nothing about the red pass. R5 said they could not go out for 48 hours. 5/28/26 at 3:30 PM, V1 (Administrator) stated the receptionist was using some old pass list when they told R5 they were on red pass. The receptionist was not using the list updated by the social worker. R5 came to me to see why they were on red pass. I looked into it, and no one knew why R5 was red pass. It was changed to green pass immediately that same day that R5 came to me. R5 said that they were upset because they were not able to go out. I don't remember when this happened, but I know it was this year and more current than December. According to R5's Physician Order Summary Report, R5 has an active order that reads: May go out on pass unsupervised, order date 8/27/2025. According to R5's MDS (Minimum Data Set) 5/1/2026, R5 has a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. Facility Outside Pass Policy, 12/2016, documents in part: This organization is dedicated to providing residents with appropriate opportunities to remain engaged in the life of the community. One means of remaining connected involves leaving the facility grounds with an outside pass privilege (in most cases under the supervision and responsibility of a family member). b. R4 is a [AGE] year-old individual whose medical diagnoses in current face sheet includes but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified abnormalities of gait and mobility, type 2 diabetes mellitus with hyperglycemia, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. R4's MDS (Minimum Data Set) section C- Cognitive Patterns documents R4's Brief Interview for Mental Status (BIMS)Score dated [DATE], documents R4's BIMS as 12/15, indicating R4 has moderate cognitive impairment. On 05/27/2026 at 10:10AM, V13 (Social Services Director) stated she is the social worker for R4. Social services are supposed to meet with a resident at least once every three months to assess their needs. The social services documents resident interaction in resident's health records under progress notes. V13 and surveyor reviewed R4's progress notes. Last Social Services (SS) meeting with R4 and her family was on 09/03/2025. V13 stated another meeting with SS should have been conducted. V13 stated SS meets with residents to discuss resident progress, medications, therapy, verify advance directives, diet, discharge plans and any other needs resident might have. V13 stated she has been too busy to meet with residents frequently. V13 stated if SS do not schedule resident meetings every quarter, resident needs will not be met. Residents can feel confused because of not have answers to their questions. Resident council meeting minutes document:03/20/2026 - Residents would like to see V13 and V37 (Psychiatric Rehabilitation Service Coordinator -PRSC) more around the floors. 04/24/2026-Residents would like to see V13 more often and available. 05/22/2026-Residents would like to see V13 on the floor or open window to talk to her due to being hard to find at times. R4's last Social Services progress note is dated 09/03/2025. Policy titled Social Work Department Policy dated 11.30.22 documents: The department shall, as necessary, work to support each resident's enhanced mental health through: -Provide individual support and attention based upon need. -Conducting rounds and wellness checks. c. On 05/27/2026 at 10:41AM, surveyor located on the third floor of the facility observes that V25 (Licensed Practical Nurse/LPN), V26 (Certified Nursing assistant/CNA), and V28 (Activity Aide) were not wearing a name tag or identification/ID badge. V25 states her ID badge is inside of her purse, V26 states her ID badge is inside of her locker, V28 states she lost her ID badge yesterday. V25, V26, and V28 state they should be wearing an ID badge. On 05/27/2026 at 10:58AM, surveyor located on the second floor of the facility observes that V24 (Registered Nurse/RN), V31 (Licensed Practical Nurse/LPN), V29 (Certified Nursing assistant/CNA), and V30 (CNA) were not wearing a name tag or identification/ID badge. V30 (CNA) states she has been working at the facility since 10/2025 and was never issued an ID badge in the facility. V31 (LPN) states he has been working at the facility for two years and has never issued an ID badge in the facility. On 05/27/2026 at 11:15AM, surveyor located on the first floor of the facility observes V40 (Licensed Practical Nurse/LPN), V20 (Certified Nursing assistant/CNA), V41 (CNA), V42 (CNA), V43 (CNA), V32 (Social Worker), and V22 (CNA) were not wearing a name tag or identification/ID badge. V40 (LPN) states she was never issued an ID badge in the facility. V41 (CNA) states the facility has not provided an ID badge for her in the facility. Facility census dated 05/26/2026 documents that 49 residents reside on the first floor of the facility, 60 residents reside on the second floor od the facility, 49 residents reside on the third floor of the facility, and R5 resides on the fourth floor of the facility. Facility Employee Handbook documents in part, Name badges are supplied by the facility and must be worn by all employees when on duty. Each employee is responsible for his/her name badge and must bear the cost of replacement if it is lost or misplaced. All employees are required to have and wear their ID cards at all times while at work.

Based on interview and record review, the facility failed to report to the State Agency a suspicion of abuse involving one (R16) of three residents in a sample of 17 residents.Findings include:On 5/26/26 at 12:18 PM, R16, said this Saturday I got a visitor, my sister. We were going out on pass. I got it approved with V2 (Director of Nursing). My sister talked to someone about going out. I'm on red pass because I was late coming back from out on pass. So, I can't go out by myself until tomorrow when my red pass is over. I can go out with family. My sister is my #1 emergency contact. I was at the front desk doing paperwork to go out. I was leaving the building. V39 (Social Service Coordinator) comes in saying They aren't leaving the building. I'm getting it (the pass) unapproved. My sister came inside. V39 said I don't need to be here, take them home with you we don't want them here. V39 started yelling at other residents to get out of their way. When V39 was yelling at V23 (Receptionist) and other residents I said to stop yelling at them if you have a problem with me. V39 said to shut up b**** to me. My sister was saying stop talking to me like that. Stop being rude to these residents. You are unprofessional. V2 came and said to go on visit. My sister and I left. I am here for brain aneurysm. I have been here since September 2025. On 5/27/26 at 12:57 PM, V23 (Receptionist) stated I was at the receptionist's desk. I document every resident that comes and goes. An incident took place that should not have taken place. The incident occurred on a Saturday after 2 PM. R16 came to me excited to be going out with their sister and nephew. I called V2 (Director of Nursing) to verify that R16 was going out. I got the release form for the person picking up R16 to complete. V39 (Social Service Coordinator) walks in and starts yelling that R16 is on red pass. V39 comes behind the reception desk, gets on my computer, and starts yelling at R16. That R16 can't go out. R16's sister, who is also an emergency contact, comes into the building. V39 was yelling at the emergency contact. I called a code gray which means an incident/altercation that's happening. Staff showed up. V39 was still yelling at R16 and then started yelling at R16's sister. R16 started crying. V39 was telling R16's sister that when R16 goes out they come back with something insinuating contraband. I called another code gray so another team would come. The current team was in shock wondering what was going on because it was a staff person not the resident that I called for. When I called for the second code grey I inadvertently turned on the intercom, so part of the incident was heard throughout the facility. Residents were lined up to get me to write their names down to go out at the same time. V39 yelled at the other residents What are you waiting on. One resident told V39 they were waiting for a cigarette. V39 was focused on R16. That incident should not have happened. It was heartbreaking. It was sad. I told V39 they were unprofessional and V39 told me I was unprofessional. V39 told me I'm not supposed to be there for the residents. Staff should not be yelling at residents. This is the resident's home. It was inhumane. R16 was being hurt and attacked for no reason. It is a form of abuse. I was upset by the incident. V39 disrespected everybody including myself and the resident. I did not hear mention of a gun from V39. R16 was red pass which means the resident cannot go out by themself. The resident can go out with an escort. I have to know who the resident is going with, and I notify management.On 5/28/26 at 1:55 PM, V1 (Administrator) stated I did not do a reportable because the incident with R16 was between the R16's family member and V39 (Social Service Coordinator) and V23 (Receptionist) and V39 had words. I'm still investigating. I have interviewed V39, R16's sister, R16, V23, a housekeeper and V2 (Director of Nursing).Facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, no date, documents in part: 7. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interviews, and record review the facility failed to ensure an adequate supply of clean towels and linens. Also, that the towels and linens are in good condition and available for resident care. This failure has the potential to affect all 52 of the residents residing on the 2nd floor.Findings include:On 12/23/25 at 11:33 AM, R3 stated she had to buy her own face and hand towels because the facility does not have enough. R3 said, they are short on everything. R3 stated they do not give the CNAs (Certified Nursing Assistants) enough towels to do their job. R3 stated one time when they had to change her, they had to dry her off using a sheet because they did not have a clean towel. R3 stated, the CNAs are always telling her, I don't have this. I don't have that and they never have enough linen especially the towels. R3 stated they must search for supplies to give her the care she needs and that is sad. R3 stated their job is hard enough. R3 stated the sheets have holes in them, and the sheets and towels look dingy (dirty looking, spots on them that look like feces stains). R3 stated one time the only fitted sheets a CNA could find each had a large hole in them. So, what she had to do is put one of the fitted sheets on R3's bed with the hole toward the head of the bed and then the CNA put the 2nd fitted sheet over the 1st sheet but turned it so the hole on that sheet was at the foot of the bed. R3 stated this way the holes were technically covered but she was still laying on sheets with holes on them and that should not be. R3 stated she does not sleep on sheets with holes on them at home and she should not be doing that here, that is not right.On 12/24/25 at 10:19 AM, R12 stated the facility needs to have more towels and face/wash cloths because they do not have enough of them. R12 stated she uses the face/wash cloths to wash her face and a lot of the time they do not have any so R12 cannot wash her face when she wants to. R12 stated when she asks for a face/wash cloth the staff tell her that they do not have any to give her. R12 stated when this happens, she is not able to wash her face and if she was at home she would be able to wash her face when she wanted which is first thing in the morning as part of her regular routine.On 12/23/25 at 12:00 PM, did not observe available towels (bath or face/wash cloths) on the 2nd floor.On 12/23/25 at 1:05 PM, V15 (Laundry) stated there are a set amount of linen supplies he is supposed to deliver each morning to the units however the amount he can deliver is dependent on what he gets back from the units, what is in rotation. V15 stated for example, this morning he only delivered 16 towels (a combination of bath and face towels) to the 2nd floor because that is all he had on hand. V15 stated he knows that is not enough towels for the unit, but the staff will have to make do because that is all he had available to send. V15 stated the staff cuts the bath towels into smaller sized face/wash towels to use as rags to wipe the residents when changing them. V15 stated those cut up towels look like this and held up tattered and very frayed pieces of cut towels, that appeared thin, worn and had a rough texture to them. The cut towels were light gray in color, not white. V15 stated they are doing this because there are not enough face/wash cloths in circulation. V15 stated because there are not enough face/wash cloths the staff uses pillowcases or the flat sheets to clean the residents with. V15 stated he knows the staff is doing this because the pillowcases and flat sheets are coming down to laundry covered in feces, pus, and blood. V15 stated he uses bleach to try to remove the stains but some of the stains will not come out. Surveyor observed V15 randomly picked up three blankets folded in the cleaned area of the laundry room and each blanket had various sized circles of brown stains on them. V15 stated he cannot get those stains out even though they have technically been cleaned. V15 stated he should throw out items he cannot get the stains out of, but the linen/towel supply is too small, so he does not want to throw anything out without being able to replenish the items. V15 stated he cannot send no linen/towels to the unit, so he must send items even if they have stains on them. V15 stated there is a supply closet with new towels/linen but he does not have a key to it or know how to access the supply inside.On 12/23/25 at 1:40 PM, V16 (Licensed Practical Nurse) stated she is one of the nurses covering the 2nd floor unit today and there are 52 residents on unit. V16 stated the staff does not have enough towels to do what they need to do to take care of the residents and that she hears the CNAs complaining all the time that laundry does not deliver enough towels. V16 stated she sees the CNAs having to leave the floor to search for towels so they can clean up their residents. V16 stated the staff uses face/wash cloths to clean up the residents when providing incontinent care and the staff are so short face/wash cloths that they cut up the bath towels into smaller sections, so they have something to use to clean up the residents with. V16 stated she has seen the staff use pillowcases and sheets to clean the residents because they have run out of towels. V16 stated there should be at least two towels per resident (one bath towel and one face cloth). V16 stated if today laundry delivered 16 towels combined (a combination of bath and face) to the unit and the unit has 52 residents living on it then that is definitely not enough towels for the CNAs to do what they need to do.On 12/23/25 at 1:53 PM, V18 (Certified Nursing Assistant) stated when she first arrives there are no towels available, and laundry delivers the linen to the unit at different times. V18 stated there are never enough towels and she needs to go downstairs to look for towels. V18 stated the staff are expected to use the face/wash cloths to clean up residents if they have had a bowel movement but there are not enough of them to use for incontinence care and for showers and drying so V18 buys her own wipes. V18 stated this way she can use the towels for showers and washing residents' face/hands and the wipes for incontinence care. V18 stated if she did not buy her own wipes, she would not be able to do her first set of initial rounds with her residents. V18 stated she has heard other CNAs saying they do not have enough towels to do incontinence care and so they use pillowcases. V18 stated laundry delivers the towels they have available for us but V18 says they deliver half of what we need on the units. V18 stated she has never seen new linens (towels, sheets, blankets etc.) unless it is for a newly admitted resident.On 12/26/25 at 10:36 AM, V18 stated she had enough towels today. V18 stated they have been delivering a lot of towels since you (the surveyor) has been here. V18 stated typically in the morning laundry delivers 16-20 towels (combination of bath and face/wash) for the entire unit but today they sent up more than double of each type (bath and face/wash cloth) so it was way more than usual. Probably because you are here.On 12/24/25 at 9:05 AM, via telephone interview V24 (Certified Nursing Assistant) stated she works the overnight shift on the 2nd floor and there are not enough towels delivered to the unit and sometimes the 2nd floor does not have any towels at all. V24 stated if we do not have towels, the staff have to get creative. V24 stated sometimes she use a clean diaper and puts soap on it to wash a resident. V24 stated she has also had to use pillowcases and flat sheets and take the one big towel and cut them into smaller pieces, so she has something to wipe up the residents to make sure they are clean. V24 stated laundry does not work in the middle of the night and even though she can get the key to go down to laundry a lot of time there is not anything down there so then she scrounges around on the other floors for towels. V24 stated the facility does not provide the staff with enough towels to do the care. V24 stated some staff buy their own wipes which she used to do but she got tired spending her own money. V24 stated administration knows we do not have enough towels, but they do not do anything about it. V24 said, I tell anyone who will listen!On 12/24/25 at 11:23 AM, V27 (Certified Nursing Assistant) stated today she is taking care of 14 residents on the 2nd floor. V27 stated of these 14 residents 11 require incontinence care for bowel/bladder. V27 stated this morning, she received five bath towels and five face/wash cloths. V27 stated the face/wash cloths are used for washing face/hands and for incontinence care but she buys her own wipes to use on her residents. V27 stated she would be short towels if she did not buy her own wipes to use for incontinence care.On 12/26/25 at 11:44 AM, via telephone interview V35 (PM Nursing Supervisor/Licensed Practical Nurse) stated the facility does have a linen shortage, V35 stated it is a recurrent problem and makes the CNAs job more difficult when they are not readily available.On 12/24/25 at 10:07 AM, V4 (Assistant Administrator/Business Office Manager/Human Resources/Housekeeping/Laundry) stated if there are 52 residents on the 2nd floor then laundry should be delivering 10 towels and 10 face cloths for each CNA and the 2nd floor unit typically runs with five CNAs. So, that would be a total of 50 towels and 50 face/wash clothes delivered to the 2nd floor. V4 stated it is important for the staff to have an adequate supply of towels so they can provide resident care. V4 stated the laundry staff is always complaining that the pillowcases and sheets have feces on them. V4 stated sometimes the CNAs do not want to come down and get more towels so they will use the pillowcases and sheets to wipe up residents when doing incontinent care because that is easier for them. V4 stated she also know some of the CNAs bring their own wipes to do patient care because the wipes are easier, more convenient and because the wipes are always available when the towels are not on the unit. V4 stated some of the CNAs cut up the big towels into smaller pieces so they can be used for incontinence care. V4 stated when laundry does not have enough towels, they notify her or V1 and they give them new towels from the supply room.On 12/31/25 at 12:15 PM, V1 (Administrator) stated she gave laundry a list of what line/towels and how much should be sent to the unit at every shift six months ago. V1 stated laundry was told that if they are short and lack supplies to let her know so she can pull them from the supply closet. V1 stated if they do not come to her to communicate that they need more linen/towels than she is not aware that it is a problem and do not know they need more supplies. V1 stated the staff should have the supplies they need to take care of residents correctly and timely, that is important.R3 has a diagnosis of but not limited to Body Mass Index [BMI] 45.0-49.9, Contracture, Right Knee, Contracture Right Ankle, Morbid (Severe) Obesity Due To Excess Calories, Type 2 Diabetes Mellitus with Hyperglycemia, Osteoarthritis of Knee, Arthrodesis Status, Presence Of Right Artificial Knee Joint, Unspecified Protein-Calorie Malnutrition. R3's MDS (Minimum Data Set) dated 10/19/25 reveals R3 is cognitively intact, has functional limitations in range of motion (ROM) to one side of left extremities, and requires substantial/maximal assistance for toileting hygiene, showering/bathing, personal hygiene and for mobility including all transfers. R3's MDS also indicates she is always incontinent of urine and bowel.R12 has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Constipation, Morbid (Severe) Obesity due to Excess Calories, Thrombocytopenia, Long Term (Current) Use Of Insulin, Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Unsteadiness on Feet, Unspecified Abnormalities of Gait and Mobility, Other Lack of Coordination. R12's MDS dated [DATE] reveals R12 is cognitively intact and requires substantial/maximal assistance for toileting hygiene, showering/bathing, personal hygiene. R12 is dependent on staff for chair/bed to chair transfers. R12's MD also indicates she is always incontinent of urine and bowel. Facility provided policy titled Resident Rights dated 06/01/22 which documents in part the federal and state laws guarantee certain basic rights to all residents of this facility and these rights include the resident's right to: a dignified existence and be treated with respect, kindness and dignity.

Based on interviews and record reviews the facility failed to prevent resident to resident physical assault for two (R10, and R11) out of four residents reviewed for abuse. This failure resulted to R10 sustaining a skin abrasion.Findings Include:R10's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (14) indicates R10 is cognitively intact. R10's Electronic Health Record/EHR shows she was admitted to the facility on [DATE], and she is [AGE] years old.On 12/24/25 at 1:07 PM, R10 reported to surveyor that as she was coming out of the dining room after eating dinner, she cannot remember the date or time R11 hit her as he was walking into the dining room. R10 used her hand to indicate that R11 hit her with a closed fist on the left side of her face. She stated R11 hit her on purpose, and it hurt when he hit her. She also stated that she went to the nursing station because she was bleeding on the left side of her face. V30 (Licensed Practical Nurse/LPN) and V31 (Certified Nursing Assistant/CNA) wiped the blood from her face, so she refused to go to the hospital because it was a little scratch. R10 stated she has not seen R11 since the incident, she feels safe in the facility, and that staff has been applying ointment twice a day and she denies any pain at this time. Surveyor observed mall scar on the left lower side of R10's face, open to air and no signs or symptoms of infection.On 12/24/25 at 1:22 PM, V1 (Administrator) stated she was made aware of the abuse allegation between R10, and R11. V1 stated R10 and R11 were both walking down the hallway, he flung his hand and hit R10 in the face, she sustained an abrasion, but she does not know if R11 intentionally hit R10 or not. R11 was sent out for psychiatric evaluation, and he is still in the hospital.On 12/24/25 at 1:57 PM, V30 (Licensed Practical Nurse) stated on 12/15/25, R10 approached her and told V30 that R11 had hit her in the face. V30 stated she called V3 (Assistant Director of Nursing) to the unit and she came up to the unit right away, called the police, R10 and R11's physicians and their family members. V30 stated she could see blood on R10's face and the blood were coming from the left side of R10s' face. V30 stated R11 hitting R10 was not an accident. V30 stated R10 is a calm person and keeps to herself. She does not provoke anyone. R10 was upset but not crying. She kept asking are they sending him out? Are they going to send him out? V30 stated R11 was petitioned to go to the hospital for a psychiatric evaluation because R11 had hit R10. V30 stated when the ambulance arrived R10 declined going to emergency room, and she signed that she did not want to go to the hospital. V30 stated R10 said that she had given her first aid and it was only a scratch and therefore she did not need to go to the hospital for anything. V30 stated she has seen R10 since this event and that R10 has not verbalized having any fear and is not saying she does not feel safe at the facility. V30 stated there has been no change in R10's behavior or mood, a resident hitting another resident is an example of physical abuse, it is important to know the different kinds of abuse and monitor the residents for abuse because the residents should feel safe in the facility.On 12/24/25 at 2:22 PM. V3 (Assistant Director of Nursing) stated when she assessed R10, she could tell R10 was frightened because she was shaking, almost as if she was in shock about what just happened. V3 stated R10 is the nicest lady and is always calm, R11 was a new admit so the facility did not really know his behavior and up until that point he did not show any signs or symptoms of agitation, irritability, or aggression. V3 stated she could see blood on R10's face coming from a superficial skin tear on the left lower side of her face.On 12/24/25 at 2:45 PM, V31 (CNA) stated that R10 came to report that R11 struck her on the side of her face. She noticed a small cut with little bleeding on R10's cheek, she stayed with R11 to provide one-on-one monitoring until the Chicago police came. V1 is the abuse coordinator, and hitting another resident is a resident-to-resident physical abuse.On 12/30/25 at 11:33 AM, R11 received in the dining room, stated he pushed his index finger (showed the surveyor his index finger) on the left side of R10's face (pointed his finger on the lower left of his face), but he did not know why he pushed his finger on her face. He also stated that he saw little blood on R10's face, he felt bad, and he will be mad if someone pushed finger on his face. He has not seen R10 since the incident, no one has been abusive to him, and he feels safe in the facility.Nurses progress notes on 12/15/25 document in part: Resident (R11) was assessed following an incident in which he struck another resident (R10) in the face while passing her in the hallway.Police report dated 12/15/25 document in part: Battery Simple.R10's skin only evaluation dated 12/20/25 document in part, skin abrasion, left face.R11's Trauma, abuse, neglect screening assessment dated [DATE].Abuse Policy, undated, document in part: Residents have the right to be free from abuse.

Based on interview and record review the facility failed to report resident to resident physical abuse to the State Agency for two (R10, R11) out of four residents reviewed for abuse.Findings Include:On 12/24/25 at 1:07 PM, R10 reported to a fellow surveyor that she was hit in the face by R11 as R11 was walking into the dining room. R10 used her hand to indicate that R11 hit her with a closed fist on the left side of her face. R10 stated she went to the nursing station to report it because she was bleeding on the left side of her face. R10's Minimum Data Set (MDS) dated [DATE] indicates R10 is cognitively intact. R10's skin evaluation dated 12/20/25 indicates skin abrasion left side of face close to the chin (1.5x1.0x0.1). On 12/24/25 at 1:57 PM, V30 (Licensed Practical Nurse) stated on 12/15/25, R10 told her that R11 had hit her in the face and V30 could see blood coming from the left side of R10's face. V30 stated she called V3 (Assistant Director of Nursing) to the unit and the police, R10 and R11's physicians and family members were notified. V30 stated R11 was petitioned to go to the hospital for a psychiatric evaluation because R11 had hit R10. R11's electronic health record (EHR) dated 12/15/25, 18:10 progress note entered by V3 (Assistant Director of Nursing) documented in part, the resident was assessed following an incident in which he struck another resident in the face while passing her in the hallway and the attending physician, resident's family and facility administrator were notified. On 12/30/25 at 11:33 AM, R11 reported to a fellow surveyor that he pushed his index finger (showed the surveyor his index finger) on the left side of R10's face (pointed his finger on the lower left of his face) and that he saw a little blood on R10's face.R11's MDS dated [DATE] indicates intact cognition. On 12/30/25 at 2:38 PM, V3 stated she was the one to call V1 (Administrator) at the time of the incident because V1 is the Abuse Coordinator. V3 stated she also called V2 (Director of Nursing) to report the incident to her as well. V30 stated she does not know who reported it to the State Agency. V30 stated that is not her job and she does get involved with reporting to the State Agency, only to notify V1. On 12/24/25 at 1:22 PM, V1 (Administrator) stated any abuse with an injury must be reported to the State Agency within 2 hours and then the facility has five business days to complete the investigation and send a final report to the State Agency. V1 stated she was notified over the phone on 12/15/25 about the incident between R10 and R11. V1 stated V2 was the one who submitted the reportable to the State Agency on 12/15/25 and the final was sent on 12/22/25. V1 stated when you submit a facility reported incident to the State Agency an email is not always generated to serve as proof of the time and date the facility submitted the report. V1 stated to get a confirmation back from the State Agency there is an extra step which needs to do done to receive one. Surveyor observed V1 looked through the facility reportable documentation dated 12/15/25 and stated, I don't see the State Agency confirmation letters attached which means the DON who submitted the report didn't know she was supposed to do that step. That is why there is no confirmation for the date/time submitted to the State Agency.On 12/30/25 at 9:05 AM, V2 (Director of Nursing) stated on the night of the incident between R10 and R11 V3 had called her and told her what happened and V3 reported that she had already notified V1. V2 stated she had already left the building and did not have access to a computer because she was at a concert. V2 stated she sometimes she completes the initial paperwork and V1 will ask her to submit the initial report to the State Agency but this time because V2 did not have access to a computer. V2 stated V1 told V3 that V1 would complete the initial paperwork and submit it to the State Agency. V2 stated if V1 wanted her to submit the report to the State Agency V1 would have texted her about it and V1 did not text her anything about it that night because V1 knew she was at a concert and did not have access to a computer. V2 stated abuse allegations need to get reported to the State Agency within two hours of the event and when V2 does submit to the State Agency she does it via email. V2 stated the State Agency does not send her a confirmation email so what she does is print out a copy of the email she sent to the State Agency which has the date/time sent and includes this email with the other paperwork for the abuse allegation/investigation as confirmation the State Agency was notified. V2 stated like she said she had no involvement in this case initially. V2 stated for the final report she did get involved in the interviewing part of the investigation but V1 did not ask her to send the initial or final to the State Agency.On 12/31/25 at 12:15 PM, V1 stated V2 keeps saying that V1 did the initial submission on 12/15/25 but V1 was under the impression that V2 was doing it. V1 said, most of the time it is me. I don't remember doing it. I thought the Director of Nursing was doing it. V1 stated it might have been a miscommunication problem. Surveyor with V1 looked through the other abuse reportables from the past three months and noted there is a confirmation of the report sent to the State Agency along with the investigation report for all of them except the incident on 12/15/25. V1 stated incident on 12/15/25 is missing because she does not think it was done. V1 stated if the State Agency does not have a record of the submission, then that means it was not done. V1 stated it is important to notify the State Agency within two hours because the State Agency needs to be made aware of the situation and know what the facility did so the residents are not in danger anymore and free from abuse.On 12/24/25 at 2:38 PM, surveyor confirmed with a Public Service Administrator at the State Agency that the facility did not submit a facility report for the incident on 12/15/25 involving R10 and R11.Facility provided initial report for incident date 12/15/25 involving R10 and R11 undated, not timed and with no evidence of submission to the State Agency.Facility provided final report for incident date 12/15/25 involving R10 and R11 undated, not timed and with no evidence of submission to the State Agency.Facility provided policy titled Abuse Investigation and Reporting undated which documents in part, all reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and an alleged violation of abuse will be reported immediately but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violation does not involve abuse and has not results in serious bodily injury.

Based on interviews and record reviews, the facility failed to follow their policy to investigate and prevent further allegation of abuse. This failure affects one (R2) out of three residents reviewed for abuse. Findings Include: On 12/23/25 at 2:58 PM, via telephone, R2 stated that V21 (Certified Nursing Assistant/CNA) was verbally abusive to her because she said that R2 cannot clean her own a** and she will get to R2 when she is able. R2 cannot remember the date/time and there was no witness. R2 also stated that V22 (Restorative Aide) played mental games with her by showing up to provide restorative therapy and often came to her when she is doing something else.On 12/23/25 at 3:58 PM, Surveyor informed V1 (Administrator) that R2 has allegation of verbal abuse against V21, and mental abuse against V22, she stated she has no report against V21 and V22 by R2, but she will follow up. On 12/26/25 at 4:12 PM, V1 stated the facility protocol/policy on staff to resident abuse is that the employee would be immediately suspended and not be allowed to return until her investigation is complete however this is different because she concluded her investigation prior to those employees being scheduled again. This situation is different because R2 is no longer in the building, and she cannot afford not to have staff here especially over the holidays so even though she has five days to complete her investigation, she completed as soon as she could so that she would not have to suspend any employees. V1 also stated that she notified V21 and V22 on 12/23/25 that there was an allegation of abuse against them and completed her investigation on 12/24/25. She talked to V22 on 12/23/25 on the phone about the allegation and interviewed him then. She finished the interviews related to V22 on 12/24/25. V22 was not working on 12/24/25 or 12/25/25. She talked to V21 on 12/23/25 about the allegation, interviewed her and finished all the interviews she needed related to V21 on 12/23/25. She felt comfortable letting her come to work on 12/24/25. Because she was able to make the determination right away the staff was allowed to return to work and did not need to be suspended. On 12/31/25 at 12:32 PM, V1 stated that technically, she had already made the decision on 12/23/25 not to substantiate the allegation so the interviews she did on 12/24/25 were not going to have an impact on her decision. Because of this she does not have any problem bringing them back to work. She allowed both to work on 12/24/25 because she had finished her investigation on 12/23/25. On 12/24/25 at 11:15 AM, V22 (Restorative Aide) stated that he did not abuse R2 mentally; he did not play mental games with her by asking to provide her restorative program when she was in the middle of something. On 12/30/25 at 11:02 AM, surveyor observed V22 on the first floor, stated that 12/24/25 was the first time V1 spoke with him about mental abuse allegation by R2.On 12/24/25 at 12:04 PM, V21 (CNA) stated she is familiar with R2, she was not verbally abusive to her, she did not abuse her, and she did not tell R2 that she cannot wipe her own a**.On 12/31/25 at 11:01 AM, V2 (Director of Nursing/DON) stated that it is the policy of the facility to suspend immediately any staff accused of abuse pending the final investigation to protect other resident from potential abuse. If the alleged staff is on duty at the time of the report, the staff should punch out immediately, but if the alleged staff is out of the facility at the time of the report, the facility will notify the staff not to come to work while investigation is ongoing.Documents reviewed for this investigation are not limited to the following: Abuse Policy documents in part: Protect residents from any further harm during investigations.Abuse Investigation and Reporting documents in part: The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Abuse in-service attendance record dated 6/23/25, and 9/7/25. Reportable dated 12/23/25, and final faxed to the State Agency on 12/30/25.

Based on interviews, and record reviews, the facility failed to administer medication as prescribed by the physician. This failure affects two (R2, R4) out of five residents reviewed for medication administration. Findings Include: R2's Electronic Health Record/EHR shows she was admitted to the facility on [DATE], she is [AGE] years old with a Brief Mental Status/BIMs score of 15. R2 has diagnoses not limited to Glaucoma, anxiety disorder, and major depressive disorder.R4's Electronic Health Record/EHR shows he was admitted to the facility on [DATE], he is [AGE] years old with a Brief Mental Status/BIMs score of 15. R4 has diagnoses not limited to cellulitis of left finger, methicillin resistant staphylococcus aureus infection, open wound of left thumb without damage to nail, homelessness, contact with and suspected exposure to other viral communicable diseases, and presence of cardiac and vascular implant and graft. On 12/23/25 at 2:58 PM, via telephone, R2 stated that twice in September, she was not given all required doses of her eye drops.On 12/30/25 at 12:30 PM, surveyor and V3 (Assistant Director of Nursing/ADON) reviewed R2 and R4's Medication Administration Record/MAR for September. V3 stated that daptomycin was not given to R4 on 9/28/25, and on 10/1/25. She also stated that R4 should not miss his antibiotic medication to ensure proper treatment of his infection. R2's eye drop (brimonidine tartrate) was not signed on 9/12/25, and 9/13/25, and when MAR is not signed, that means the medication was not given.On 12/30/25 at 1:07 PM, via telephone, V46 (Nurse Practitioner/NP) stated that she has been in the facility since June 2024, she is familiar with R4, and he was on daptomycin antibiotic intravenous/IV daily from 9/26/25 until 10/29/25. On 9/29/25, the pharmacy sent a memo that R4's insurance will not cover daptomycin without a prior authorization which she completed on 9/29/25, but it was still not approved so she ordered vancomycin as an alternative on 10/2/25 because that was when she was told that daptomycin was not approved. V46 stated R4 should not miss his antibiotic because it could worsen his infection.On 12/30/25 at 2:47 PM V49 (Registered Nurse/RN) has been in the facility for eighteen years, she works 3pm-11pm shift mostly on the first floor. Nurse should follow doctors order to maintain health of the resident. She stated the MAR should be signed once medication is given, if MAR is not signed it means the medication was not given. She stated she worked on 9/12/25 and 9/13/25 with R2, she does not know why she did not sign the MAR on both days for R2's eye drop (brimonidine tartrate). The potential effect of missing eye drops as ordered could increase R2's eye pressure.R2's Physician Order Sheet/POS active order as of 9/1/25 shows brimonidine tartrate ophthalmic solution 0.15%, instill 1 drop in both eyes every eight hours related to glaucoma.R2's MAR showed missed doses of Brimonidine Tartrate on 9/12/25 at 6am, and on 9/13/25 at 10pm.R4's Physician Order Sheet/POS active order as of 9/26/25 shows daptomycin intravenous/IV solution, one time a day for thumb cellulitis until 10/29/25.R4's MAR showed daptomycin IV was not given on 9/28/25, 10/1/25, and 10/2/25 at 9am. Progress notes, R4 was transferred to the hospital on [DATE]. Registered Nurse and Licensed Practical Nurse Job description, document in part, Carry out medical providers orders according to the order and in accordance with local, state, federal, and facility policies and procedures. Policy on Administering Medication dated 9/2/25, document in part, medications are administered in a safe and timely manner, as prescribed.

Based on interview and record review, the facility failed to treat a resident's personal belongings with respect. This failure affects one (R1) resident out of four residents reviewed for resident rights. Findings include: On 09/19/2025 at 9:47AM, V3 (R1's Family Member) states she transferred R1 to another nursing home and her uncle went to pick R1's items up from the facility. V3 states her uncle noticed chocolate leaking on R1's clothes and all of R1's things were placed in one bag and on a filthy cart. On 09/23/2025 at 11:39AM, V2 (Director of Nursing/DON) states she was out of the facility and received a phone call from V6 (Licensed Practical Nurse/LPN) informing her that R1's male family member arrived to the facility to pick up R1's belongings. V2 states the facility was not aware that R1's family would be picking up R1's belongings. V2 states to her understanding, R1's clothes were placed in a clear plastic bag and given to R1's male family member. V2 states V6 (LPN) told her that she would let a Certified Nursing Assistant/CNA staff member pack up R1's belongings. V2 states the male family member refused to take R1's clothes and only took a picture of R1's belongings. V2 states she later found out that R1's male family member refused to take R1's belongings due to them being covered in chocolate. V2 states a week later, she received a phone call from V3 (R1's Family Member) stating that V3 wanted a refund for R1's belongings due to chocolate getting all over R1's clothes. V2 states she offered V3 to wash R1's belongings but V3 refused. V2 states V3 also asked to speak with V1 (Administrator) about the matter. V2 (DON) states she informed V3 (R1's Family Member) that V1 was in a meeting. V2 states she gave V1's contact information to V3 and V3 stated she would call V1 back. V2 states she informed V1 about the matter and later asked V1 (Administrator) if V3 had contacted her and V1 said V3 had not contacted her yet. V2 states when a resident goes out to the hospital, their belongings are packed up by the CNA staff and placed in storage. V2 states resident belongings should be packed properly and food items are not supposed to be packed with clothing items. On 09/23/2025 at 2:23PM, V6 (Licensed Practical Nurse/LPN) states R1's brother came to the facility to pick up R1's belongings but she was unaware of where R1's belongings were located. V6 states she then called V2 (DON) and sent V7 (CNA) to go and try to locate R1's belongings. V6 states she is not sure who packed R1's belongings but V7 came back with R1's bag already packed and brought it down on a rolling cart. V6 states R1's brother refused to take R1's belongings due to chocolate being spilled all over R1's clothes. V6 states she saw there was a bottle of chocolate syrup located inside of R1's clothing bag and had wasted all over R1's clothes. V6 states the facility offered to wash R1's clothes but R1's brother refused to take R1's belongings and then left the facility. An attempt to contact V7 (CNA) was made on 09/23/2025, no answer, left voice message, awaiting call back.On 09/23/2025 at 2:36PM, V1 (Administrator) states she was never made aware by anyone that V3 (R1's Family Member) wanted to speak to her about a refund regarding R1's clothing. V1 states V2 (DON) just informed her today that there was an incident involving R1 having chocolate wasted on her clothes. V1 states food items should not have been placed in a bag with R1's clothes and it was most likely an error. Facility policy dated 03/2025 titled Personal Property documents in part, 2. Resident's belongings are treated with respect by the facility staff, regardless of perceived value.

Based on interview and record review, the facility failed to prevent verbal abuse by a staff member for one resident (R1) and physical abuse by residents for three residents (R3, R5, R7) reviewed for abuse, in a total sample of eight. Findings include: Facility's final incident report date (4.23.2025) documents in part: On 4.17.2025, at approximately 11:40 AM, writer received a report of a verbal altercation between a resident (R1) and employee (V3 LSW-Former Licensed Social Worker) in the 2nd floor dining room. Investigation completed. Based on statements and observations it is determined that employee (V3) was inappropriate in the way she was speaking to the resident. Although the resident was very inappropriate as well and antagonizing towards the employee, it is not acceptable for employees to engage in argumentative behavior or use profanity with residents. The employee has been terminated. On 5.29.2025, at 12:25 PM, via telephone, V8 (LPN-Licensed Practical Nurse) stated, I didn't see it happen (altercation between V3-Former LSW and R1), I heard everything. I heard people arguing. It was during lunch time. As I was rounding the corner with my medication cart, on my may way to the dining room. I saw V3 first, she was yelling F*** you, b****. Then I heard R1 say, no F*** you. Then V3 say, no F*** you. V3 continued to the desk, saying what is her problem? V3 picked up the phone, called someone then ran downstairs. I went downstairs after attending to R1 and reported the incident to V2 (DON-Director of Nursing). V8 stated I also spoke with V2 (Administrator), she took my statement. When asked by surveyor if this was an example of abuse, V8 responded, absolutely, it's abuse, that's why I reported it. On 5.29.2025, at 2:21 PM, V5 (CNA-Certified Nursing Assistant) stated, I was passing trays. I didn't hear exactly how it started. I just heard some loud arguing between V3 and R1. From what I heard, R1 had said a bad word to V3, that's how it escalated. V3 screamed back at R1 using the f word and the b word. It was screaming back and forth, V3 just walked out. She (V3) shouldn't had done that. That's verbal abuse. That was wrong to scream back even though she was overwhelmed. V3 was not available for interview. On 5.29.2025, at 3:07 PM, R1 stated, I was talking to someone, V3 interrupted. I told her (V3), I wasn't talking to you. V3 said, 'you don't tell me what to do. I told her she's always up in people's business and to mind her own business. She said f*** you. I said no, f*** you. She kept repeating that as she was going down the hall. I couldn't believe it. I felt that was abusive, that was so wrong. Facility's final incident report dated (5.4.2025) documents in part: it was reported that (R2) allegedly hit (R3) on her head. Based on the investigation it does not appear the (R2) was willful in his actions. On 5.29.2025, at 4:00 PM, R2 denied hitting R3. On 5.30.2025, at 10:00 AM, via telephone, V11 (CNA-Certified Nursing Assistant) stated, R3 was sitting in a chair near the nurse's station. R2 was walking around the unit. He (R2) passed by R3 and hit R3 on the head with his fist and kept walking. It was unprovoked. I reported it to the nurse. R3 was not available for interview. Facility's final incident report dated (5.13.2025) documents in part: residents started arguing and (R4) used a comb and scratched (R5) on her face. Interviews of both residents conducted. (R4) stated that she felt like (R5) was putting gas in her face when she noticed (R5's) stump shrinker in the bathroom. She (R4) did not know what it was and in her mind it was spreading gas in her face. When interviewing (R5) she stated that all of a sudden (R4) came out of the restroom and hit her in the face with her comb causing some superficial scratches. On 5.28.2025, at 12:03 PM, R5 stated, R4 was angry with me about my sleeve (for prosthetic devices). I washed my sleeve and told R4 it was hanging on the towel rack to dry. She (R4) started to make all these accusations. She (R4) said I was going to give her coronavirus and a foot disease. She (R4) attacked me with a sharpened comb. She (R4) raked it across my face. I defended myself and I hit her (R4). She (R4) left the facility. They promised me she wouldn't return to the facility, that's why I didn't press charges. But she's (R4) back. I don't feel safe here. She's (R4) on a different unit. On 5.29.2025, at 12:52 PM, V10 (CNA-Certified Nursing Assistant) stated, the two of them (R4 and R5) were arguing, getting into an altercation of fighting. What it was about, I think, was that R4 thought that she could catch coronavirus or a disease from R5's sleeve (prosthetic). I was at the nurse's station; I heard a loud commotion. I ran toward the arguing. They were just verbally arguing when I first found them. Then, R4 was getting more excited and swung at R5 with a comb. R4 made contact with the comb. R5 had scratch on her face. On 5.29.2025, at 3:55 PM, R4 stated (referencing R5's prosthetic sleeve), it was burning my face. She (R5) was hitting me and rolling over me with her wheelchair. I did not touch her at all. Facility's final incident report dated (5.23.2025) documents in part: residents had a verbal confrontation and (R6) slapped a cup out of (R7's) hand causing the cup to hit her (R7) in her lip. (R6) was very apologetic that he lost his temper but feels (R7) kept telling him what to do. (R7) denied saying anything to (R6) Abuse Prevention Program (reviewed 9.1.2024) documents in part: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Residents' Rights for People in Long-term Care Facilities (undated) documents in part: You have the right to safety and good care. You must not be abused by anyone-physically, verbally, financially or sexually.

Based on interview and record review, the facility failed to follow their fall clinical protocol for one (R1) resident out of four residents reviewed for falls in a total sample of five residents. Findings include: On 04/22/2025, at 11:38 AM, V3 (Registered Nurse/Nursing supervisor) states that upon checking on R1 at 9:30 AM, he was eating breakfast by himself. Staff did the rounds again. Staff has the 72 hours post fall procedure, because he fell at 6:30 AM, I think. We are going to recheck again what happened. V2 stated when I saw him around 10:00 am, I (V3) saw that his (R1s) left side was getting a little bit weaker, because that's his strong side. His right-side is usually the weak side. V3 stated, I (V3) checked his vital signs immediately. I think R1s oxygen saturation became low. V3 stated I (V3) documented in the electronic medical record, in the nurses' note, and documented the vital signs. I (V3) asked someone to be with R1 and I called 911. V3 stated I (V3) informed the doctor and the daughter as well. V3 states that the policy and procedure for an unwitnessed fall is if we see the resident on the floor, we immediately assess vital signs, complete a head-to-toe assessment, check the range of motion, assess changes in level of consciousness, and do a pain assessment. If the resident is alert, staff asks them if they hit their head. V3 stated that if a resident is not alert and cognitively able to answer questions, then we need to check the head-to-toe assessment, check head for bumps, and skin (redness, skin tears). After the assessment, if there no injuries, staff will safely get them back to their bed or wheelchair. It depends on where they fell . V3 continues we will inform the doctor regarding what happened and the assessments. Then, staff will see if there are new orders and inform the family too. On 4/22/2025, at 12:50 PM, V5 (Licensed Practical Nurse) reported it is important to review medications especially if the resident is on a blood thinner. I would call the doctor, let them know, and make them aware of the medications that they are on. V5 stated sometimes I can convince the doctor, based on his medications that he is taking. For example, if they are on blood thinners, this places the resident at risk for internal bleeding. V5 stated that the complications of internal bleeding are death and/or brain damage. On 04/22/2025, at 1:35 PM, via telephone V6 (Registered Nurse) stated that when V6 was rounding and starting her medication administration pass, one of the CNA (certified nursing assistant) notified her that R1 was found sitting on the floor next to his bed. V6 states I went in there immediately. All of his vital signs were normal. Staff assisted him back to his bed. Five minutes later he was back on the floor again. V6 reported that R1's vital signs were taken. R1's doctor and family were notified. V6 states that she reported to V13 (R1's primary physician) that R1 had an unwitnessed fall. Staff assessed R1 immediately and vital signs normal. We kept monitoring him closely. V6 reports that she does not know if R1 hit his head because it was an unwitnessed fall. V6 reports that R1 was able to respond to his name or where he was. V6 asked him if he hit his head. R1 stated no and denied any pain. On 4/23/2025, at 10:36 AM, via telephone V7 (Certified Nursing Assistant) stated the nurse came to help me get him up off the floor. I don't know what happened. When I got to his room, I saw him sitting on the floor. V7 states that R1 did not have any visible injuries. V7 stated that R1 was assessed by V6 (Registered Nurse). I just helped R1 back to bed. V7 stated that R1 fell around 6:30 in the morning. On 4/23/2025, at 2:59 PM, via telephone V13 (R1's primary physician) states staff can do neuro checks. But if he (V13) was informed that the resident is taking antiplatelet medication and had unwitnessed fall, and we do not know if he hit his head or not, R1 would need to have a CT (brain) scan. Even if it was reported to V13 that R1's vital signs were stable. V13 reports that V13 would order for R1 to be sent out with this information. V13 states that the nurses should be following the facility's policies and procedures. R1's face sheet documents that R1 is a [AGE] year-old male with diagnoses not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, dysarthria and anarthria, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications, depression, unspecified, cerebral infarction, unspecified, long term (current) use of oral hypoglycemic drugs. R1's MDS/Minimum Data Set, dated dated dated [DATE], documents that R1 has a BIMS/Brief Interview for Mental Status score of 04/15, indicating that R1 is severely cognitively impaired. R1's care plan documents in part the resident is at risk for falls r/t (related to) dx/hx (diagnoses/history) of CVA (Cerebrovascular accident) with right hemiparesis. R1's health status note dated 3/28/2025, 9:24 AM, documents 6:30 AM staff reported that resident was found sitting on the floor, next to his bed. Resident (R1) was assessed immediately, with no complaints of pain or discomfort at this time. Vital signs were obtained, 130/70, P (pulse):76, RR (respirations):18, Temp (temperature):96.4, O2 (oxygen):97%. Family and MD (medical doctor) notified. Will continue to monitor. R1's health status note dated 3/28/2025, 10:13 AM, documents in part 9:55 AM Observed resident with left sided weakness. Vital signs taken. Head of bed elevated, placed on oxygen. Called 911. V13 (R1's primary physician) notified. Daughter made aware. Facility document dated 09/01/2024, titled falls- clinical protocol documents in part, the nurse shall assess and document/report the following: all current medications, especially those associated with dizziness or lethargy; and all active diagnoses. The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant.

Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident (R2) during incontinence care out of three residents reviewed for resident rights. Findings include: On 1/14/2025, at 9:53 AM, V6 (Laundry and housekeeping) stepping out of the laundry room. This surveyor asked V6 where the clean towels are. V6 showed this surveyor the folding laundry room. There were two towels in the folding laundry room. On 1/15/2025, at 2:29 PM, R2's room door closed with small linen cart in front of the room, no washcloth towels or regular towels noted. R2 agreed for this surveyor to observe V11 (Certified Nursing Assistant) providing patient care to R2. R2 lying on her bed, and in no apparent distress. V11 seen throwing one soiled towel in a clear bag. R2 is turned to her left side, facing the window, but able to turn her head to view the front end of her bed. V11 walked outside of R2's door and approached the small linen cart. R2 states they are always running out of towels and sometimes they wipe her (R2) with pillowcases and bed sheets. V11 then walked in and utilized a white bed/flat sheet to wipe R2's bottom. R2 states if they would provide them with towels, they will be able to provide residents with proper patient care. On 1/15/2025, at 2:33 PM, V11 (Certified Nursing Assistant) states that she used a bed/flat sheet to wipe R2's bottom because she didn't have any more towels. On 1/16/2025, at 2:04 PM, V1 (Administrator) states that before she was administrator there was a concern about having enough linen towels. V1 states that she has asked V7 (Transportation coordinator/Central Supplies) to routinely order the towels. V1 states that she thinks nursing aid staff get confused and throw away the towels. V1 continues I can't have housekeeping checking the garbage. V1 states that she does not refuse to buy towels. V1 reports that if the staff were to be not using the linen towels, the residents can have skin breakdown, and it also affects the residents' dignity. They have the right to have the same environment as they would at home. R2's current face sheet documents that R2 is a [AGE] year-old individual with diagnoses not limited to: osteoarthritis of knee, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus with hyperglycemia, contracture, right knee, contracture, right ankle. R2's MDS/Minimum Data Set Section C dated 10/16/2024 documents that R2 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R2 is cognitively intact. R2's MDS/Minimum Data Set Section H dated 10/16/2024 documents that R2 is always incontinent of bowel, and occasionally incontinent of bladder. R2's current care plan does not document that R2 is to be provided incontinence care with bed sheets. Facility document not dated title Statement of Resident Rights Cont. documents in part respect and dignity. The resident has a right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on observations, interviews, and record reviews, the facility failed to provide timely nail trimming and care for one resident (R1) in the sample of three residents (R1, R2, R3) when reviewed for activities of daily living (ADL) care. Findings include: R1's Admission Record documents, in part, diagnoses of moderate intellectual disabilities, acute kidney failure, major depressive disorder, hypertensive heart disease without failure, anxiety disorder, schizoaffective disorder, and scabies. R1's Minimum Data Set (MDS) dated [DATE], documents in part a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact. R1's Functional Abilities and Goals for Self-Care documents, in part, that for shower/bathe self is coded as partial/moderate assistance where helper does less than half the effort, and for personal hygiene as the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands is coded as supervision or touching assistance where assistance may be provided throughout the activity or intermittently. On 9/30/24 at 12:34 pm, this surveyor entered R1's room with R1 laying in bed and observed R1 holding an unopened milk carton (8 fluid ounces). R1 observed struggling to open the milk carton by R1's self. R1's fingernails observed long on all fingers with debris noted under the nails. R1 asked for assistance with opening the milk carton from this surveyor. Surveyor called staff to come to help open R1's milk carton. On 9/30/24 at 12:36 pm, V3 (Registered Nurse, RN/Wound Care Nurse, WCN) answers R1's call light. R1 observed asking V3 for help opening milk with slight shaking to R1's hands. R1 stated, I (R1) can drink it, but I don't want to spill it. V3 and V14 (Licensed Practical Nurse, LPN) assisted to reposition R1 up in the bed and elevated R1's head of the bed. R1's arms and legs observed with small scabs on arms and legs from R1's healing rash. V3 then took the milk carton from R1's hands with long fingernails, opened the milk carton and assisted R1 with positioning milk carton with a straw so R1 can drink the milk. After staff left R1's room, R1 stated that R1 has had R1's skin rash to hands, arms, and legs for a few months, but it's healing. R1 held up R1's hands to show this surveyor all R1's fingernails are long with yellow, brown, and black debris under the nails. R1's right 4th fingernail and left pinky (5th) fingernail are very long with the fingernail tips being curved down back towards the tip of R1's fingers. This surveyor asked about R1's fingernail length and if R1 has been offered to have R1's fingernails cut or trimmed by staff. R1 stated, Yes. I have. I want them done. They should be cut. I don't know if they (staff) are too busy. On 10/1/24 at 10:05 am, R1 observed in bed in R1's room with R1's fingernails remaining long with yellow, brown, and black debris under the nails (unchanged from 9/30/24). On 10/1/24 at 10:17 am, V16 (Certified Nursing Assistant, CNA) called into R1's room by this surveyor. When asked about the care that R1 received today from V16 since 7:00 am today. V16 stated that V16 feed R1 breakfast, gave R1 a shower, changed R1's fitted sheets, shaved R1, and got R1 dressed. V16 stated that V16 washed all R1's body during shower and combed R1's hair afterwards. V16 stated that V16 offered R1 grooming care in shaving R1's face. This surveyor pointed out to V16 R1's fingernails, long with debris under them. V16 stated that R1 did say that R1 wanted R1's fingernails cut. V16 stated that R1 has no fingernail clippers and that they are kept with the nurse. V16 then observed going to V7 (LPN) who retrieved fingernail clippers from the locked medication cart. On 10/1/24 at 12:36 pm, V3 (RN/WCN) stated that R1 has received treatment in the facility for intrinsic eczema and tinea [NAME] to R1's bilateral hands, arms, and legs. V3 stated that R1 was educated not to scratch at the body rash, and that they (staff) keep nails short so long nails won't open up R1's skin. When asked about V3 assisting R1 with care, drinking from the milk carton on 9/30/24 and seeing R1 hands, V3 stated that V3 did not remember seeing R1's fingernails. This surveyor informed V3 of 9/30/24 and 10/1/24 observations of R1's long fingernails with yellow, brown, and black debris under the nails. V3 stated that nail care is provided by staff as needed for R1; and that staff should be cleaning under R1's fingernails to decrease the risk of infection if R1 is scratching R1's body. On 10/2/24 at 12:46 pm, V2 (Director of Nursing, DON) stated that R1 was being treated by the wound care team for intrinsic eczema and that staff make sure that (R1's) fingernails are trimmed. When asked why is that important for R1 having a skin rash, V2 stated, So it will prevent the nail from making skin tears, make the skin not intact. When asked how often fingernail should cleaned and trimmed, V2 stated, I (V2) always tell them (staff) when you get up residents, clean and change them, shave them and clip their nails. Check every time during care. Daily, it is supposed to be daily. I tell them imagine if that's you, take care and clean them when you get them up. Shave and keep nails clipped. R1's Care Plan, date initiated 9/20/24, documents, in part, that R1 has a focus of impairment to skin integrity, upper and lower extremities-rash/pruritus, bilateral hands and palms-other pruritis dermatitis with an intervention of education of R1 of causative factors and measures to prevent skin injury. R1's Care Plan, date initiated 1/7/21, documents, in part, that R1 has a focus of self-care deficit related to inability to comb hair, inability to brush teeth, inability to wash/dry face, inability to wash perineum, bilateral arms and torso with an intervention of provide supervision, verbal cues and physical assistance. R1's Care Plan, date initiated 5/8/19, documents, in part, that R1 has a focus of fluctuating ADL self-care deficit R/T (related to) disease process, impaired balance and limited ROM (range of motion) with interventions of inform of tasks to be perform and allow sufficient time to perform ADL tasks. On 10/2/24 at 3:21 pm, V2 stated that there is no facility policy specific for grooming/nailcare, and grooming/nailcare for residents is included in the ADL policy already provided to the surveyor. Facility policy titled Policy and Procedure: Activities of Daily Living and dated 1/6/23 documents, in part, Residents are given routine daily care and HS (hour of sleep) care by a C.N.A or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day at intervals that are coordinated between the care giver and the resident. ADL care of the resident includes: Assisting the resident in personal care such as bathing, dressing, eating. Facility job description dated 3/24/22 and titled Certified Nursing Assistant documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for provide resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . Provide assistance in personal hygiene . Assist (Assist) with ADL Care . Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements. Facility job description dated 3/25/16 and titled Registered Nurse (RN) documents, in part, Summary: The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times.

Based on observations, interviews, and record reviews, the facility failed to implement fall prevention interventions for high fall risk residents; failed to supervise high fall risk residents; and failed to perform quarterly fall risk assessments which affected two residents (R2 and R3) in the sample of three residents when reviewed for improper nursing care. Findings include: 1) R2's Admission Record documents, in part, diagnoses of Parkinson's disease without dyskinesia, hemiplegia and hemiparesis following cerebral vascular accident (CVA) affecting right dominant side chronic obstructive pulmonary disease, heart failure, peripheral vascular disease, hypertensive heart disease, schizoaffective disorder, anxiety disorder, Alzheimer's disease, psychosis, dementia, osteoarthritis, seizures, mood disorders, anemia, syncope and collapse, and gastritis without bleeding. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score is not conducted due to R2 rarely/never understood. Therefore, R2's Staff Assessment for Mental Status indicates that R2 has a short-term and long-term memory problems, and R2's Cognitive Skills for Daily Decision Making is coded as moderately impaired - decisions poor; cues/supervision required. R2's Behaviors include delusions and wandering (which occurs 1 to 3 days a week). R2's Functional Abilities and Goals for Safety and Quality of Performance documents, in part, that for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) is coded as partial/moderate assistance where helper does less than half the effort, and for walking 10 feet is coded as supervision or touching assistance where helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently. On 9/30/24 at 12:22 pm, V11 (Escort) observed supervising R2 in the dining room. R2 observed in a reclining wheelchair, dressed, and wearing regular white socks which are not skid proof. This surveyor spoke to R2 to ask R2 about recent fall incident in the facility, and R2 nodded yes, but did not nod yes or no to further questions or verbalize details of R2's fall incident on 9/16/24. R2 observed with a yellow/purple color fading bruise behind R2's left ear down to R2's neck. On 9/30/24 at 12:25 pm, V4 (Certified Nursing Assistant, CNA) stated that V4 is the assigned CNA for R2. When asked what care has V4 provided to R2 since beginning of the day shift, V4 stated, I (V4) dressed (R2) and waited for sitter. V4 stated that R2 is a fall risk resident. On 10/1/24 at 9:58 am, R2 observed sitting in R2's reclining wheelchair inside the nurse's station past the swinging half door separating the nurse's station from the hallway, and V15 (RN) observed sitting inside the nurse's station on the telephone. This surveyor inquired about R2 today, and V15 stated that R2 is fine, calm. When asked why is R2 inside the nurse's station, V15 stated, I (V15) have to wait for the sitter to come, (R2's) a fall risk. On 10/1/24 at 3:54 pm, V9 (CNA) stated that V9 was R2's assigned CNA on 9/16/24 on the 3:00 pm to 11:00 pm shift. V9 stated, (R2) had a fall at the end of the shift on 9/16 (2024). (R2) was with the sitter. She (the sitter) leaves and (R2) sat at the nurse's station. When asked what time the sitter left on 9/16/24, V9 stated, It was before 11 pm, around 8 pm. V9 stated, (R2) tries to get up. (R2) gets up and moves on (R2's) own. We don't want (R2) to fall. That's why (R2's) at the nurse's station till I (V9) put (R2) down to sleep. V9 stated, I saw (R2) on the floor one time. I instantly got the nurse (V10, Licensed Practical Nurse). When asked what time was R2's fall on 9/16/24, V9 stated around 9 to 10 pm, almost time to go. When asked where the nurse (V10) was, V9 stated that V10 was towards the back (of the floor). V9 stated that V9 walked away from R2 who was on the floor in the nurse's station to inform V10, and then V9 and V10 both walked back to the nurse's station. V9 stated that V9 did not witness R2 falling on 9/16/24, and R2 was laying on (R2's) side on the floor already when I came back to nurse's station. When asked were there any staff members present at the nurse's station when V9 returned to the nurse's station seeing R2 had fallen on the floor, V9 stated, No, nobody was there. V9 stated that R2's head was down, (R2) was alert, and (R2) was on the floor grabbing to lift self-up. V9 stated that R2 was sitting in R2's reclining wheelchair before V9 left R2 unsupervised at the nurse's station. When asked if R2 is a high fall risk resident, V9 stated, Yes, that's why (R2) sits at the nurse's station, so someone is around to watch (R2) and not leave (R2) unattended. We are sitting watching (R2). When asked about V9 leaving R2 unattended at the nurse's station on 9/16/24, what about V9 supervising R2, and V9 stated, All staff are helping to watch (R9). On 10/1/24 at 12:01 pm, V10 (LPN) stated that that R2 is alert, oriented times 1 to 2, confused and ambulates around with monitoring. V10 stated that R2's gait is not that stable and that R2 is forgetful. When asked if R2 is a fall risk resident, V10 stated, No, not that really. (R2) walks around. We (staff) monitor everyone, to see where they are. When asked how is R2 prevented from having falls, V10 stated, The only thing we can do is just monitor (R2) all the time. All the staff. When asked about R2's fall incident on 9/16/24, V10 stated that V10 was R2's assigned nurse on the 3:00 pm to 11:00 pm shift. V10 stated that on 9/16/24 at 11:00 pm, I (V10) got report that (R2) had a fall, (R2's) on the floor. V10 stated that V10 was making rounds by going to the dining room to direct any resident to their room for sleep, and V9 (CNA) came into the dining room to notify V10 that R2 was on the floor in the nurse's station. V10 stated that V9 and V10 then went back to the nurse's station, and V10 stated, When I got to (R2), (R2) was laying on (R2's) back. V10 stated that R2's chair was in the middle of the nurse's station and where I find (R2) laying down was closer to the door that leads out by the crash cart. V10 stated that R2 was alert, had no injury (no skin tear, no cut, no bruise, no discoloration, and no bleeding) and could not tell V10 what happened. V10 stated that V10 last saw R2 at 10:00 pm in the nurse's station only with V9 present. V10 stated that V10 documented this fall incident for R2 in the facility's incident report documentation. In R2's Fall Incident report dated 9/16/24, V10 (LPN) documents, in part, At 2300 (11:00 pm), the C.N.A (V9) reported to the writer that the resident (R2) is on the (floor) in the nursing station. On getting to the nursing station (V10) observed (R2) lay on (R2's) back, beside the wheelchair; faced the ceiling in no apparent distress . (R2) noted with unbalance gait . head to toe assessment was done. No noted skin tears, bruise or bleeding. On 10/1/24 at 7:30 am, V19 (Registered Nurse, RN) stated that V19 worked from 9/16/24 11:00 pm to 9/17/24 7:00 am shift. V19 stated that V19 was informed by V10 of R2's fall incident around 11:00 pm. V19 stated that around 5:30 am, V19 performed a follow up neurological assessment of R2 post fall and observed a small bruise the size of 2 quarters and dark purple in color behind R2's left ear, and R2 denied pain with palpation of area. V19 stated that V19 notified V17 (Attending Physician) who ordered for continued monitoring with neurological checks. In R2's Health Status Note dated 9/17/24 at 6:59 am, V19 (RN) documents, in part, that R2 was noted with discoloration of back of (R2's) L (left) ear post fall. R2's Fall Risk Assessment, dated 9/17/24 and titled Fall Scale, documents, in part, Instructions: Fall Risk is based upon Fall Risk Factors, and it is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall with R2's score as 100 which indicates that R2 is a high fall risk (Fall Scoring: High Risk 45 and higher). R2's Fall Risk Assessment, dated 8/15/24 (score of 55) and dated 7/12/24 (score of 95), indicate that R2 has been a high fall risk. R2's Care Plan, initiated 4/17/19, documents, in part, a focus of R2 is at high risk for falls r/t (related to) gait/balance problems, psychoactive drug use, Parkinson's disease, Unaware of safety needs, history of Syncope, history of fall, Impulsive behavior, altered thought process, resident overestimate (R2's) ability with interventions of ensure that (R2) is wearing appropriate footwear and anticipate and meet (R2's) needs. R2's Care Plan, initiated 1/7/2020, documents, in part, a focus of R2 with impaired mobility as evidence by inability to ambulate independently and requires assistance with verbal cues and supervision with a focus of provide physical assistance when ambulating. 2) R3's Admission Record documents, in part, diagnoses of cerebrovascular vasospasm and vasoconstriction, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (DM), seizures, schizoaffective disorders, hyperlipidemia, vitamin D deficiency, hypertensive heart disease without heart failure, psychosis, acute peptic ulcer, gastrostomy status, seborrheic dermatitis, weakness, lack of coordination, abnormalities of gait and mobility, history of falling, pulmonary fibrosis, dysphagia, and long term use of oral hypoglycemic drugs. R3's MDS, dated [DATE], documents, in part, a BIMS score is not conducted due to R3 rarely/never understood. Therefore, R3's Staff Assessment for Mental Status indicates that R3 has a short-term and long-term memory problems, and R3's Cognitive Skills for Daily Decision Making is coded as severely impaired - never/rarely made decisions. On 9/30/24 at 11:55 am, R3's room door is observed closed. This surveyor entered R3's room observing R3 laying in bed with 2 dark blue floor mats not on the floor on R3's sides of bed. One floor mat is observed propped up against the wall away from R3's bed, and the second-floor mat is folded in half leaning against R2's bed and is in contact with privacy curtain in between R2 and R3's bed. There is a chair and a bedside table noted at the foot of R3's bed. R3 observed laying with R3's head towards the foot of R3's bed and is holding a cellular phone which is playing a cartoon. This surveyor is asking R3 questions; however, R3 is intently watching the phone and not answering this surveyor. On 9/30/24 at 12:00 pm, an alarm goes off loudly coming from the cellular phone, and R3 begins leaning over the side of the bed, towards R2's bed. On 9/30/24 at 12:03 pm, this surveyor comes to the doorway to call out for staff assistance. V3 (Registered Nurse, RN/Wound Care Nurse, WCN) enters R3's room, removes the alarming cellular phone from R3, and R3 is saying, I want. I want. I want. V3 stated, The nurse (V5, RN) was watching (R3). V3 assists R3 with repositioning in the bed, and R3 is resistive to care. V3 stated to other staff, Can you get the sitter? On 9/30/24 at 12:25 pm, V4 observed sitting in a chair inside R3's room with both fall mats now down on the floor on both sides of R3's bed. V4 stated that V4 is the assigned CNA for R3. When asked if R3 is a fall risk resident, V4 stated no. When asked does R3 have any fall prevention interventions, V4 stated that R3 has fall mats. When asked where the fall mats to be placed, V4 stated, On floor next to the bed for a fall. When asked how does V4 know which residents are high fall risk residents, V4 stated, The nurse will tell me most of the time. I can tell by the mats seen on both sides of the bed. Some people (residents) have a fall risk band on their wrist. On 9/30/24 at 12:17 pm, when asked if R3 is a fall risk resident, V5 (RN) stated, No. I (V5) have never seen him fall. When asked what fall precaution interventions are in place for R3, V5 stated, bed in lowest position and that R3 is bed bound. This surveyor informed V5 that there are floor mats near R3 folded up away from R3's bed. When asked where floor mats are to be placed, V5 stated, on both sides on the floor. When asked the purpose of this, V5 stated, So if (R3) goes to the floor, (R3) won't land on hard floor. Have a cushion if (R3) rolls out of bed. When asked about seeing a table and chair in R3's room, V5 stated that V5 was recently in R3's room supervising R3, but V5 stepped out when R3 was sleeping. On 10/1/24, this surveyor requested from V2 (Director of Nursing, DON) the last two (most recent) fall risk assessments for R3. On 10/2/24, V2 provided this surveyor with R3's last two fall risk assessments, dated 3/27/24 and 6/8/24. R3's Fall Risk Assessment, dated 6/8/24 and titled Fall Scale, documents, in part, Instructions: Fall Risk is based upon Fall Risk Factors, and it is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall with R3's score as 75 which indicates that R3 is a high fall risk (Fall Scoring: High Risk 45 and higher). R3's Care Plan, initiated 3/14/24, documents, in part, a focus of R3 is at high risk for falls r/t COPD, DM, HTN (hypertension), history of fall with interventions of Floor mats/Floor pads at bedside and anticipate and meet (R3's) needs. On 10/2/24 at 12:46 pm, when asked how the facility is preventing residents from falling, V2 (Director of Nursing, DON) stated that residents are assessed when admitted to the facility, they are assessed for falls. V2 stated that fall risk assessments are then done quarterly if the resident has a fall or there is a significant change. V2 stated that quarterly means every 3 months. V2 stated that the fall risk assessment will determine if the resident is a low or high risk for falling which will then drive the fall precaution interventions to be in place. V2 stated that nurses communicate to CNA staff in report who the high fall risk residents are, and we (staff) make sure extra staff are there to gather them in the dining room so somebody will watch them. V2 stated that R2 is a high fall risk resident and tries to get up and walk at times. V2 stated that V2 tries to have staff with R2 as much as possible. When asked if R2 is awake inside the nurse's station, is there to be a staff member watching R2, and V2 stated, Yes. When asked how staff find out who is a fall risk resident, V2 stated that the nurse will check the care plans and will let the CNAs know. When asked about a fall risk wrist band, V2 stated that the facility does not use this as a fall risk identifier, and that a few residents still have these wrist bands when they return from the hospital. V2 stated that floor mats should be placed on both sides of the bed on the floor. When asked the purpose of fall mats, V2 stated, To prevent injury. On 10/2/24 at 2:51 pm, V2 stated that the staff nurses (RN, LPN) are responsible for performing the quarterly fall risk assessments. When this surveyor showed R2's most recent fall risk assessment (6/8/24) being over 3 months, V2 stated that the MDS nurse will give V2 a list of residents with required assessments, and nurse gets busy. V2 stated that V2 participated in the intradisciplinary team (IDT) meeting for R2's 9/16/24 fall investigation. V2 stated asked why did V9 leave R2 alone in the nurse's station. V2 stated V9 went to the bathroom when R2 was sitting calm. On 10/2/24 at 4:33 pm, when asked what footwear should R2 be wearing when R2 is out of bed, V2 stated, Shoes, sturdy shoes or the non-slip socks. When asked what's the purpose for this, V2 stated, You don't want (R2) to slip and fall. We even put non-slip socks on when (R2's) in bed just in case (R2) would stand up from bed. V2 stated that the sturdy shoes and non-slip socks provide R2 with traction when standing so R2's feet won't slip upon standing causing R2 to fall. On 10/2/24 at 2:06 pm, V13 (Restorative Nurse) stated that V13 participates in intradisciplinary team (IDT) meeting whenever a resident has a fall occurrence to investigate how the fall occurred and what individualized intervention is to be put in place to prevent another fall incident. V13 stated that V13 remembered R2's 9/16/24 fall incident investigation. V13 stated, CNA (V9) went to the bathroom for a minute. And that's when (R2) fell . (R2) was being monitored. When asked the root cause of R2's fall on 9/16/24, V13 stated, The CNA not handing (R2) over to another staff member. Facility policy titled Fall Prevention Program and dated 12/31/23 documents, in part, Policy: 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. 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 . Standards: 1. A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool with incorporate current clinical practice guidelines. 2. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. 3. Safety interventions will be implemented for each resident identified at risk using a standard protocol. 4. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained . Standard Falls/Safety Precautions for All Residents: 1. All staff will be oriented and trained in the Fall Prevention Program . 16. All nursing personnel will be informed of residents who are at risk of falling. The fall risk classification will be identified on the care plan . 19. Footwear will be monitored to ensure the resident has proper fitting shoes and footwear is non-skid. Facility job description dated 3/24/22 and titled Certified Nursing Assistant documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for provide resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: . Assist (Assist) with ADL Care . Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements . Performs other duties as assigned. Facility job description dated 3/25/16 and titled Registered Nurse (RN) documents, in part, Summary: The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistants. Meet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs and activities. Make written & oral reports/recommendations concerning the activities of the shift as required. Facility job description dated 4/1/17 and titled Licensed Practical Nurse (LPN) documents, in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Responsibilities: Direct the day-to-day functions of the nursing assistants. Meet with your assigned nursing staff, as well as support personnel, in planning the shift's services, programs and activities. Make written & oral reports/recommendations concerning the activities of the shift as required.

Based on observation, interview, and record review the facility failed to properly monitor and supervise a resident (R1) with known risk of elopement. This failure resulted in R1 eloping from the facility [DATE]. R1 was found deceased in an abandoned building one month later by South Suburban police on [DATE]. This was identified as an Immediate Jeopardy began on [DATE]. On [DATE] at 11:36am, V1 (Administrator) was notified of the Immediate Jeopardy. The facility presented an abatement removal plan on [DATE] at 6:57pm and was not approved. The facility submitted a revised abatement plan and was approved on [DATE] at 12:36pm. Findings include: Facility reported incident dated [DATE] documents at 6:30pm, alarm was activated from the first-floor South exit. R1 was noted exiting the facility through the South fire exit door and staff did not find R1. Nursing Progress notes dated [DATE] 19:30 document R1 left the facility without permission or pass. Search conducted throughout unit and outside facility without any sightings of the resident. Police called to file a missing person report. A WGN Chicago news article dated [DATE] documents in part, the Police Department is asking for the public's help in locating R1, a missing [AGE] year-old man with Dementia. R1's death certificate dated [DATE]th, 2024, documents R1 cause of death as Atherosclerotic Cardiovascular Disease, and further documents in PART II- other significant conditions contributing to death but not resulting in the underlying cause given in PART I as Chronic Substance Abuse, Dementia. R1's current face sheet documents R1 was admitted to the facility on [DATE] and R1 has diagnoses that include but not limited to Dementia, Bipolar, and Post-Traumatic Stress Disorder. R1's MDS/Minimum Data Set, dated dated dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status score of ,d+[DATE], indicating that R1 is cognitively impaired. On [DATE] at 12:07pm, V22 (Social Services Director) stated R1's community survival skills assessment was completed on [DATE], and it documented that R1 is not sufficiently alert, oriented, coherent, knowledgeable, and not able to navigate safely on community streets by himself. V22 further stated R1 does not know the facility address or location, or how to contact the facility in an emergency, and R1 is not able to refrain from harm or socially inappropriate behavior while out in the community independently. V22 stated based on these assessments, R1 was not able to go out into the community independently safely and R1 needed a facility escort. On [DATE] 10:45 am, V1 (Administrator) stated that R1 left in March against Medical Advice, V1 stated that R1's case is a closed case. V1 stated she was informed by staff that R1 left the unit on [DATE] during the evening shift and R1 left through one of the side doors. V1 stated she is not the one who completed R1's report to the State Agency. V1 stated R1 left the facility AMA (Against Medical Advice). V1 stated R1 called the facility (V1 did not provide a date or time) and stated R1 would not be coming back to the facility. V1 stated R1 spoke to V8 (receptionist) when R1 called. V1 stated R1's call was not documented. V1 stated facility's camera footage only goes back five days therefore there was no footage for [DATE]. On [DATE] at 1:59 pm observed R3 walking out of the second-floor elevator. R3 stated that he just returned from smoking outside. R3 stated that he has been living in the facility for six years. R3 stated that he uses the elevator and the stairs to leave the second floor by himself without any restrictions. R3 stated they (facility) changed the code on the elevator about two or three months ago, but a CNA (Certified Nursing Assistant) told him the code. R3 stated that prior to the facility changing the code, the code was the same for about five years. Surveyor questioned R3 if there are residents that he has seen trying to leave, R3 stated that there was a resident but that resident left. R3 stated that R1 stayed in the room across from R3's room. R3 stated that he thinks R1 left through the South stairs (as R3 pointed at the South stair's doorway). R3 stated that he thinks R1 left through the basement exit. R3 stated that R1 didn't want to be at the facility. R3 stated that R1 asked him which way to get out from the floor, and R3 stated that he told R1 that he can open the second-floor South door and just press the button that is on the wall to turn off the alarm. R3 stated that R1 would get anxious and R1 had episodes of not knowing what he (R1) was doing. R3 stated that one time, R1 grabbed R3's belongings and placed them on the floor aggressively and R1 told R3 to leave. R3 stated that R1 was also a smoker. R3 stated that he observed staff escort R1 and other residents to go on smoking breaks. On [DATE] at 2:07pm, R4 was observed in her room seated on her wheelchair next to her bed talking to R5 (roommate) who was seated on the bed. R4's BIMS (Brief Interview for Mental Status) dated [DATE], documented as ,d+[DATE], indicating R4 has intact cognitive abilities. R4 stated she knows the code to the elevator and pulled out a paper from her pocket and showed surveyor the code for the second-floor elevator. R4 stated she uses the code to get in and out of the elevator to go to the patio on the first floor, to go to the other units. R4 stated facility staff give residents the elevator code. R5 asked R4 what the elevator code was, R4 gave R5 the code. R4 stated the elevator code was not a secret and residents just ask the facility staff for it, and it is given to them. R4 stated she has not seen staff prevent anyone from getting on the elevator. On [DATE] 2:16 pm observed exit signs on the basement ceiling leading to an exit door in the basement, no observation of any poster or signage alerting that there is an alarm that goes off when the door opens. Surveyor opened the door, and an alarm went off. Surveyor observed that the door leads to the outdoors. Surveyor heard an overhead announcement code 99 basement door. On [DATE] 2:18 pm, surveyor observed several staff members hurried to the door. V2 stated that she does not have the key to turn off the door's alarm. Observed V4 (Assistant Administrator) and other staff rush towards the exit door. Observed V2 rush to a nearby storage/utility closet and observed V2 obtain a key with a pole stick Attached to it. Observed V2 use key to turn off the door's alarm in the basement (South exit). 0n [DATE] and [DATE] during tour of the units, surveyor observed residents putting in the elevator code and operating the elevator to go up and down the units. On ,d+[DATE]/ 2024 at 10:07am, V27 (R1's family member) stated he found out that R1 was missing from the facility from a WGN Chicago news article dated [DATE]. The news article notes Chicago police had put out a plea for R1, who was missing from the facility and police were asking for public assistance to help find R1. V27 stated R1's family was notified by Suburban Police that R1 was found deceased in an abandoned building. R1's date of death was listed as [DATE]. V27 stated R1's family have not yet received the death certificate. V27 stated he and R1's family members went to the facility to try and find out what happened to R1, but they were told to leave the premises. V27 stated the South Suburban police report number dated [DATE] is HV2400009283.V27 sent police report to the State Agency on [DATE]. South Suburban police report number HV2400009283 dated [DATE] documents: -On 19 [DATE] at approximately 1219, Reporting Officer (R/O) #400 was dispatched to W154th street apartment # 4 in reference to a suspicious subject in an abandoned apartment building. Upon arrival R/O entered the abandoned apartment and observed a male black subject age approximately ,d+[DATE] years old sitting face up on a black in color couch located in the living room of the apartment. The subject was wearing a gray in color shirt, blue jeans with no shoes. R/O also observed subject's body was decomposed. On [DATE] at 1:50pm during the tour of the second floor unit with V18 (Registered Nurse-RN/supervisor/Infection control Preventionist) and V2(Director of Nursing-DON), V18 stated the second floor unit houses residents with mixed need such as residents who need supervision because these residents have diagnosis of Dementia, residents who need assistance with ADL (Activities of Daily Living)and also residents who are alert and ambulatory. V18 stated residents exit the second floor by asking the nursing staff for the elevator code and residents can go to the first and fourth floor units where the vending machines are located or go to smoke outside of the facility at the front of the building or at the patio which is located on the first floor on the North side of the building. V18 showed surveyor the exit on the South side of second floor and stated there is a code but there is also a release button on the side of the stairs that if the door is opened from the side of the unit and the release button on the side of the stairs is pushed, the alarm will not go off the person can leave the unit without activating the alarm. V18 stated some residents know how to use the release button to get out of the unit without triggering the alarm. V2 stated the second floor is a locked unit because some residents who reside on the unit have Dementia, are confused and/or are at risk for falls. V2 stated the second floor is a semi locked unit because the residents with Dementia, are confused and can attempt to leave the unit/elope. V2 stated residents on the second floor who are not confused, residents with a BIMS (Brief Interview for Mental Status) of above ,d+[DATE] meaning their cognation is Moderate or intact can get the elevator code from the nursing staff. On [DATE] at 10:55am, V17 (Maintenance Director) stated there are four exit doors in the building, three on the first floor which includes the main entrance/exit and the North and South exit. V17 stated the other exit door in the basement on the [NAME] side on the building. V17 stated all the exit doors have an alarm to prevent residents who are confused from exiting the facility or unwanted individuals from entering the facility. V17 stated there must be alarms on all exit doors to prevent residents from exiting the building because they (residents) can be hit by cars, or they can freeze during the wintertime. V17 stated the alarms go off so that the facility staff can protect/prevent the residents who are attempting to run away from leaving the facility. V17 stated the alarms are a safety precaution to make sure residents are safe in the facility. V17 stated when the exit doors are pushed, the doors open, and the alarm goes off immediately. V17 stated if the alarm goes off, the staff members call a code, and everyone goes to the exit doors to check what is going on. V17 stated the second-floor elevator has a code that is used to get in and out of the unit, but V17 stated he does not know why there is a code, and it has been there since V17 started working in the facility, and the code has been the same more than ten years. V17 stated residents know the code and V17 has seen residents putting in the code and operating the elevator to move up and down the units and outside facility. V17 stated the second-floor South exit door has a keypad with a code, but it does not work, and anyone can go up and down the stairs using the South door exit on the second floor and the alarm will not go off because it is not working. V17 stated the second-floor North exit door has a keypad for a code, but it is an old device, and it does not work, and the residents can go on or off the unit using any of the two doors and the alarm will not go off. V17 stated the 1st floor South exit goes directly to the South parking lot of the building and if you turn left, you go to a busy main road. V17 measured the distance from the first-floor exit door to the main road and it was 45 feet/15 yards. V17 stated maintenance department checks all the exit doors and elevator doors every day to make sure they are working. On [DATE] a8 11:18am V8 (Receptionist) V8 stated she lets people including visitors, staff, residents in and out of the front entrance door because it is a locked door, and the receptionist must buzz the person in and out of the facility. V8 stated the door is locked so that residents cannot leave/elope by just pushing the door open and leaving the facility. V8 stated the receptionist must monitor the door. V8 stated between [DATE]th and 15th, during the evening shift, V8 was sitting at the reception desk when V8 heard the alarm on the 1st floor South exit door which opens to the parking lot go off. V8 stated she looked at the cameras and saw R1 going out of the door, therefore, V8 called a code 99 to the 1st floor South door. V8 stated all staff went running towards the 1st floor South exit door and started looking for R1. V8 stated after about 10 minutes, staff come back to the facility and stated they did not find R1. V8 stated V19 (Registered Nurse), and V20 and V21 (Certified Nursing Assistants-CNA) got into their cars and drove around the neighborhood looking for R1 but did not find R1. V8 stated since she started working at the facility, she did not see R1 trying to leave the unit, but V8 has not had any interactions with R1. V8 stated for a resident to go outside, they must have a green community pass, which means the resident can go out to the community independently. V8 stated she was not aware if R1 had a phone or not, but later that week after R1 left the facility, around [DATE]th, 2024, V8 stated R1 called the facility in the evening around 7pm and stated he was not coming back to the facility. V8 stated V8 tried to ask R1 to hold on so V8 could transfer R1 to the nurse on duty, but R1 hung up. V8 stated she informed V2 (Director of Nursing-DON) that R1 had called. V8 stated she did not document that she (V8) had received a call from R1. On [DATE] at 12:07pm, V22 (Social Services Director) stated Social Services is responsible for completing residents BIMS (Brief Interview for Mental Status) assessment and updating the resident's care plan based on the outcome of the assessments. V22 stated R1's BIMS (Brief Interview for Mental Status) score, dated [DATE] was ,d+[DATE] indicating R1 has moderate cognitive impairment. V22 stated a BIMS score of ,d+[DATE] means that R1 has impaired decision-making ability and possibly not oriented to person, place, time, and situation. V22 stated R1 was only oriented to time. V22 stated it was not safe for R1 to go out to the community by himself without a facility escort because R1 had cognitive impairment. V22 stated if R1 went out in the community by himself, R1 could become a victim of a crime, R1 might not remember how to get back to the facility, and R1 could possibly get injured crossing the streets, or R1 can fall and get injured. V22 stated R1 did not have the necessary essentials and survival skills to survival in the community independently. V22 stated R1 did not have a personal phone while at the facility and could not call the facility independently after R1 left the facility, and R1 was receiving 30 dollars a month and R1 did not have money when R1 left the building. V22 stated R1 had an ID (identification) bracelet with just his name on it because R1 was an elopement risk resident based on R1's BIMS score and his elopement assessment which was completed on [DATE] and documented R1 had a history of trying to leave the facility in the past. V22 stated the ID bracelet did not have the facility name or address on it. V22 stated R1 was strong enough to push the exit door open, but R1 should have been supervised and redirected by facility staff so he (R1) does not leave the facility by himself because R1 needed staff supervision while outside the facility. V22 stated leaving AMA (Against medical Advice) means the resident is cognizant, oriented and can make decisions for themselves and decide to leave the facility against medical advice. V22 stated Elopement is when a resident leaves the facility without permission from staff and not having a staff or family escort the resident while out in the community. V22 stated R1 could not make an AMA decision because R1 was cognitively impaired. V22 stated if R1 wanted to leave AMA, staff could not have accepted his AMA because R1 could not make decisions for himself. On [DATE] at 3:03pm, V19 (Registered Nurse) via phone stated she heard an alert after receptionist called code 99 which means someone escaped. V19 stated she was working on the first-floor unit at that time, and it was almost evening time after 6:00pm, after smoking time which ends at 5:30pm, and it was almost dark outside. V19 stated V8 stated she saw R1 go out through the first-floor South exit door that goes directly to the parking lot. V19 stated when she heard the code, she run towards the South exit door where R1 left and saw R1 a head of her on the sidewalk on Central Road, then R1 turned to the [NAME] side block of the building and by the time staff got to where R1 turned, the staff could not see/find R1. V19 stated staff continued looking for R1 and could not find R1. V19 stated she turned back and went to her car and drove around looking for R1 but could not find him. V19 stated there were other staff members (no names provided) who got in their cars and were driving around looking for R1. V19 stated R1 was not found, and staff went back to the facility. V19 stated she has taken care of R1 occasionally and he did not try to leave the building during the time she took care of R1. V19 stated R1 was a smoker and used to go to the patio or to the front by the front entrance and smoke. V19 stated smoking at the patio is around 8:30am, then 1:30pm, and 5:30pm. V19 stated to smoke at the front, the receptionist on duty gives the resident the lighter and cigarettes, and when the residents come back from smoking, they give back the lighter to the receptionist. V19 stated after dinner time which is around ,d+[DATE]:00pm, the residents are not allowed to go outside the facility. V19 stated she does not remember how R1 came down the second-floor unit to get to the first-floor South exit. V19 stated staff and some of the residents who are alert to person, place, time, and situation, have the second-floor elevator a code. V19 stated residents who are only alert to self and have illnesses such as Dementia do not have the elevator code because they will forget the code or can use the code to get out of the second floor. V19 stated even if the residents who have Dementia have access to the code and use it to get on the elevator, the receptionist must buzz the residents in and out of the building. V19 stated anybody can push the exit doors including the first-floor South side exit door and the doors will open, then the alarm will go off. V19 stated all the exit doors have an alarm and the South side of the building exit door it is an emergency exit door with an alarm. V19 stated you cannot open the exit doors from the outside, but anybody can push it open and get outside from the inside, but the alarm will go off. V19 stated R1 needed to be redirected because he wanted to go outside or to the patio to smoke and R1 had to be reminded it was not yet time to smoke on multiple occasions. V19 stated the nursing staff waited an hour to pass before calling the police as they were searching for R1 to see if R1 would come back to the facility. V19 stated R1 did not come back to the facility after one hour, therefore V24 (Licensed Practical Nurse) called the police to report R1 missing since she (V24) was the nurse on duty for R1 when R1 left the facility. V19 stated she works double shifts most of the time in the morning and in the evening and does not remember if she had done a double shift on that that day. V19 stated she has been working at the facility for fifteen years as a registered nurse. R1's physician order sheet/POS documents in part the following orders: - Quetiapine Tab 100mg one tablet by mouth every 12 hours. -Donepezil 5mg tablet every day at bedtime R1's elopement risk assessment dated [DATE] documents that R1 is at risk to elope and should be placed on the elopement risk protocol. A care plan for Elopement is indicated. R1's community survival skills assessment dated [DATE] documents that R1 does not appear to be capable of unsupervised outside pass privileges at this time. R1's progress note dated [DATE] documents in part that R1 left from facility unauthorized without permission or community pass. Police department called to file a missing person report. There is no known family contact on R1's profile. [DATE] 1:41 PM via telephone V7 (Psychiatric Nurse Practitioner) stated that he forgot if he was informed or not that R1 eloped from the facility. V7 stated that if a resident has a diagnosis of Dementia, the resident should not be allowed to go out of the facility alone, and the resident should be monitored/supervised by facility staff. V7 stated If a resident has Dementia and leaves the facility, the resident can get lost, the resident can forget where the resident was going, which way to go and might not be able to come back to the facility. V7 stated a resident with Dementia who leaves the facility unaccompanied or supervised by staff might end up far from facility and get lost and might not be able to come back to the facility to take prescribed medications. V7 stated that the resident with a diagnosis of Dementia would not be safe in the community independently and an accident could happen to the resident. V7 stated that R1 was not totally demented and R1 still had some alertness. V7 stated if R1 could not find shelter while out in the community by himself and if the weather gets cold or hot, R1 can get exposed to below normal cold temperatures or very hot weather temperatures which could affect R1. V7 stated that he (V7) expected R1 to be monitored and supervised by facility staff and further stated that R1 should not have been allowed to go out of the facility into the community unless R1 was accompanied by staff for supervision or family member who is alert enough and responsible with R1. V7 stated R1 was on Seroquel medication and Seroquel is a psychotropic medication given for aggressive behavior. V7 states that R1 might sometimes have behavior disturbance like psychosis. V7 stated that sometimes patients with Dementia have psychotic behavior. V7 stated that psychosis is when someone is having delusions and hallucinations. V7 stated that is why R1 was taking Seroquel medication. V7 stated that R1 was also taking Aricept medication for R1's memory. Because residents with Dementia have memory loss. [DATE] 1:58 PM via telephone V6 (Physician) stated that he got a call from the facility stating that R1 had eloped from the facility. V6 stated that he asked the nurse on duty (no name provided) what happened and V6 stated that the nurse told him that it happened so suddenly, when R1 left the facility and facility staff could not reach or catch R1 as R1 was leaving the facility. V6 stated that he told the nurse (V6 cannot remember which nurse) to inform the police department because V6 stated that the facility didn't want anything bad to happen to R1. V6 stated that the nurse also called V2 (DON) and followed the facility protocol for elopement. V6 stated that the next day he was informed that the facility had done what was supposed to be done per facility elopement protocol. V6 stated when he was paged by the facility for another resident, V6 asked about R1 and V6 was informed that R1 didn't come back to the facility. V6 stated that R1 had some psychiatric issues and R1 was diagnosed with Dementia, mild to moderate, history of Bipolar and Post-Traumatic Stress Disorder (PTSD). V6 stated that R1 was able to answer questions appropriately and V6 stated that R1 was able to understand things and follow commands while at the facility. V6 stated any patient with psychiatric history along with mild Dementia to not be allowed to go out of the facility without a responsible family member or an escort because anything can happen to the resident while crossing the road. V6 stated a resident with diagnosis of Dementia and/or psychiatric illnesses can get lost, and, a resident/patient with mood swings can do anything. V6 stated that the facility does not allow residents to go out of the facility independently unless the resident is capable of remaining safe while out in the community. V6 stated that psychiatry was following R1 weekly for management of R1's psychiatric illnesses. V6 stated that R1 never expressed that he wanted to leave the facility. R1's elopement care plan dated [DATE] documents two interventions which are to assure R1 is wearing ID (identification) bracelet. Facility Assessment tool, ,d+[DATE]-,d+[DATE] documents: -Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, intellectual or developmental disabilities noted. Facility policy titled Missing Resident, no date, documents: -It is the policy of this facility to report and investigate all reports of missing residents. All residents are afforded supervision to meet each residents nursing and personal care needs. All residents will be assessed for behaviors or conditions that put them at risk foe elopement. -Unless otherwise identified, all residents who are at risk for elopement when leaving the facility shall be accompanied. The accompanying party shall sign the resident out of the facility on the approved sign-out sheet. 49666 The surveyor confirmed, by reviewing the staff in-service list that included in the approved Abatement Plan, reviewed the following residents' care plans regarding elopement risk, elopement risk assessments: R6, R7, R8, R9, R10, R11, R12, R13, R14, interviewing staff and confirming that they were in-serviced about elopement risk, interviewing V13 (LPN), V17 (Maintenance Director), V18 (Registered Nurse/Supervisor/Infection Preventionist), V22 (Social Service Director), V34 (Nurse Consultant), V31 (Certified) V28 (Registered Nurse) V29 (CNA), V30 (CNA), V31 (Agency Nurse), that the immediacy was removed on [DATE]. The immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: A. To ensure residents are who are at risk for elopement are supervised, monitored and accounted for: 1. R 1 is no longer at the facility. 2. Resident head count of the whole facility was completed by the DON/clinical managers on [DATE]. There was no concern identified. 3. Headcount is done during shift change as part of the nurse-to-nurse shift reporting and when the staff identifies that a resident is missing. 4. Facility wide audit was done to identify residents that are high risk for elopement by the DON (director of nursing), unit manager, Administrator and Social Services. Completed on [DATE]. 5. Any resident who is identified with wandering behavior/ elopement risk will have care plans developed. This will be completed by the IDT on [DATE]. 6. The elopement binders have been updated and all elopement binders in all floors. The elopement binder is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit seeking- behavior/risk for elopement. 7. The Maintenance Director or designee will check all exit doors. Initially done. today [DATE] and daily. 8. The DON or designee will provide education and competency test to the staff including agency staff on [DATE] The education items include but not limited- to: a) Code 99 b) Use of the elopement binders c) Exit-seeking behaviors and interventions d) Elopement risk and wandering and interventions e) Policy on missing resident f) Responding to alarms g) Resident safety and supervision The training was completed on [DATE]. Any staff who are not available, on vacation or leave of absence will have training completed at the start of their- shift upon return to work. 9. The DON or designee also reviewed the general orientation to ensure that the following items were included: a) Code 99 b) Use of the elopement binders c) Exit-seeking behaviors and interventions d) Elopement risk and wandering and interventions e) Policy on missing resident f) Responding to alarms g) Resident safety and supervision B. Systems to develop interventions to address the risk of elopement for a resident known to be a risk for elopement. 1. Ad-Hoc QAPI meeting was completed on [DATE] which were participated by the leadership team which includes the Director of Nursing (DON), ADON (Assistant Director of Nursing) Social services Director (SSD), Assistant Administrator, Rehabilitation Manager, and the Activities Director (AD). The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events. 2. Elopement drill was completed on [DATE] by the Administrator. This will also be completed daily, for the seven (7) days, and will be done at different- shifts. After seven (7) days, the elopement drills will be done weekly for three- (3) months, then monthly thereafter. 3. All exit doors in the facility will also be checked by the Maintenance Director on [DATE] to ensure all doors were locked, secure and alarms are- functioning. Staff will be stationed at each identified exit until the identified- exits have a delayed egress installed. Service has been contacted and scheduled to install egress delays on [DATE]. Door checks will be completed daily, including weekends by the MOD- manager or designee. The door checks will be completed by Maintenance- Director, or designee. If there is any concern identified, the Administrator- and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed. 4. Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/ exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that- appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD (manager on duty)/charge nurse or designee will also conduct weekend clinical meetings to review new or worsening exit- seeking/wandering behaviors and ensure interventions are in place to prevent- elopement. 5. New admissions will be reviewed by the DON or designee for elopement risk and any resident identified as being at risk will be updated into the facility- elopement books. 6. The QAPI team will hold a weekly Ad-Hoc QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional- corrective actions are necessary based on concerns identified. C. System to ensure residents who are at risk for elopement do not have- access to the facility's exit doors which are not secured. 1. Staff is stationed at each identified exit until the identified exits have a delayed egress installed. 2. The identified exits are emergency exits and will have 15 second delayed egress installed. 3. Service with outside vendor has been contacted and scheduled to install egress delays on [DATE]. 4. All staff on the unit will respond to the codes. Follow up by the nurse- supervisor. 5. Codes were changed to door. Residents do not have access to codes.<b [TRUNCATED]

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview, and record review, the facility failed to: rapidly identify residents with potential symptoms of COVID-19 infection; notify residents' physicians of potential symptoms of COVID-19; isolate residents with potential symptoms of COVID-19 from other residents; encourage social distancing while residents smoked; and have a method of surveillance to detect residents with possible symptoms of COVID-19. This had the potential to affect all 218 residents in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. The IJ began on 3/29/20, when R1 developed an elevated temperature, a possible symptom of COVID-19, and the facility failed to separate the resident from other residents in the facility. R1 subsequently tested positive [DIAGNOSES REDACTED]-CoV-2, the coronavirus associated with COVID-19. The facility is located in a county with sustained community transmission, many active cases of COVID-19 and many deaths have occurred. The Director of Nursing (DON) was notified of the Immediate Jeopardy 4/9/20 at 4:57 pm. Findings include: According to the Centers for Disease Control (CDC), Given their congregate nature and residents served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, residents are at increased risk of serious illness, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on 4/15/20 at 10:42 am. 1. During an entrance interview on 4/9/20 at 11 am, with the DON and ADON, when asked if the facility had any confirmed cases of residents with COVID-19 or persons under investigation, the ADON stated that R1 was in the hospital and had been tested for COVID-19. The DON then stated, We have residents with temperatures. They are being monitored. 2. Observation on 4/9/20 at 11:52 am, 15 residents were observed smoking cigarettes on the first floor patio. Seven of the 15 residents were observed standing or sitting within 6 feet of one another. None of the residents observed on the patio were wearing personal protective equipment (PPE) such as face masks. The staff designated as the smoking monitor did not encourage residents to practice social distancing. 3. Review of R1's Electronic Medical Record (EMR) Medical Diagnoses, revealed R1 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 3/29/20 to 4/2/20, revealed that R1 had the following elevated body temperature: 3/29/20, not timed, 100.9 degrees Fahrenheit; 3/31/20, not timed, 99.5 degrees Fahrenheit; 4/1/20, not timed, 99.4 degrees Fahrenheit; and 4/2/20, not timed, 99.5 degrees Fahrenheit. Review of R1's Progress Notes, revealed the following: 4/2/20 at 11 pm, .10:50PM- Noted resident with O2 sat (oxygen saturation which measures the oxygen in the blood) of 88% RA (room air), O2 given 3LPM (liters per minute) via NC (nasal cannula which is a tube used to deliver oxygen). BP (blood pressure)- 110/70, PR (pulse rate)-95, RR (respiratory rate)-25, T (temperature)-99.5F, O2 sat 93% on 02 3LPM. Called (name of physician) with new order to send resident to ER (emergency room ) via 911. 11:00PM- 911 here. Resident (sic) left with the paramedics . 4/3/20 at 4:34 am, .Resident was sent out this evening via 911. Resident got admitted to (name of hospital) with Dx (diagnosis): R/O (rule out) Covid (sic) .Acute [MEDICAL CONDITION] with fevers - due to Covid (sic) 19 . Review of R1's laboratory report, dated 4/9/20 at 10:28 pm, revealed that R1 had a lab test for COVID-19 collected on 4/3/20 at the hospital. The subsequent results, dated 4/9/20 at 10:28 pm, revealed, The specimen is positive for [DIAGNOSES REDACTED]-CoV-2, the coronavirus associated with COVID-19. Review of R1's hospital Progress Note, dated 4/10/20 at 12:09 pm, revealed, .Principal Problem: Pneumonia, primary atypical due to COVID 19 . Review of the facility's Vitals Log, dated 3/29/20 to 4/2/20, also revealed that R1 was sharing a room with three other residents, R17, R18, and R19 and had not been isolated from other residents in the facility after having elevated temperatures, possible signs and symptoms of COVID-19. 4. Review of R2's EMR Medical Diagnoses, revealed R2 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of R2's Progress Note, dated 4/9/20 at 2:10 pm, revealed, 10PM Went out for [MEDICAL TREATMENT] on (sic) wheelchair, with escort with communication form. 12PM tested positive for COVID . Review of R2's Results COVID-19 PCR, dated 4/9/20 at 2:24 am, revealed that the test was collected on 4/8/20 at 11:35 am by the hospital and the subsequent results revealed COVID-19 was detected for R2. Review of the facility's Daily Census, on 4/8/20 and 4/9/20, revealed that R2 was sharing a room with one other resident, R20 and had not been isolated from other residents in the facility pending the results of the COVID-19 testing. 5. Review of R5's EMR Medical Diagnoses, revealed R5 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Logs, dated 4/8/20, revealed that R5 had the following elevated body temperature: 4/8/20, not timed, 102.9 degrees Fahrenheit. Review of R5's Progress Notes revealed the following: 4/9/20 at 6:45 am, .Resident will be returning back to facility. Test performed in the ER (emergency room ): Nasal swab done to R/O (rule out) Covid (sic)-19 with result pending 3-5 days . 4/9/20 at 2:14 pm, .4th floor nurse received a call from the hospital that nasal swab was done to r/o (rule out) covid (sic). resident (sic) placed on contact and droplet precaution to r/o (rule out) covid (sic) . Review of R5's hospital After Visit Summary, dated 4/8/20, revealed, Instructions. This patient was tested for coronavirus and those test results will not be available for 3 to 5 days. Please quarantine this patient as best as you are able . Review of the facility's Vitals Log, dated 4/9/20, also revealed that R5 was sharing a room with one other resident, R25, after returning to the facility from the hospital, and had not been isolated from other residents in the facility pending the results of his COVID-19 lab test until several hours after returning to the facility. Review of the facility's Vital Log, dated 4/11/20, revealed that R25, R5's roommate, had subsequently experienced an elevated temperature of 101.6 degrees Fahrenheit. 6. Review of R12's EMR Medical Diagnoses, revealed R12 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/5/20 to 4/9/20, revealed that R12 had the following elevated body temperature: 4/5/20, not timed, 99.8 degrees Fahrenheit; 4/6/20, not timed, 99.8 degrees Fahrenheit; 4/7/20, not timed, 100 degrees Fahrenheit; 4/8/20, not timed, 101.8 degrees Fahrenheit; and 4/9/20, not timed, 101.7 degrees Fahrenheit. Review of R12's Progress Notes and Physician order [REDACTED]. temperatures. Review of the facility's Vitals Log, dated 4/5/20 to 4/9/20, also revealed that R12 was sharing a room with three other residents, R36, R37, and R13 and had not been isolated from other residents in the facility after having an elevated temperature that is a possible sign and symptom of COVID-19. R12's roommate R13 subsequently developed a temperature on 4/8/20. 7. Review of R13's, R12's roommate's, EMR Medical Diagnoses, revealed R13 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/8/20 to 4/9/20, revealed that R13 had the following elevated body temperature: 4/8/20, not timed, 100.8 degrees Fahrenheit; and 4/9/20, not timed, 102.3 degrees Fahrenheit. Review of R13's Progress Notes and Physician order [REDACTED]. temperature until after this surveyor spoke with Registered Nurse (RN1) regarding R13's elevated temperatures on 4/9/20. Review of the facility's Vitals Log, dated 4/8/20 to 4/9/20, also revealed that R13 was sharing a room with three other residents, R36, R37, and R12 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 8. Review of R15's EMR Medical Diagnoses, revealed R15 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/5/20 to 4/8/20, revealed that R15 had the following elevated body temperature: 4/5/20, not timed, 99.8 degrees Fahrenheit; 4/6/20, not timed, 99 degrees Fahrenheit; 4/7/20, not timed, 100 degrees Fahrenheit; and 4/8/20, not timed, 100.8 degrees Fahrenheit. Review of R15's Progress Notes and Physician order [REDACTED]. temperature. Review of R15's Progress Note, dated 4/8/20 at 12:48 pm revealed, .recieved (sic) call yesteday (sic) fever was 102. today (sic) she is 98.2 today after Tylenol (sic). patient (sic) slouched in bed. patient (sic) is (sic) bed resting with oxygen. Cxr (chest x-ray) was ordered yesterday awaiting the results at this time . Review of R15's Progress Note, dated 4/11/20 at 4:45 pm, revealed .resident is admitted at (name of hospital) with Dx (diagnosis) AMS (altered mental status), pneumonia, suspected covid (sic) 19 . Review of the facility's Vitals Log, dated 4/5/20 to 4/9/20, also revealed that R15 was sharing a room with three other residents, R29, R30, and R31 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. Review of the facility's Vital Log, dated 4/10/20, revealed that R30, R15's roommate, had subsequently experienced an elevated temperature of 102.9 degrees Fahrenheit. 9. Review of R14's EMR Medical Diagnoses, revealed R14 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/8/20, revealed that R14 had the following elevated body temperature: 4/8/20, not timed, 100.6 degrees Fahrenheit. Review of R14's Progress Notes and Physician order [REDACTED]. temperature. Review of the facility's Vitals Log, dated 4/8/20 to 4/9/20, also revealed that R14 was sharing a room with one other residents, R38, and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. Review of the facility's Vital Log, dated 4/10/20, revealed that R38, R14's roommate, had subsequently experienced an elevated temperature of 101.4 degrees Fahrenheit. 10. Review of R7's EMR Medical Diagnoses, revealed R7 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Logs, dated 4/8/20, revealed that R7 had the following elevated body temperature: 4/8/20, not timed, 100.2 degrees Fahrenheit. Review of R7's Progress Notes and Physician order [REDACTED]. temperature. Review of R7's Progress Note, dated 4/10/20 at 2:04 pm, revealed .resident was under investigation, place on strict contact isolation, droplet . Review of the facility's Vitals Log, dated 4/8/20 to 4/9/20, also revealed that R7 was sharing a room with three other residents, R26, R27, and R28 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. Review of the facility's Vital Log, dated 4/10/20, revealed that R27, R7's roommate, had subsequently experienced an elevated temperature of 101.2 degrees Fahrenheit. 11. Review of R3's EMR Medical Diagnoses, revealed R3 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Logs, dated 3/29/20 to 4/4/20, revealed that R3 had the following elevated body temperature: 4/2/20, not timed, 99.1 degrees Fahrenheit and 4/4/20, not timed, 99.3 degrees Fahrenheit. Review of R3's Progress Notes, dated 4/3/20 at 9:36 pm, revealed that R3 had an additional elevated temperature of 99.6 degrees Fahrenheit. Review of R3's Physician Orders, revealed the following: 4/2/20, Vital signs (pulse rate, temperature, respiration rate, and blood pressure) Q (every) shift x (times) 5 days. Chest X-ray. 4/5/20, Send to .ER (emergency room ) via 911 . Review of R3's EMR, dated 4/2/20 to 4/5/20, and review of the facility's Vitals Log, dated 4/2/20 to 4/5/20, revealed R3's vital signs were documented one time each day and were not documented every shift per the physician's orders [REDACTED]. Review of R3's hospital Progress Note, dated 4/10/20 at 2:46 pm, revealed, .She was sent to the emergency room and Intubated (insertion of a tube into the airway) for airway protection and severe hypoxemia (low oxygen levels). She was placed on mechanical ventilation (a form of life support) .Now still sedated and remains In ICU (intensive care unit) with poor prognosis .Continue supportive care patient remains intubated receiving IV (intravenous) antibiotic patient has positive COVID 19 . Review of the facility's Vitals Log, dated 4/2/20 to 4/5/20, also revealed that R3 was sharing a room with three other residents, R21, R22, and R23 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 12. Review of R4's EMR Medical Diagnoses, revealed R4 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/5/20 to 4/10/20, revealed that R4 had the following elevated body temperature: 4/8/20, not timed, 100.3 degrees Fahrenheit. Review of R4's Progress Notes and Physician order [REDACTED]. temperature. Review of R4's Progress Note, dated 4/10/20 at 4:32 pm, revealed, .The resident is .noted with generalized weakness, verbalized feeling alright .At 6 pm noted resident did not eat dinner, verbalized not hungry. VS (vital signs) checked: BP (blood pressure) 106/70, P (pulse) 110, R (respirations) 19, T (temperature) 100.8F, O2 sat (oxygen saturation) 87% on RA (room air). MD (medical doctor) made aware with an order to give Oxygen at 3L/min (liters per minute) via NC (nasal cannula) and to send resident to .ER (emergency room ) for evaluation .At 11 Pm: resident admitted with DX (diagnosis) Pneumonitis (inflammation in the lungs) . Review of the facility's Vitals Log, dated 4/8/20 to 4/10/20, also revealed that R4 was sharing a room with one other resident, R24 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 13. Review of R6's EMR Medical Diagnoses, revealed R6 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Logs, dated 4/5/20 to 4/10/20, revealed that R6 had the following elevated body temperatures: 4/5/20, not timed, 101.2 degrees Fahrenheit; 4/6/20, not timed, 101.3 degrees Fahrenheit; and 4/7/20, not timed, 101 degrees Fahrenheit. Review of R6's Progress Note, dated 4/8/20 at 11:58 pm, revealed, .11:35PM- Noted resident desaturating (dropping oxygen saturations in the blood) at 88%RA (room air). O2 (oxygen) given at 15LPM (liters per minute) via non re-breather mask O2sat (oxygen saturation) 95%RA (room air), BP (blood pressure)- 140/80, P (pulse) -96, T (temperature) -99.5F, RR (respiratory rate)-25, BS (blood sugar)-174. Alert but with bouts of confusion. Called 911. 911 here. 12AM- Resident left with 911 paramedics via stretcher . Review R6's hospital Progress Note, dated 4/10/20 at 12:06 pm, revealed, .The patient desaturated yesterday and was Intubated currently on ventilator support, continue to have low-grade fever .Rule out COVID-19: Labs pending . Review of the R6's EMR dated 4/5/20 to 4/10/20, revealed that R6 had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 14. Review of R8's EMR Medical Diagnoses, revealed R8 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Logs, dated 4/5/20 to 4/9/20, revealed that R8 had the following elevated body temperature: 4/8/20, not timed, 100.1 degrees Fahrenheit and 4/9/20, not timed, 100.8 degrees Fahrenheit. Review of R8's Progress Notes and Physician order [REDACTED]. temperature. Review of the facility's Vitals Log, dated 4/5/20 to 4/9/20, also revealed that R8 was sharing a room with two other residents, R32 and R33 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 15. Review of R9's EMR Medical Diagnoses, revealed R9 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/9/20, revealed that R9 had the following elevated body temperatures: 4/9/20, not timed, 100.1 degrees Fahrenheit. Review of R9's Progress Notes and Physician order [REDACTED]. temperature until after this surveyor discussed R9's elevated temperature with RN1 on 4/9/20. Review of the facility's Vitals Log, dated 4/9/20, also revealed that R9 was sharing a room with one other resident, R34 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 16. Review of R10's EMR Medical Diagnoses, revealed R10 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/5/20 to 4/9/20, revealed that R10 had the following elevated body temperature: 4/5/20, not timed, 99.8 degrees Fahrenheit; 4/6/20, not timed, 99.8 degrees Fahrenheit; 4/7/20, not timed, 99.8 degrees Fahrenheit; 4/8/20, not timed, 100.4 degrees Fahrenheit and 4/9/20, not timed, 101.2 degrees Fahrenheit. Review of R10's Physician Orders, dated 4/7/20, revealed, .monitoring B. temp Q shift . Review of R10's EMR, dated 4/7/20 to 4/9/20, and review of the facility's Vital Signs log, dated 4/7/20 to 4/9/20, revealed R10's vital signs were documented one time each day and were not documented every shift per the physician's orders [REDACTED]. Review of R10's Progress Notes and Physician order [REDACTED]. temperature of 101.2 until after this surveyor spoke with RN1 about R10's elevated temperature. 17. Review of R11's EMR Medical Diagnoses, revealed R11 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/7/20 to 4/9/20, revealed that R11 had the following elevated body temperature: 4/7/20, not timed, 99 degrees Fahrenheit; 4/8/20, not timed, 99.8 degrees Fahrenheit; and 4/9/20, not timed, 100.3 degrees Fahrenheit. Review of R11's Progress Notes and Physician order [REDACTED]. temperature. Review of the facility's Vitals Log, dated 4/7/20 to 4/9/20, also revealed that R11 was sharing a room with one other residents, R35 and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 18. Review of R16's EMR Medical Diagnoses, revealed R16 was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the facility's, Vitals Log, dated 4/5/20 to 4/8/20, revealed that R# had the following elevated body temperature: 4/5/20, not timed, 99 degrees Fahrenheit; 4/7/20, not timed, 99.9 degrees Fahrenheit; 4/8/20, not timed, 99.1 degrees Fahrenheit; and 4/9/20, not timed, 100.7 degrees Fahrenheit. Review of R16's Progress Notes and Physician order [REDACTED]. temperature until after this surveyor spoke with RN1 regarding R16's elevated temperature on 4/9/20. Review of the facility's Vitals Log, dated 4/5/20 to 4/9/20, also revealed that R16 was sharing a room with two other residents, R39 and R40, and had not been isolated from other residents in the facility after having possible signs and symptoms of COVID-19. 19. During an interview on 4/9/20 at 11 am, with the DON and ADON, the DON and ADON revealed that R5 had been sent to the emergency room and was tested for possible COVID-19. The ADON and DON confirmed that R5 return to the facility with COVID-19 test pending and was put back into his room with roommate, R25. During the same interview, when asked how the facility is addressing residents that go to the hospital and return to the facility, the DON stated, If they don't have any signs or symptoms we put them back to their (original) rooms. During the same interview, when asked if R5's temperature is a possible symptom of COVID-19, the DON stated, I just hope not but to play safe we had a swab for him .We had previous readmissions and they were negative for COVID so we put them in their room. During an interview on 4/9/20 at 11 am, with the DON and ADON, when asked how the facility is doing surveillance for residents with potential symptoms of COVID-19, the ADON and DON, revealed that the facility is taking temperatures on all the residents daily and if the resident has a fever their temperature is taken every shift. During an interview on 4/9/20 at 11 am, with the DON and ADON, when asked about how the facility is preventing transmission when the residents go out to smoke cigarettes, the ADON stated, So they got distance. We try to encourage them to limit going (outside in groups). During an interview on 4/9/20 at 11 am, with the DON and ADON, when asked about the facility's plan to cohort residents with confirmed COVID-19 or potential signs and symptoms of COVID-19 infection, the ADON stated, Honestly I'm not sure what to say. If we do get COVID patients? That's something we will have to plan. We do plan to isolate them but not on a specific wing yet. 20. During an interview on 4/9/20 at 1 pm, Nurse Practitioner (NP), when asked if she had any concerns related to the facility's efforts to prevent COVID-19 transmission, the NP stated, Transfer communication was an issue with a resident that came back from the hospital and had a test. The hospital never told the nurse. 21. During an interview on 4/9/20 at 1:15 pm, with the Infection Preventionist, when asked if the facility was isolating residents immediately when the resident had potential symptoms of COVID-19, the Infection Preventionist stated, We do. We put them in a single room right away. When asked the facility's process when a resident returns to the facility after going to the hospital, the Infection Preventionist stated, Now we (sic) isolating them until we get the results (of COVID-19 testing). When asked if R5 was put in isolation pending the results of his COVID-19 test, the Infection Preventionist stated, (R5) came back this morning. No he was put in the same room and then we transferred him (to another room) around 11 am. During the same interview on 4/9/20 at 1:15 pm, with the Infection Preventionist, when asked how many residents in the facility were being monitored for elevated temperatures and/or respiratory symptoms, the Infection Preventionist stated, I should say probably four or five. The charge nurse is monitoring every floor. When asked if the facility was collecting vital signs every eight hours per the Illinois Department of Public Health's Long Term Care Facilities Guidance, the Infection Preventionist confirmed that the facility was only monitoring resident vital signs once daily. According to the Illinois Department of Public Health, All residents should be screened by obtaining full set of vitals AND pulse oximetry every 8 hours . retrieved from https://www.dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/coronavirus/long-term-care-guidance on 4/9/20 at 1:30 pm. During a follow-up interview on 4/9/20 at 2:20 pm with the Infection Preventionist, regarding R5, the Infection Preventionist stated, The hospital just called the first floor this morning that they did swab him (to test for COVID-19. During the (nurse to nurse) report when he came back they did not mention the swab. The Infection Preventionist then confirmed that R5 returned to the facility after being tested for COVID-19 at 4:30 am and was returned to his original room with three roommates and was not isolated from other residents until the following afternoon. 22. During an interview on 4/9/20 at 2:07 pm with Licensed Practical Nurse (LPN1), when asked about R5, LPN1 stated, So doctor called me and just mentioned to start the [MEDICATION NAME]. He just came from the hospital so I guess it was best to isolate him from other residents. We moved (R5 to a room by himself) just before lunch. LPN1 then confirmed that R5 had been in a room with three other residents since returning from the hospital during the prior nurse's shift and was not isolated from other residents while awaiting the results of COVID-19 testing. During the same interview on 4/9/20 at 2:07 pm with LPN1, when asked if R4 was being monitored for elevated temperatures and/or respiratory symptoms, LPN1 stated, She's been good. No fevers and her vitals have been good. When asked about R4's elevated temperature on 4/8/20 of 100.3 degrees Fahrenheit, LPN1 stated, That one I'm not sure about. When asked if there was any indication in the R4's record that the physician had been notified, LPN1 stated, I'm not aware of that. When asked if R4 was exhibiting any respiratory symptoms, LPN1 stated, She usually asks for cough syrup and I did see her cough a couple times. During the same interview on 4/9/20 at 2:07 pm with LPN1, when asked when the nurse should notify the physician of a resident's elevated temperature, LPN1 stated, I usually notify them as soon as possible. 23. During an interview on 4/9/20 at 2:32 pm, with RN1, when asked if R10 was being monitored for elevated temperatures and/or respiratory symptoms, RN1 stated, We are checking on his temperature and blood pressure per the doctor. He saw him (R10) and he was a little weaker than usual. His temperature now is 97-98. He is a smoker but I don't think he went out today. RN1 then verified that the Vitals Log, dated 4/9/20, documented R10's temperature as 101.2 degrees Fahrenheit. RN1 then stated, That was from the other nurse. When I come in I check it myself and I didn't get that temperature. When asked if the prior nurse had told the on-coming nurse about R10's elevated temperature, RN1 confirmed that he had not been told R10 had an elevated temperature. During the same interview on 4/9/20 at 2:32 pm, with RN1, when asked if R14 was being monitored for elevated temperatures and/or respiratory symptoms, RN1 stated, No concerns about him. RN1 then confirmed that the Vitals Log, dated 4/8/20, documented R14's temperature as 100.6 degrees Fahrenheit. When asked when the nurse should notify the physician of a resident's temperature, RN1 stated, For me, a 100 and up. During the same interview on 4/9/20 at 2:32 pm, with RN1, when asked if R16 was being monitored for elevated temperatures and/or respiratory symptoms, RN1 stated, No concern for me at least. RN1 then confirmed that the Vitals Log, dated 4/9/20, documented R16's temperature as 100.7 degrees Fahrenheit. When asked if the physician had been notified of R16's elevated temperature, RN1 confirmed that there was no documentation that the physician had been notified in R16's medical record. During the same interview on 4/9/20 at 2:32 pm, with RN1, when asked if R9 was being monitored for elevated temperatures and/or respiratory symptoms, RN1 stated, I check on her because she does complain that she will feel warm. She is a smoker so she does have some shortness of breath that's not new for her. RN1 then confirmed that the Vitals Log, dated 4/9/20, documented R9's temperature as 100.1 degrees Fahrenheit. When asked if R9 had gone to the smoking patio during the designated smoking time 11:52 am, RN1 stated, She has gone to smoke at least once today. Maybe twice. During the same interview on 4/9/20 at 2:32 pm, with RN1, when asked if R11 was being monitored for elevated temperatures and/or respiratory symptoms, RN1 stated, They didn't give anything in report for him. He just stays in the room on his own. No shortness of breath or any other symptoms. RN1 then confirmed that the Vitals Log, dated 4/9/20, documented R11's temperature as 101.3 degrees Fahrenheit. When asked if the physician had been notified of R11's elevated temperature, RN1 confirmed that there was no documentation that the physician had been notified in R11's medical record. During the same interview on 4/9/20 at 2:32 pm, with RN1, when asked if R15 was being monitored for elevated temperatures and/or respiratory symptoms, RN1 stated, We been monitoring her very closely. She was not doing well a day or two ago and we put her on oxygen. We get an order for [REDACTED].

Based on interview and record review, the facility failed to provide a two person assist while providing care for one of three residents (R1), reviewed for falls, in a total sample of four. This failure resulted in R1 falling from the bed while facility staff provided care. R1 was sent to the local hospital and was diagnosed with [REDACTED]. Findings include: R1 is non-verbal and non-interviewable. R1 has the following Diagnoses: [REDACTED]. On 04/26/2019 at 12:15PM, R4 stated, A loud sound woke me up. R1 was on the floor. It was just one CNA (Certified Nursing Assistant) giving R1 care. It was supposed to be two CNAs changing R1. It was a very loud bump. On 04/26/2019 at 12:57PM, V5 (Assistant Director of Nursing) stated, This happened the night shift before breakfast. V4 (Certified Nursing Assistant) was providing care for R1 and R1 started to slide. V4 lowered R1 to the floor and then she called the nurse. V4 was by herself. R1 is supposed to have two people to assist her. Progress note dated 04/17/2019 documents that V7 (Registered Nurse) responded to a call light coming from R1's room. V7 observed R1 on the floor. Per V4 (Certified Nursing Assistant), V4 was giving care to R1, V4 turned R1 to change her incontinence brief when R1 started to slide off the bed. V4 eased R1 to the floor and notified V7 for assistance. On 04/26/2019 at 1:10PM, V4 stated, I was providing care to R1 on 04/17/2019. I have always given care by myself to R1 and have never had a problem. I was changing R1 and I turned R1 to her side facing me. R1's legs slid out and the weight from R1's legs made her come out of the bed. I put my arm around R1 and slid her to the floor. The facility is fine with it. On 04/26/2019 at 1:34PM, V7 stated, I was the medication nurse that night. I responded to a call light from R1's room. Staff called me to check on R1's room. When I got there R1 was on the floor. V4 was the CNA that was giving R1 care and R1 started to slip. We were short staffed at that time. MDS (Minimal Data Set) dated 03/26/2019 documents that R1 is a total dependence resident with a two person assist when R1 is turned side to side and positioning in bed. Care plan, undated, notes that R1 is a two person assist for ADL (Activities of Daily Living) care and is a high risk for falls. Hospital records dated 04/17/2019 document that R1 has a closed [MEDICAL CONDITION] end of the left humerus after a fall out of bed.