Every finding on record at Clark Manor

Based on interview and record review, the facility failed to follow their policy to report an allegation of abuse, to the facility Administrator/Abuse Coordinator, for one resident (R1) in a sample of four residents reviewed for abuse.Findings include:On 7/16/26 at 12:21 PM, V9 (Certified Nursing Assistant) stated, I overheard R1 saying that R2 hit them. I don't know who R1 was talking to. R1 was in their wheelchair moving around on one side of the hall. R2 is permanently in bed. R1 is the agitated one. R1 wants the room to themself. R1 does not want R2 in the room. If a resident hits another resident, it is abuse. I did not report it because it was not my side.On 7/16/26 at 2:48 PM, V2 (Executive Director) stated, R1 did not report being assaulted by R2 to me. No staff reported to me that R1 reported being assaulted. R1 did not report being hit or assaulted by anyone else. V1 (Administrator) did not inform me that R1 reported being assaulted. V1 did not inform me a staff member reported abuse. If a resident hits another resident that is abuse. Staff would need to report it immediately to the administrator who is the abuse coordinator or to the designee. If staff hear about an abuse allegation they need to report it. If staff overhear an allegation of abuse, they should report it so we can do a thorough investigation. We do abuse training annually, upon hire, and as needed, post abuse allegation findings. All staff are trained on the abuse policy. The last abuse training was in April.On 7/17/26 at 1:05 PM, V1 (Administrator) stated, I am the abuse coordinator. We do train on abuse, annually, and as needed. New hires are trained as part of onboarding. We started in-servicing yesterday and continue today because of this survey finding. R1 did not report being assaulted by R2 to me. Staff did not report to me on R1 claiming to be assaulted by R2. If staff witness abuse, they should separate the residents, then report to me, the abuse coordinator. If a resident says they were hit by another resident that is abuse and it should be reported immediately. It should still be reported if the resident is not a part of the staff members' assignment.Facility Abuse and Retaliation Policy, 7/3/26, documents in part: All allegations and/or suspicions of abuse and retaliation must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee.

Based on interview and record review, the facility failed to follow its abuse policy and procedure. Facility employees failed to report an abuse allegation to the abuse coordinator. This failure affected one (R1) out of four residents reviewed for abuse. The Findings Include: R1's clinical records show an admission date of 3/25/25. R1's Minimum Data Set, dated [DATE] shows R1's BIMS (Brief Interview for Mental Status) score was 13 (Cognitively Intact).On 12/23/25 at 9:57 AM, R1's lying comfortably in bed noted with forgetfulness. Dry dressing noted on R1's forehead. R1 stated that Friday morning, a CNA [Certified Nursing Assistant] was mad at R1 for pressing the call light too many times, took the bed control remote and hit R1 on the forehead. R1 denied being hit on the stomach or with a wet diaper. R1 stated he called the nurse for help, but the nurse did not believe R1 when he told the nurse what happened. R1 was unable to say the names of the staff involved, but R1 described the CNA and the nurse as both Black heavy-set ladies. R1 said he was sent to the emergency room and had stitches on his forehead. R1 stated he feels safe right now in the facility and no staff is abusing him.On 12/23/25 at 10:44 AM, Surveyor informed V1 (Administrator) and V3 (Assistant Administrator) regarding R1's abuse allegations. Both stated they have not heard of any complaints or allegations from R1 regarding physical abuse. Both stated R1 did not mention any abuse allegation nor did not receive any abuse allegation from the hospital. V1 stated will start abuse reportable and start investigating. Both stated nobody called from the hospital that R1 was alleging abuse. V1 stated that the staff is expected to report to V1 immediately for any abuse allegations and V1 will do initial investigation and reporting to IDPH [Illinois Department of Public Health] within 2 hours. Final is sent within 5 days. V1 said hitting a resident is physical abuse.On 12/23/25 at 12:34 PM, a phone interview was conducted with V9 and stated that she's been coming to work in the facility as agency CNA since 2023. V9 stated, It was Sunday 21st around 6:45 AM I went to his [R1] room to change R1's adult brief. V9 stated I (V9) was doing my rounds. [R1] was awake. I (V9) took the bed remote to bring [R1's] bed up to my height to do incontinence care. [R1] did not want to be changed. [R1] snatched the bed remote from my hand. [R1] pulled the cord forcefully and then it hit his forehead. [R1's] forehead started bleeding, so I called the nurse right away. I called [V10]. [V10] came in the room with me. [R1] was telling [V10] that I hit [R1] with the cord. I did not hit [R1] with the cord. It was an accident. I was there when [R1] was telling [V10] that I hit him. [V10] assessed [R1] and cleaned the wound on [R1's] forehead. It was just me and [V10] went to [R1's] room. I did not report to anybody of [R1's] accusations. It was just the nurse who was there [V10]. After that incident I was not assigned with [R1] again.On 12/23/25 at 1:53 PM, a phone interview was conducted with V10 (Registered Nurse) and stated, It was around 6:45 in the morning. The CNA [V9] was making her incontinence care rounds. I did not witness the incident [V9] told me she went inside the room and started to assist him [R1] to change him but the patient was very resistant while [V9] was holding the bed control to adjust the bed [R1] pulled the cord from [V9's] hand the bed control slipped out of her hand and hit [R1's] forehead. [V9] immediately called me. [R1] is always resistant to morning care. [R1] has a behavior of very resistant every morning. [V9] called me because his [R1] head was bleeding. I went inside [R1's] room I saw that there was bleeding on the forehead, so I put treatment. I cleaned the wound and put pressure dressing. The bleeding was controlled. I asked [R1] what happened, and [R1] said that [V9] was holding the bed control, and [R1] grabbed the remote control slipped from [V9's] hand then hit his [R1] head accidentally. [R1] did not want to be changed. [R1] never told me that the [V9] hit him [R1]. We sent to the hospital [R1] via 911.A review of R1's progress notes dated 12/21/25 at 4:07 PM documented by V8 (R1's Nurse Practitioner) reads in part: [R1] was seen today. A 3-4 cm [centimeters] fresh laceration in the mid of forehand. [R1] reports a confrontation with nurse staff and hit by the remote.On 12/23/25 at 12:20 PM, a follow-up interview was conducted with V1 and V3. Both stated they did not receive any report from V8 (R1's Nurse Practitioner) regarding R1's abuse allegation. R1 said that the expectation is for V8 to report it to V1 immediately for any abuse allegations. They would start the abuse reporting and abuse investigation right away and suspend the staff involve pending investigation if they were informed. Both stated an in-service will be provided right away to V8 about the facility's abuse policy and procedures.On 12/23/25 at 12:23 PM, called V8 and left a message through the answering service, but V8 never returned Surveyor's call.Facility provided V8's in-service on abuse prevention and reporting dated 12/23/25.The facility's Abuse and Neglect policy and procedure dated 6/26/25 documents in part: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.

Based on observation, interview and document review the facility failed to maintain an effective pest control program so that the facility is free of rodents on 3 of 4 resident floors. Findings include: On 6/26/2025 at 09:52 AM, R1 stated, that she has seen mice in the room by a bed. R1 said, that since she has been residing at this facility, there have always been mice seen in the resident's rooms. R1 stated, that she was moved from another room before multiple times and each time, she saw mice in the room. R1 stated that the mice could be seen sometimes running from one resident's room to the other, mainly at night, but she seen it during the day too. On 6/26/25 R1's room was observed with mouse droppings on the floor behind the bedside cabinet and under the heat/air conditioning unit. On 6/26/2025 at 10:32 AM, Observed R3 laying in the bed, dressed, and groomed appropriately, wearing shoes in the bed. No insect or roaches noted on the bed or the clothes. R3 stated, that he has seen mice recently, in his bathroom. R3 said that the mice ran from under the bathroom door and slide under the room's door, into the hallway. R3 stated that he does not like the mouse trap being in the room. On 6/26/25 R3's room was observed with mouse droppings on the floor in corner next to bed. On 6/26/25 at 11:05 AM R8 stated I see mice in my room all the time at night. On 6/26/25 at 11:05 AM R8's room was observed with mouse droppings on the floor and behind the bed and under heating / air conditioning unit. On 6/26/25 at 1:15 PM R11 stated yes I see mice in my room at night. They come in here from the hallway. On 6/26/25 at 1:25 PM R12 stated I see mice in at night. I don't like seeing mice in my room. On 6/26/25 at 1:25 PM R12's room was observed with mouse droppings on the floor next to window. On 6/26/25 at 1:40 PM R13's room was observed with mouse droppings on the floor next to the heating/air register. A hole was observed next to the register at the baseboard. Facility Policy titled Pest Control Revised 8/16/24 states It is the facility policy to ensure that there is an effective pest control process in the building.

Based on interview and record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in a total sample of four residents. Findings include: On 6.11.2025, at 12:37 PM, R1 said, R2 was screaming at me that my television was too loud. The nurse, I don't remember her name, came into my room. She said the television was not too loud. I was sitting on my bed, R2 was standing about 1 ½ feet from me. He hit me with his fist on my left cheek and part of my nose. It happened so fast; the staff couldn't have prevented it. The nurse called for help. CNAs (Certified Nursing Assistants) came and escorted R2 out of the room. As he was leaving, R2 said to me, I'm going to come back and kill you. I didn't sleep all night because of his threat. I feel great now that he isn't here in the facility. I'm okay if he comes back. I have V3's (Assistant Administrator's) phone number. V2 (DON-Director of Nursing) assessed me after the incident. I was interviewed multiple times; I signed my statement after reading it. On 6.12.2025, at 9:59 AM, via telephone, V8 (LPN-Licensed Practical Nurse) said, on that day (6.9.2025), around ten something at night, I was at the nurses' station. I heard a noise. V7 (CNA) was on her way to call me, I met her on the way. She went into the room with me. I got to the room they, R1 and R2, were arguing about the TV being too loud. I tried to separate them. I asked R2 to follow me to the nurses' station, he did. I notified the nursing supervisor. She told me to separate them. Neither resident said anything about R2 hitting R1. On 6.10.2025 at 10:20 AM via telephone, V7 (CNA) said, it was on Monday (6.9.2025) between 10:00 PM and 11:00 PM. R2 was calling me to come see. R2 said R1's television was too loud. I went into their room. R1's television was too loud. With R1's permission, I turned his television down. I left the room, I reported to V8 what happened. She told me to move R2 to the 5th floor to prevent anything further from occurring. Facility's initial incident report of 6.10.205, documents in part: On 6.10.2025, at around 2:00 PM, V1 (Administrator) and V3 (Assistant Administrator) were approached by (R1) who stated that he had a disagreement with his roommate over the loudness of television in their room. During the process, his roommate (R2) made contact to his face. Both parties were immediately separated. R1 was assessed and had no redness, bruises, or discoloration noted to his face. R2 was sent to the hospital for a psych eval. R1's signed statement regarding the disagreement with R2 dated 6.10.2025, (no time) documents: My roommate and me had a disagreement the other night about the TV. He thought I had it too loud, and he wanted me to turn it down. That is when he put his hand up and ran it down my face. I don't think he had any intention to cause harm. The situation is over, he is gone, and I love my room. I don't want to discuss it anymore. R2's signed statement regarding disagreement with R1 dated 6.10.2025, (no time) documents: The other night my roommate had his TV up too loud. I was turning down the TV and (R1) walked up to me. I got startled because he is bigger and waved up my hands. I am a short, little guy. I wasn't trying to hit (R1) or cause any harm. R2 was not available for interview during the survey. R1's face sheet documents R1 is a [AGE] year-old admitted to the facility on 12.16.2024, with diagnoses including but not limited to: Chronic systolic (Congestive) heart failure, Bipolar disorder, current episode manic severe with psychotic features; Gastro-esophageal reflux disease without esophagitis, Major depressive disorder, recurrent, severe with psychotic symptoms; Chronic kidney disease, stage 3A. R1's MDS (Minimum Data Set of 3.25.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R1 is cognitively intact. R2's face sheet documents R1 is a [AGE] year-old admitted to the facility on 7.21.2022, with diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alcohol abuse, uncomplicated; Other specified diseases of liver, Essential (Primary) hypertension. R2's MDS (Minimum Data Set of 4.16.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R2 is cognitively intact. On 6.10.2025, at 2:30 PM, R1's General Progress Note documents in part: On 6.10.2025 at around 2:00 PM, Administrator (V1) and Assistant Administrator (V3) were approached by R1. R1 stated that he had a disagreement with his roommate over the loudness of the television in their room. During the process, his roommate R2 made contact to his face. Both parties were immediately separated. A complete physical assessment was done for R1. No redness, bruising or discoloration noted on (R1's) face and no other visible injury noted to his body as well. (R2) will be sent out for psych evaluation. On 6.10.2025, at 6:41 PM, R2's Behavior Note documents in part: Resident was alleged of physical aggression towards his peer. Both were separated immediately, and he was placed on 1:1 monitoring. Resident requires immediate hospitalization to prevent harm to self and others. (Physician) was informed. An order was given to send resident to the local hospital emergency department on involuntary petition for psych evaluation. Order noted and carried out. On 6.11.2025, at 7:55 AM, R2's General Progress Note documents in part: Placed a call to (local hospital) emergency department to inquire about resident's disposition and made aware that resident is admitted to the psych unit due to aggressive behavior. R2's Petition for Involuntary/Judicial admission (dated 6.10.2025) documents in part: -Emergency inpatient admission by certificate. The Respondent is currently detained in a mental health facility or hospital. -Person continues to be subject to involuntary admission on an inpatient basis. -R2 is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another person in physical harm or in reasonable expectation of being physically harmed; a person with mental illness who: because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm without the assistance of family or others, unless treated on an inpatient basis; a person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or paragraph two above. (Is) in need of immediate hospitalization for the prevention of such harm. (R2) was alleged of physical abuse towards his peer. He has been placed on 1:1 monitoring until sent to the hospital for psych evaluation. (R2) requires immediate hospitalization to prevent harm to self and others. Administrator and physician were notified. Initial report has been sent to IDPH (Illinois Department of Public Health) with final report to follow. Abuse and Neglect policy (Reviewed/Revised 4.24.2025) documents in part: -Policy Statement: it is the policy of the facility to provide care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. -Definitions of abuse: Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse.

Based on interview and document review the facility failed to ensure the rights of residents to be free from abuse in one of four residents (R1, R7, R8 and R10) in a sample of 10 residents. This resulted in R7 sustaining a superficial scratch to left side of face near eye. Findings include: R7 is a [AGE] year-old male with diagnoses including Parkinsonism, COPD, Schizoaffective Disorder, Diabetes 2, and Alcohol Abuse. R7 was first admitted to the facility on [DATE]. R7 has a BIMS (Brief Interview for Mental Status) score of 15/15. R7 hospital record dated 3/8/25 shows R7 sustained superficial abrasion to the left bridge of nose/near eye. No other injuries sustained in the altercation. On 3/11/25 at 2PM R7 stated yes, I had an altercation with R8 out on the smoking patio. R8 started urinating out on patio and did it on my leg. I pushed him away and he pushed my face with his hand. My glasses fell off my face and broke on the ground. He poked my eye, and I had a small scratch on my eyebrow. I went in and told staff. Staff called the police and got R8 from the patio. The police came but I didn't want to press charges. I didn't get hurt. They sent us both to the hospital and I returned without any injury except the scratch. I haven't seen R8. I don't want to talk about this anymore. I am safe here. R8 didn't mean it he is just sick so it's not a big deal to me. On 3/11/25 at 1:56PM V2 (Assistant Administrator) stated we received a call that R7 allegedly received a scratch. We immediately separated both residents. Both were assessed. There was no serious injury just a tiny superficial scratch to the face of R7 with no significant injury. R7 was not in pain or distress. We reported to the State Agency immediately. Chicago Police called. R7 refused to press charges. R7 stated the patient is sick and no need to do anything. Both were sent to hospital. R7 was sent to hospital with no significant injury and returned the same day. On 3/12/25 at 1:40PM V8 (RN/Registered Nurse) stated R7 came in from patio and told me R8 scratched his face and broke his glasses. I assessed him with a small scratch below his eye. I notified other staff who came and provided 1:1 to both R7 and R8. The police arrived. Family and doctor was notified. Both residents were sent to the hospital. R7 3/11/25 Social Service note states this writer went to speak to R7 to see how he was doing in regard to an incident that allegedly happened this past Saturday. He (R7) told this writer, I'm fine, and there is nothing to talk about its over with and I don't want to talk about it anymore. Social services will continue to offer support as needed. R8 is a [AGE] year-old male with diagnoses including Bipolar Disorder, Hepatitis C, Nicotine Dependence, Other Drug Induced Secondary Parkinsonism and Thrombocytopenia. R8 was first admitted to the facility on [DATE]. R8 has no BIMS (Brief Interview for Mental Status) score non scorable. R8 is care planned for including Verbally Physically Aggressive Behavior as the result of the 3/8/25 incident, R8 is care planned for Delusional Behavior. Review of facility alleged abuse investigations show that on 3/8/25 at around 4:05 PM Administration received a call from V3 (RN), Nursing Supervisor who stated that resident R7 has alleged that R8 had scratched his face. R7 was assessed and had no significant injury. R8 has a diagnosis of Bipolar D/O and Mild Cognitive Impairment and other medical conditions. R7 was sent to hospital for medical and R8 was sent to hospital for psych eval. Chicago Police Department was notified, and officer responded, and a report was filed. NP/nurse practitioner and mother of R7 were both notified. This will serve as the facilities initial report. Investigation immediately initiated. R8 3/8/25 progress note states resident noted with verbal and physical aggression towards others. Un-redirectable, placed on 1:1 monitoring. DR/doctor notified with order to send resident to Hospital ER/emergency roiagnom on involuntary petition for psych evaluation. Order noted and carried out. Resident became uncontrollable, 911 was called and transferred him to Hospital. Doctor informed. Resident has no family contact. Report given to Hospital psych intake c/o. Resident face sheet, POS/physician order sheet, most recent lab results and medication list faxed to 773-xxx-xxxx. R8 3/8/25 progress note states in addition, resident was transferred to hospital with the assistance of Chicago Police, report filed. Facility policy titled Abuse and Neglect Revised 7/12/24 includes statement: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment.

Based on observation, interview, and record review the facility failed to a) ensure a residents' self-releasing seat belts (used to keep a resident positioned properly in their wheelchair) were secured in a manner which allowed the residents to freely release the belt, b) failed to complete an assessment for the need of a restraint and c) failed to code the Quick Release Belt in the MDS (Minimum Data Set) as a restraint for 1 (R1) out of 3 residents reviewed for physical restraints. Findings Include: R1 was initially admitted to the facility on [DATE] with a readmitted [DATE] with diagnoses not limited to Chronic Kidney Disease, Stage 3, Nephrogenic Diabetes Insipidus, Extrapyramidal and Movement Disorders, Drug Induced Subacute Dyskinesia, Other Specified Forms of Tremor, Diabetes Insipidus, Pain In Leg, Low Back Pain, Drug Induced Secondary Parkinsonism, Schizoaffective Disorder, Bipolar Type, Unilateral Primary Osteoarthritis, Right Knee, History of Falling and Anxiety Disorder. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderately impaired. Progress note dated 07/30/24 at 4:57 pm document in part: Restorative Note Text: R1 has been provided a Quick Release Seat Belt to protect her from falls and/or injuries sustained by falls due to poor posture. R1 has tendency to frequently bend over from waist when ambulating or sitting. R1 is currently in a wheelchair and bending over while sitting can cause R1 to fall out of her chair. Progress note dated 10/09/24 at 7:52 am document in part: Behavior Note Behavior: Observed sitting up in wheelchair with face leaning on table in day room, refused to go to the bed. Refused pillow when offered. List education provided: Quick release belt provided D/T (due/to) resident EPS (Extrapyramidal Symptoms). Order Summary Report document in part: My have Quick Release Torso Safety Belt Daily when up in wheelchair to reduce risk of fall and/or injury sustained from fall dated 10/29/24. Document titled Physical Restraint Informed Consent dated 07/30/24 document in part: Method of Physical Restraint Used: Quick Release Safety Belt. The Reason the Physical Restraint is Needed: To Prevent Falls/Injury Sustained from Fall. Times when restraint will be applied: Daily when in wheelchair. Care Plan document in part: Focus: R1 is at high risk for fall d/t (Due/to) slipping from wheelchair going to the washroom, unsteady gait secondary to dx. (diagnosis) of Cerebral Infarction, delusional episodes, failure to get up from bed slowly and possible side effects from use of anti-psychotic medication. Date Initiated: 02/10/25. Interventions: R1 has tendency to frequently bend over at waist (due to back pain she states when she bends it relieves the pain somewhat) causing poor posture and risk for fall. R1 has been provided a Quick Release Belt for her wheelchair which will help to prevent her falling and/or sustaining injury. This belt should remain in place when she is sitting in her wheelchair to be released only for care and toileting needs. Date Initiated: 07/30/24. MDS Section P - Restraints and Alarms document in part: Physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The coding of 0 not used is documented on the MDS Section P. Facility Matrix indicate R1 has a Physical Restraint. Document titled Side rail/Other Devices evaluation has no restraint devices documented. On 02/25/25 at 12:22 PM V6 (Licensed Practical Nurse) stated R1 has a quick release belt in the chair due to her posture. I can't recall any falls just the quick release. On 02/25/25 at 02:07 PM R1 was sitting in wheelchair in the dining room with the quick release belt in use. R1 was transported to her room in the wheelchair by a staff member. R1 stated they never showed me how to release this belt. If it was an emergency, I would be a goner. It is connected somewhere in the back of the wheelchair. R1 was pulling the quick release belt near the bottom of the belt near the lower area around the abdomen. R1 stated its tight and not giving. R1's quick release belt Velcro was connected at R1 right lower side out of view and reach for R1 to release. On 02/26/25 at 10:40 AM V11 (Restorative Nurse/Licensed Practical Nurse) stated the quick release self-release is considered a restraint because R1 wears it. R1 is able to take it off anytime she wants. R1 is alert and oriented x/times 3. R1 has a tendency to lean forward with her head between her legs and the belt is helping her to understand to sit upright. R1 has had the belt for some months. The resident should be able to get out of the quick release belt. We had a couple of short trails to remove the quick release belt, but we put it back. We don't want R1 to tumble out of the chair. R1 is a high fall risk. I was unaware there is a physical restraint assessment. V11 was shown by the surveyor MDS Section P Restraints and Alarms that indicate R1 has no restraints. On 02/26/25 at 11:33 AM V12 (MDS Coordinator) stated the restorative nurse is in charge of restraints. The restorative nurse will assess and do the care plan because they are in charge of the order. We divide the MDS, the restorative nurse fills out section P. The quick release belt would be considered as a trunk restraint. The MDS is indicating the resident has no restraints because it is coded as zero. The MDS section P was incorrect meaning there were no restraints in use. I believe there is and assessment or evaluation that is done for restraints. On 02/26/25 at 01:23 PM R1 was in wheelchair in the dining room with the quick release belt in use. On 02/26/25 01:24 PM V13 (Certified Nurse Assistant) stated R1 leans forward in the wheelchair and the quick release belt is released every 2 hours. I put the quick release belt on R1 when I get her up. On 02/26/25 at 01:49 PM V2 (Assistant Administrator) stated R1 leans forward so we see the quick release belt for support. On 02/26/25 at 04:03 PM V19 (Licensed Practical Nurse) stated we put on the quick release belt to prevent R1 from falling. When in the wheelchair R1 will lean forward. If R1 takes the quick release belt off by herself R1 will be getting up and fall. On 02/27/25 at 10:15 AM V20 (Director of Rehabilitation) stated R1 is unable to sit at the edge of the bed. According to the physical therapy evaluation it does not have any indication that R1 cannot sit up in a wheelchair. R1 had a sitting and standing instability. The physical therapist usually put recommendations in the discharge note. The quick release belt is for safety, so R1 does not fall and hurt herself. The more R1 sits upright, it helps her with her trunk control. That is nursing not therapy to reevaluate R1. On 02/27/25 at 10:37 AM V20 (Director of Rehabilitation) stated Physical Therapy was working on R1's lateral trunk stability, sitting up. Weight shift dynamic stability and facilitation of anticipatory postural adjustments to pull herself up. If R1 was leaning forward, conscious enough to pull herself back. There was training, limit balance and R1's trunk technique to facilitate proprioception and adjustment of center of mass over base of support improving proactive sitting balance training. This was in July 2024 when R1 was discharged from physical therapy R1 has made progress with skilled interventions. There were no recommendations other the restorative nursing program for ambulation and range of motion. On 02/27/25 at 11:19 AM V2 (Assistant Administrator) stated regarding the vest for R1 we gave R1 and the staff education. On 02/27/25 at 11:22 AM R1 was in the dining room in a wheelchair with the quick release belt in use. On 02/27/25 at 11:23 AM R1 was transported to her room in the wheelchair by a staff member. R1 stated they said the belt is to keep me from sliding out of the chair. The chair is low so where am I to go to. I can sit up; they don't give me enough time to demonstrate I can you sit up straight. R1 was sitting in the wheelchair with the left shoulder strap of the quick release belt hanging off of the left shoulder. R1 was leaning to the right side with her right arm hanging near the wheel of the wheelchair. When asked can she (R1) sit up straight in the wheelchair, R1 readjusted herself and sat upright in the wheelchair. R1 stated I don't feel the belt is helping, it is unnecessary and don't make sense. They put this belt on me every day when they get me up. They showed me how to take the belt off today. On 02/27/25 at 12:29 PM V4 (Direction of Nursing) stated R1 has improved a lot. The restorative nurse recommended the quick release belt. We have to assess and evaluate if they need that quick release belt, get an order, consent, and monitor if they are okay with that one. We did the in-service yesterday. Document titled In-Service Topic and Attendance Sheet dated 02/26/25 Topic: Quick release Torso Support. Summary of In-Service Topic: Use of Quick Release Torso Support for Poor Trunk Control. Attachments: (Two Pictures of the Posey Torso Support for Wheelchair). Policy: Titled Restraints reviewed 08/19/24 document in part: It is the facility's policy to ensure that each resident is not restrained for the purposes of discipline or convenience. The facility will utilize non- restraining interventions first before trying restrain-type devices which will be considered as last resort. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that. A) attached or adjacent to the resident's body. B) that the individual cannot intentionally removed easily, and C) restricts freedom of movement or normal access to one's body. Procedures: 1. In the event that resident's condition warrants the use of restraint, a restraint device assessment will be done to determine if the device is appropriate for the resident. 2. Once the assessment determines that the device or intervention is a restraint, a physician order will be obtained indicating the type of device to be used. The order may be accompanied by the indication/reason for the device, the duration of use, and how often it is supposed to be released. If this information is not reflected in the POS (Physician Order Sheet), these should be specified in the device assessment, in the Progress Notes, or in the care plan. 5. T use of the restraining device may be assessed and reduced at least quarterly. 9. Any device including mobility alarms that may have a restraining effect on a resident should be assessed and evaluated to determine it is a restraint or an enabler.

Based upon observation, interview, and record review the facility failed to ensure accuracy of wound location, failed to document a thorough wound assessment, failed to follow physician orders, failed to ensure that treatment administration is not documented when not performed and/or failed to implement care plan interventions for three of three residents (R2, R3, R4) reviewed for wound care. Findings include: On 8/14/24, IDPH (Illinois Department of Public Health) received allegations that the facility does not take wounds seriously. R3's diagnoses include dementia and xerosis cutis (abnormally dry skin). R3's (8/2/24) BIMS (Brief Interview Mental Status) states resident is rarely/never understood. R3's (8/2/24) functional assessment affirms resident is dependent on staff for ADL (Activities of Daily Living) care. R3's (8/15/24) initial skin/wound notes includes the following: right posterior knee abrasion. 4.0 x 1.0 x 0.1cm (centimeters). 100% epithelial. Periwound: intact, fragile. R3's (8/15/24) POS (Physician Order Sheets) includes right posterior knee: cleanse with NS (Normal Saline), pat dry with gauze, apply xeroform to the base of the wound and cover with border gauze dressing every day shift (Tuesday, Thursday, Saturday) and PRN (as needed). R3's (1/25/21) care plan includes abrasion to right posterior knee, intervention: (8/20/24) cleanse with NS, apply xeroform to base of the wound, secure with gauze 3x per week (Tuesday, Thursday, Saturday) and PRN. R3's (8/20/24) skin/wound notes state right posterior knee improving without complication, wound care will follow until resolved [therefore the wound was not resolved]. On 8/20/24 at 11:16am, surveyor inquired about R3's wound however R3 did not respond. Surveyor inquired if R3 is able to communicate, V4 (CNA/Certified Nursing Assistant) stated Sometime he talk but not really. Two (2) large, scabbed areas (with redness surrounding each) were observed on the back of R3's right lower posterior thigh (not the posterior knee) and there was no dressing present. Surveyor inquired about the appearance of R3's wound, V4 responded It some sore, it look like it was a blister but it dry. Surveyor inquired if a dressing was present on R3's wound, V4 replied When they put him here temporarily last week it wasn't having dressing and affirmed she (V4) did not know that R3's wound required a dressing because he didn't have one on. On 8/20/24 at 11:24am, surveyor inquired about R3's wound, V5 (Licensed Practical Nurse) stated I could call the wound care nurse, I know that they were treating it. V5 inspected R3's wound (as requested) and responded, I see a reddened area and scabbing that's all I can really describe. Surveyor inquired if a treatment was on R3's wound (as ordered) V5 replied I don't see like a patch or anything. R3's (August 2024) TAR (Treatment Administration Record) affirms the right posterior knee dressing was last documented on 8/17 (3 days prior), the PRN entries are blank. On 8/21/24 at 11:39am, surveyor inquired about staff requirements when resident skin alterations are identified, V6 (Wound Care Coordinator) stated Somebody will call me, I (V6) do the assessment, I take picture and I call the NP (Nurse Practitioner). She (NP) will give me the treatment order and when she comes in, she will see the patient. Surveyor inquired about staff requirements if a dressing falls off a resident, V6 responded We will change it again, most of them (Residents) have PRN orders. Surveyor inquired about R3's wound, V6 replied It has like a skin tear like laceration I think it happened on the 15th of August. I called the NP, got the order and when she (NP) came in, she saw him (R3). Surveyor inquired about R3's current treatment orders, V6 stated It's a xeroform 3 times a week and PRN. That's Tuesdays, Thursdays, Saturdays and PRN. Surveyor inquired why R3's (right posterior thigh) wound was observed Tuesday (8/20/24) without a dressing, V6 replied Usually the CNA is supposed to call me when the dressing comes off. They should have called me. ---- R4's diagnoses include dementia and xerosis cutis. The facility wound report includes (R4's) right 5th finger laceration (acquired 8/1/24). R4's (8/1/24) progress notes state, notified by nurse that patient injured his right 5th finger last night, assessed by wound care nurse, noticed the laceration may need to be sutured. Refer to wound care notes for description. R4's (8/1/24) initial wound assessment states, small cut on the 5th finger however measurements and/or a description of the wound were excluded. On 8/21/24 at 11:49am, surveyor inquired about R4's wound, V6 (Wound Care Coordinator) stated He has like a cut on his 5th finger. Surveyor requested a description of R4's wound, V6 responded Oh, laceration, he (R4) have laceration [laceration was excluded from R1's initial wound assessment]. Surveyor inquired if R4's (8/1/24) wound was measured during the initial assessment, V6 replied I think it was my colleague that did the assessment, there is no measurement there. It's supposed to be measurements there. ---- R2's diagnoses include morbid obesity, xerosis cutis and cellulitis of left lower limb. The facility wound report includes (R2's) left calf partial thickness wound (acquired 7/11/24). R2's (7/12/24) POS includes Gentamycin Sulfate external cream 0.1% apply to left calf topically every day shift for reopened surgical wound. Cleanse with NS, apply gentamycin ointment, cover with bordered gauze. The facility census affirms R2 was hospitalized [DATE] through 8/19/24. R2's (August 2024) TAR (Treatment Administration Record) affirms on 8/15/24 the left calf treatment was documented as administered [R2 was hospitalized at this time]. Surveyor inquired why R2's (8/15/24) treatment administration was documented when R2 was hospitalized [therefore not in the facility] V6 (Wound Care Coordinator) reviewed R2's TAR and responded, It must be a mistake. The wound care policy (revised 1/24/24) states this facility adheres to the Federal and State requirements for wound care management. The facility shall develop a plan of care and implement intervention. The resident's skin alteration/breakdown shall be documented in the resident's clinical records in accordance with the facility's policy and in compliance to current regulatory standards.

Based on interview and record review, the facility failed to have sufficient staffing on the weekend. This failure affects all 245 residents residing in the facility reviewed for lack of staff. Findings include: Review of staffing data submitted via the Payroll-Based Journal (PBJ) system revealed the facility had been triggered for weekend staffing data is excessively low. On 05/14/2024, V2 (Assistant Administrator) provided surveyor with the facility's Payroll-Based Journal (PBJ) report dated 10/01/2023 to 12/31/2023. Facility document, dated 02/01/2024, titled Facility Assessment Tool documents in part, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Plan (please list the actual plan being used in your facility, as below are examples that may not fit your facility's staffing plan and status. Please check as well that your building is compliant with Illinois' Minimum Staffing calculation). RN (Registered Nurse) or LPN (Licensed Practical Nurse) Charge Nurse: 10 for Days and Evenings, and 5 Nights shift, 1:29 LN ratio Days and Evenings 1:58 LN. facility's Payroll-Based Journal (PBJ) report reviewed for the following weekend dates: 10/15/2023, 11/04/2023, 11/05/2023, and 12/17/2023. 10/15/2023 documents that there were 23 licensed nurses working with total hours of 182.25. 11/04/2023 documents that there were 19 licensed nurses working with total hours of 182.5. 11/05/2023 documents that there were 23 licensed nurses working with total hours of 179. 12/17/2023 documents that there were 23 licensed nurses working with total hours of 198.25. Facility's document dated 10/15/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 186. Facility's document dated 11/04/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 192. Facility's document dated 11/05/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 192. Facility's document dated 12/17/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 192. 05/16/2024 at 9:59 AM V33 (Staffing Coordinator) states that she is responsible to make sure there are enough staff working on the units. V33 states that both nurses and CNAs (Certified Nursing Assistants) work 8-hour shifts. On 05/16/24 at 11:25 AM V33 states that first floor 1 nurse 7-3 3-11, 2nd floor we have two nurses, 3rd floor two nurses, 4th floor two nurses, and 5th floor two nurses. V33 states that there should be nine nurses on 7am-3pm shift, nine nurses on 3pm-11pm shift, and five nurses on the 11pm-7am shift. V33 states that there should be a total of 23 nurses providing resident care in a 24-hour period. Facility census dated 05/14/2024 documents that a total of 245 residents reside in the facility.

Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated per facility policy, b.) keep food storage areas clean, c.) conduct hand washing in between handling dirty and clean plate ware/equipment, d.) thaw frozen meat under running cold water. These failures have the potential to affect all 242 residents receiving food prepared in the facility's kitchen. Findings include: On 05/14/24 at 9:33 AM, during initial kitchen tour V5 (Culinary Development Specialist) stated everything should be labeled and dated with an open and use by date. Dry good items are labeled with the received/delivery date and dated with an open and use by date once the item is opened. V5 stated there are different use by dates depending on what the item is. V5 referred to a sign posted on the outside of the walk-in refrigerator which listed different use by dates titled Visual Aid Use by Dates. On 05/14/24 at 9:40 AM, observed in the walk-in refrigerator the following: 1.) Opened gallon of Coleslaw Dressing labeled with received date 04/17/24, opened date 04/26/24, use by date 06/26/24. Black speckled material observed around ridges of the lid to the Coleslaw Dressing. V5 stated, that is mold and it should be thrown out despite the expiration date still being within use by range. 2.) Opened 5-pound bag of shredded mozzarella cheese wrapped tightly in plastic. Not labeled or dated. V5 stated because the item is not labeled/dated there is no way to know how long the item has been in there and it may not be safe to still use. 3.) Black material imbedded into the folds of the refrigerator door seal/gasket. V5 stated that is mold and should not be there. V5 stated that needs to be cleaned and should be part of the cleaning process. On 05/14/24 at 10:00 AM, observed in dry storage area an opened container of Worcestershire Sauce labeled with delivery date 10/19/22. There was no opened date or use by date on the container. V5 stated this product should be thrown out after 6 months from when it was opened because bacteria can grow in it. V5 stated because there is no opened date on it, and therefore it should be tossed. On 05/14/24 at 10:13 AM, surveyor and V5 observed two employees working in the dish machine area. Observed one staff was bringing in the dirty carts and breaking them down and the other staff (V6, Dietary Aide) was observed putting dirty trays and lids into the dish washer and grabbing the cleaned items from the dish washer without performing hand hygiene in between. V5 stated the dish machine area is staffed with two to three people. V5 stated if there are two people working in the dish room then the person handling the dirty items needs to wash their hands before handling the cleaned items to prevent cross contamination. V5 stated V6 should have washed V6's hands before touching the cleaned items. On 05/14/24 at 10:20 AM, V6 (Dietary Aide) stated there are supposed to be three people working in the dish room but if they do not have the staff there are only two. V6 stated, I am supposed to wash my hands after putting the dirty items into the dish machine and before pulling the cleaned items out of the dish machine. On 05/15/24 between 10:50 -11:28 AM, observed V26 (Chef) prepare pureed lunch meal items in the kitchen using two sets of blender container/lid/blades. On 05/15/24 at 11:35 AM, V26 (Chef) stated V26 needed to puree dinner rolls because they do not have a mix. Observed V25 (Kitchen Supervisor) bring the two dirty blender container/lid/blades to the dish room for cleaning. On 05/15/24 at 11:36 AM, observed V25 place the two dirty blender containers/lids/blades into dish racks and place the dish racks into the dish machine. On 05/15/24 at 11:39 AM, observed V25 remove two cleaned blender containers/lid/blades in dish racks out of the dish machine. Observed V25 pick up the blender containers and lids with V25's hands looking inside and then turning them upside down and placing them back into the dish rack. V25 did not wash V25's hands in between touching the dirty and cleaned blender items. On 05/15/24 at 11:50 AM, observed V26 retrieve a blender container/lid/blade from the dish room area and add dinner rolls to the container to begin the puree the dinner rolls. On 05/15/24 at 11:55 AM, observed large plastic bag containing meat sitting in a sink filled with water. There was no running water from the faucet into the sink containing the meat. V25 stated the meat was cubed steak and it was being defrosted. V25 stated usually they defrost items ahead of time in the refrigerator for a couple of days but in an emergency, they defrost items under cold running water in the sink. V25 stated the cubed steak should be defrosted under cold running water and someone just turned off the water. V25 stated if the frozen meat is left sitting in a sink full of water without running cold water over the product, then the water in the sink could be at room temperature which means it could reach the danger zone temperature between 41-135 degrees F. On 05/15/24 at 12:29 PM, V23 (Regional Director of Operations) stated when staffing the dish room there should be one person assigned to the dirty side of the dish machine and another person pulling out the cleaned items from the dish machine. V23 stated if there is only one person working the dish machine then that person would need to wash their hands after handling the dirty items and before handling the cleaned items. V23 stated handwashing is needed due to infection control concerns to prevent cross contamination. On 05/14/24, facility provided list of diet orders for all residents in the facility printed 05/14/24 at 11:20 AM from the facility electronic health system. Diet order list indicates there are three residents receiving nothing by mouth (NPO). Facility provided policy titled Receiving dated October 2019 documents in part safe food handling procedures for time and temperature control will be practiced in the transportation, delivery and subsequent storage of all food items, and all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. Facility provide policy titled Labeling Processes Standards and Procedures dated 2024 documents in part, TCS (Time/Temperature Control for Safety) refrigerated food label requirements these food labels intended for storage must include item name, preparation date, use-by-date (within 7 days of preparation or opening commercially prepared TCS foods), and employee initials. Facility provided document titled Visual Aid Use by Dates dated 2019 documents in part, Commercially Prepared Ready-To-Eat (RTE) Foods - opened shredded cheddar/mozzarella use by date 14 days after opening and RTE Non-Temperature Control for Safety (TCS) Food - condiments, sauces use by date 30 days after opening. Facility provided policy titled Hand & Arm Hygiene dated 2021 documents in part, employees must wash hands before handling clean dishes, utensils, and glasses and after handling dirty equipment and utensils. Facility provided policy titled Food Handling - Thawing dated 2024 documents in part thawing under cold running water steps: run cold water continuously over the product and maintain an air gap between faucet and water.

Based on observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 245 residents who reside in the facility. Findings include: On 05/15/24 at 8:35 AM, upon entry to the facility observed one of four lids opened to the north facing dumpster outside the facility. The lid was wide open. On 05/15/24 at 12:36 PM, during observation of the outside garbage dumpsters with V24 (Visiting Food Service Manager) observed one of the four lids opened to the south facing dumpster. The lid was wide open. V24 stated the lid should be closed so that garbage does not fly out and pests do not get inside. On 05/16/24 at 11:53 AM, during observation of the outside dumpsters with V40 (Housekeeping Director) observed one of the lids to the south facing dumpster propped open with garbage and boxes. V40 stated the lid should be fully closed but it may be unavoidable if the dumpsters are completely full. The other three lids to the south facing dumpster were opened and observed that the rest of the south facing dumpster was completely empty. V40 observed the empty dumpster sections and stated, oh, yes that is avoidable then. V40 stated the staff should have put the trash in one of the other empty sections of the dumpster because clearly there is room and that way the lid could be fully closed flat. V40 stated the lids should be closed all the way. V40 stated the way the dumpster is now rodents could jump in and start feeding on the food thrown away by the kitchen. On 05/16/24 at 11:40 AM, V40 (Housekeeping Director) stated the lids of the dumpster should be closed after the Floor Technician puts the trash into the dumpster to prevent anything from flying out or any animals' such as rodents climbing inside. V40 stated the garbage inside the dumpster could attract rodents and/or pests and if the lids are left open, they could get inside and feed on the garbage inside. V40 stated we do not want rodents or pests close to the building for sanitation reasons because they can carry disease. Kitchen policy titled, Environment dated October 2019 documents in part, the Dining Services Director will insure (ensure) that all trash is properly disposed in external receptables (dumpsters).

Based on observation, interview, and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 6 residents (R31, R36, R40, R129, R139, R205) reviewed during dining in a total sample of 35 residents. Findings include: On 05/14/24 at 12:35 PM, observed R20, R36, R129, R139, R205 sitting at the same table in the unit dining room with R20 eating lunch from R20's lunch tray unassisted. R36, R129, R139 and R205 observed sitting at the table without food in front of them watching R20 eating R20's lunch. At 12:46 PM, observed R129 receive R129's lunch tray and began to eat unassisted. At 12:49 PM, observed R205 receive R205's lunch tray and began to eat unassisted. At 12:50 PM, R36 asked surveyor where is my food? At 12:51 PM, R139 said to surveyor I'm hungry. I'm waiting. At 12:55 PM, observed R36 and R139 provided with their lunch trays and began to eat right away unassisted. On 05/14/24 at 12:44 PM, observed R31, R40, R144, and R187 sitting at the same table in the unit dining room with R144 and R187 eating from their lunch trays. At this time R31 and R40 did not have any food in front of them and were watching R144 and R187 eating. At 12:49 PM, observed R31 receive R31's lunch tray and began to eat right away unassisted. At 12:56 PM, observed R40 receive R40's lunch tray and began eating right away unassisted. On 05/14/24 at 1:00 PM, V12 (Activity Aide) stated V12 usually monitors the dining room during the lunch meal and that the residents sitting in the dining room today usually eat in the dining room on a regular basis and can feed themselves without assistance. V12 stated usually the meals are served table by table and V12 does not know why the trays were not passed out like that today. V12 stated we want everyone sitting at the same table to be fed at the same time because we do not want people having to watch other people eating without having any food for themselves. On 05/14/24 at 1:12 PM, V13 (Certified Nursing Assistant) stated the meal trays are organized by room not dining location and passed out in the order organized on the carts. On 05/14/24 at 1:15 PM, V14 (Certified Nursing Assistant) stated that V14 tries to serve residents sitting at the same table at the same time but that is not always possible depending on the location of their meal tray in the cart. On 05/15/24 at 12:18 PM, V23 (Regional Director of Operations) stated residents sitting at the same table should receive their food at that same time. V23 stated this is a dignity issue because one resident should not have to sit and watch another resident eating food when they do not have anything to eat. V23 stated there should be a seating chart for the dining rooms so that all the residents sitting at the same table get served their meals at the same time. V23 stated currently there is no seating chart for the dining rooms. On 05/16/24 at 8:21 AM, V34 (Registered Dietitian) stated residents sitting at the same table should receive their meals at that same time. V34 stated it is a dignity issue because everyone should not be watching one person eating their food. R31's diagnoses which includes but not limited to Parkinson's Disease without Dyskinesia, and Schizoaffective Disorder Bipolar Type. R31's Physician Orders dated 05/15/24 documents in part General diet regular texture, thin liquids consistency ordered 05/13/20. R31's MDS (Minimum Data Set) from 02/22/24 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. R36's diagnoses which includes but not limited to Polyosteoarthritis, Mild Dementia without Behavioral Disturbance, Chronic Peptic Ulcer, Chronic Obstructive Pulmonary Disease, and Paranoid Schizophrenia R36's Physician Orders dated 05/15/24 documents in part No restriction (Regular) diet regular texture, thin liquids consistency ordered 02/07/24. R36's MDS (Minimum Data Set) from 05/03/24 BIMS (Brief Interview for Mental Status) was 10 out of 15 indicating moderately impaired cognition. R40's diagnoses which includes but not limited to Polyosteoarthritis, Epileptic Seizures, Schizoaffective Disorder, Bipolar Type, Sensorineural Hearing Loss, Unspecified Dementia without Behavioral Disturbance, Chronic Obstructive Pulmonary Disease, and Gastroesophageal Reflux Disease without Esophagitis. R40's Physician Orders dated 05/15/24 documents in part NAS (No Added Salt) diet regular texture, thin liquids consistency ordered 03/22/22. R40's MDS (Minimum Data Set) from 03/12/24 BIMS (Brief Interview for Mental Status) was 05 out of 15 indicating severely impaired cognition. R129's diagnoses which includes but not limited to Major Depressive Disorder, History of Falling, Anxiety Disorder, Gastroesophageal Reflux Disease, and Unspecified Dementia. R129's Physician Orders dated 05/15/24 documents in part General diet regular texture, thin liquids consistency ordered 07/10/21. R129's MDS (Minimum Data Set) from 03/12/24 BIMS (Brief Interview for Mental Status) was 10 out of 15 indicating moderately impaired cognition. R139's diagnoses which includes but not limited to Asthma, Schizoaffective Disorder, Dementia, Restlessness and Agitation, Gastroesophageal Reflux Disease without Esophagitis, Paranoid Schizophrenia, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. R139's Physician Orders dated 05/15/24 documents in part CCHO (Consistent Carbohydrates) diet regular texture, thin liquids consistency large portions to current diet ordered 12/22/22. R139's MDS (Minimum Data Set) from 04/02/24 BIMS (Brief Interview for Mental Status) was 07 out of 15 indicating severely impaired cognition. R205's diagnoses which includes but not limited to Arthritis, Bipolar Disorder, Mild Cognitive Impairment, Chronic Diastolic (Congestive) Heart Failure, Dementia, and Peripheral Vascular Disease. R205's Physician Orders dated 05/15/24 documents in part Regular diet regular texture, thin liquids consistency ordered 03/31/23. R205's MDS (Minimum Data Set) from 04/03/24 BIMS (Brief Interview for Mental Status) was 04 out of 15 indicating severely impaired cognition. On 05/15/24 at 2:01 PM, V2 (Assistant Director) showed surveyor document titled, HCCI Health Care Council of Illinois, Resident Admission Packet and stated every resident receives this packet upon admission to the facility. Facility provided document titled, HCCI Health Care Council of Illinois, Resident Admission Packet dated July 2023, which documents in part no resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the Community and a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, and the facility must protect and promote the rights of the resident.

Based on observation, interview, and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the development and worsening of pressure ulcers. The facility failed to a. follow the provider order in the prevention of pressure injury for one resident (R44), b. follow policy and manufacturer directions when adding multiple layers on low air loss mattresses for two residents (R212) and (R91) and c. provide adequate supervision for low air loss devices to prevent accidents for one resident (R158) out of a total sample of thirty-five residents. Finding include: On 05/14/24 10:00AM R91 observed in bed with a drive low air loss mattress head of bed elevated. R91 observed laying on one fitted sheet, two incontinent cloth pads and a folded flat sheet used for a draw sheet along with adult brief. On 05/16/24 11:00AM PM surveyor accompanied with V27 and V10 observed R158 lying in bed on air mattress g-tube infusing rate of 60ml/hr. Observed V27 and V10 reposition and do skin check. Observed R158 with redness to sacral area. R158 on low air loss mattress Drive manufacturer. Low air loss mattress noted unplugged. On 05/15/24 9:50AM surveyor observed R212 in bed with g-tube feeding infusing. R212 with foley catheter. Surveyor observed R212 on low air loss mattress with one fitted sheet, flat sheet double folded, one cloth pad and incontinence brief. On 05/14/2024 at 12:38PM V9 states, residents that have air mattresses should have two layers and diaper. If multiple layers are on the air mattress can possibly cause bed sores or make the wounds worse. On 5/14/2024 at 9:50AM V10 states, residents with air mattress should only have one layer on the mattress multiple layers can cause wounds to get worst. On 5/15/2024 at 2:00PM V27 (Wound care nurse) stated, I've been here for 9 years. Residents with air mattresses should only have flat sheet and pad on each. Resident with wounds should only have two layers. Individuals that don't have wounds and is on the air mattress for prevention can have fitted sheet and a pad. If multiple layers are on the air mattress it can cause additional skin breakdown. All staff should make sure air mattresses are working properly and making sure mattress are plugged. If mattress malfunction staff should report immediately. R91 record reviewed physician orders dated 5/9/2024 document SITE: Right ischial tuberosity- Cleanse with normal saline. apply Collagen and calcium alginate to base of the wound, secure with Bordered gauze. physician order dated 11/08/2023. Reviewed R91 current wound assessment dated [DATE],4/30/2024,5/7/2024,5/14/24 showed wound had increase from 5/7/2024 to next assessment date 5/14/2024. Foley catheters care every shift for pressure injury. Physician order dated 11/08/2023 low air loss mattress. On 5/16/2024 2:30PM Review of R91 care plan dated 4/17/2024 includes the following focus areas: R91 has pressure injuries to the following sites: left buttocks- stage 3-resolved 12/2/2023 right ischium- stage 3 R91 pressure injuries will show signs of healing and remain free from infection by/through the next review date. R91 requires low air loss mattress bed and gel cushion for his wheelchair. Braden Scale and Clinical Evaluation dated 4/21/2024 documents R91 is high risk for pressure ulcer development score 12. On 4/16/2024 at 2:30PM reviewed R158 record physician order sheet dated 4/24/2024 documents, SKIN: Mattress: Low Air Loss Mattress due to prevention of decubitus. R158 Braden Scale and Clinical Evaluation dated 4/28/2024 score is 8 high risks. 50057 On 5/14/24 at 8:11 PM R44 was observed sleeping on a specialty bed. R44 heel protectors were observed off of the resident and on the bedside table. On 5/15/24 at 10:01 AM R44 was in bed and heel protectors were observed on the bedside table. R44 was awake and lying in bed. V33 (Staffing Coordinator) was at R44's bedside. V33 stated that heel boots are only used at night. R44 confirmed that he only wears the heel boots at night. On 5/16/24 at 8:40 AM R44's skin care and pressure injury prevention orders were reviewed with V4 (RN/ADON). V4 (RN/ADON) stated that bilateral heel protectors were ordered to be on R44 any time R44 is in bed. The heel protectors should be on R44 while R44 is in bed. V4 (RN/ADON) stated that R44 gets up in the chair two to three times a week. Aside from being in the chair, the heel boots should be on. V4 (RN/ADON) stated that the risk to R44 if the heel boots are not on, is that R44's skin will break down. He is at risk for skin breakdown. On 5/16/24 at 8:43 AM V27 (Wound Nurse) stated that R44 has no wounds but is at risk of skin breakdown. V27 (Wound Nurse) stated that prevention measures for R44 are the low air loss mattress, moisture barrier cream, frequent turning, and heel protectors. V27 stated The heel protectors should be on when he is in bed. On 5/14/24 at 02:14 PM record review shows a provider order dated 4/19/2024 by V39 (Physician) and entered by V4 (RN/ADON). The order states: Bilateral heel protectors while in bed. On 5/15/2024 at 1 PM review of R44 care plan dated 4/29/2024 includes the following focus areas: R44 has impaired mobility function related to diagnoses adult failure to thrive. R44 is on bed mobility program. I am assessed to be at risk for pressure sore development, based on Braden score of 13 related to: occasional bladder and bowel incontinence and fragile skin. Currently my skin status is intact. Review of policy titled Physician Orders adopted 11/10/2014 and revised 7/28/2023 states in part: Policy Statement: It is the policy of the facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. Procedures: 5. The nurse may question and clarify physician orders that are not clear and or questionable.

Based on observation, interview and record review, the facility failed to ensure one (R221) resident had access to call light of six residents reviewed for call lights in a sample of 35 reviewed. Findings include: Minimum Data Set, 2/21/2024, Brief Interview for Mental Status score indicates R221 has moderate cognitive impairment; does not have behavioral concerns with inattention, disorganized thinking, altered level of consciousness. Nursing-Admission/Readmission UDA, 2/14/2024, call light evaluation indicates R221 is cognitively able to use the call light and is able to call for assistance by pulling the call light string with the use of the right and left finger(s), hand or arm. On 5/14/24 at 12:29 PM, observed R221 lying in bed watching television. The call light was observed clipped to the upper right corner of R221's pillow that was behind R221's head. No part of the string draped to the front of the pillow. R221's call light system consists of a string that reaches from a toggle switch located on the wall behind and to the right of R221's bed. The other end of the string has a clip. R221 was observed with limited mobility in all four extremities. R221 stated R221 requires assistance to get up. Writer asked R221 where R221's call light is. R221 responded Not sure where the call light is. Writer informed R221 that the call light was clipped to the pillow behind R221. Writer asked R221 to pull the call light. R221 raised the right arm, bent at the elbow, and swung it back toward the pillow. R221 said I can't reach the call light. On 5/14/24 at 12:40 PM, observed R221's call light with V22 (Licensed Practical Nurse). V22 moved/clipped the call light down toward the center of the pillow to the right side. R221 attempted to reach for the call light but could not reach it. V22 stated, usually restorative assesses the call light placement so the resident can pull it. V22 had V47 (Restorative Aide) come into R221's room to add string to R221's call light to make it longer. V47 added string to lengthen R221's call light and clipped it to the pad that R221 was lying on close to R221's right hand. R221 was shown where the call light was placed and asked to pull the call light. R221 grabbed and pulled the string and was able to activate the call light. R221 stated That's better. I can pull it. V22 stated, restorative rounds in the mornings to see if residents can pull the call light. The CNA's (Certified Nursing Assistants) put the call lights in place after cleaning the resident. R221 could not use the call light where it was originally placed on the pillow. R221 would not have been able to call for help. The purpose of the call light is for emergencies, call for help, to get staff attention. Writer asked R221 what was the purpose of the call light? R221 responded To call for help if I'm having trouble. R221 stated R221 has a sense of completeness now that R221 can find the call light. On 5/14/24 at 12:55 PM, V8 (Certified Nursing Assistant) stated V8 clipped the call light to the center of R221's pillow. On 5/14/24 at 1:09 PM, writer asked V47 (Restorative Aide) what did V47 just do to R221's call light? V47 stated V47 added a longer string to R221's call light because V47 was told it was too short. V47 stated the call light was clipped to the upper right corner of R221's pillow when V47 assessed R221 this morning. V47 stated R221 was centered in the bed and able to reach it. I asked R221 if R221 could reach it. I was not able to test R221's reach because R221 was receiving care from the CNA. V47 stated the purpose of the call light is for emergency if the resident needs help. V47 stated we do a call light assessment on admission. V47 stated we assess/round every morning. V47 stated we are checking to see if the call light is reachable. V47 stated staff is not in the resident's room [ROOM NUMBER]/7. If R221 is unable to reach the light, then R221 cannot call for help. On 5/14/24 at 3:20 PM, V3 (Director of Nursing) stated the call light is for if the resident needs help. All residents should have a call light and it should be reachable. If the call light is not reachable the resident cannot call for assistance. Facility Call Light Policy, 7/27/23, documents in part: Be sure call lights are placed within reach of residents who are able to use it at all times.

Based on observations, interviews and records review, the facility failed to protect one (R101) resident's personal and confidential information of 6 residents reviewed for patient information protection in a sample of 35. Findings include: On 5/14/2024 at 10:02am during inspection of the medication cart on the 5th floor with V28 (Licensed Practical Nurse-LPN), V28 was observed going to the medication room and leaving her computer on, with the computer screen displaying R101's picture, medical and personal information. The computer screen was observed facing the main hallway of the unit, and it was visible to staff members and residents passing by. V28 stated she should have closed or made sure the contents of the screen were hidden and not visible to anyone (public) because that's a HIPAA (Health Insurance Portability and Accountability Act) violation. V28 stated she should have closed the computer, but since she was not going far, she didn't think she needed to close the computer. On 5/14/2024 at 12:44pm, V4 (Assistant Director of Nursing-ADON) stated computer screen needs to be closed for privacy of the residents because their pictures and medications are showing and other people might look and see what medications the resident is taking, and that's a violation of their privacy. On 05/16/2024 at 12:26 V1 (Administrator) and V2 (Assistant Administrator) stated they educate their staff on privacy, such as covering the date of birth, diagnosis, full names, not to be provided to anyone not providing care to the residents. V2 stated if the nurse is stepping away from her computer even for a short time, the nurse needs to minimize, close the screen to make sure the resident information is not visible to anyone passing by staff or residents. If the computer screen is left visible to other people not taking care of the resident, because that's a HIPPA violation and other people can get hold of resident's information which is sensitive confidential personal information for the resident. Facility Policy titled Statement of Resident Rights Cont. Documents: -(h) Privacy and Confidentiality. The Resident has a right to personal privacy and confidentiality of his or her personal and medical records.

Based on interview and record review, the facility failed to initiate a new Level I screen for a resident with a known mental illness for one (R223) resident reviewed for Pre-Admission Screening and Record Review (PASARR) in a sample of 35. Findings include: R223's Face sheet documents that R223 was admitted to the facility on [DATE] with diagnoses not limited to: Schizoaffective Disorder Bipolar Type. R223's Level II PASARR outcome letter documents that R223 has a short-term approval without special services dated [DATE] with an expiration date of [DATE]. R223's Level II PASARR outcome letter documents in part, This determination allows you a limited number of days in a Medicaid-certified nursing facility. The short-term approval will end on the Date Short Term Approval Ends listed on the Notice of PASRR Level II Outcome that came with this letter. If you or your care provider thinks you need to stay after that date, a nursing facility staff member must submit a new Level I screen. The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. On [DATE] at 2:08PM, V19 (Social Services Director) stated he has been working at the facility for five years. V19 states a PASARR/Preadmission Screening and Resident Review is a screening that needs to be done prior to a resident being admitted to the facility. V19 states he is unaware of what the PASARR screenings are indicative of. V19 states the facility checks to see if a resident has a PASARR screening upon admission. V19 states the PASARR indicates the determination of needs/DON score for the individual resident. V19 states based on the DON score, it is determined if a resident is appropriate for the nursing home setting or not. V19 states he is unaware of the DON score ranges or what the different DON score ranges are indicative of. V19 states a PASARR Level II is needed for a resident if it is determined that the resident has an SMI/severe mental illness. V19 states the determination for a Level II PASARR screening is based off of the results of the Level I PASARR screening. V19 states he reviews the PASARR screenings at least once a month and also reviews the PASARR screenings for expirations. V119 states the last time he checked the PASARR screenings was on [DATE]. V19 states he is the person responsible for submitting resident PASSAR screenings. V19 states when a resident's PASARR screening expires, he should submit another one as soon as he can. V19 states he is not sure if there is a time frame for submitting a new PASSAR screening once it expires. On [DATE] at 3:52PM, V19 states R223's PASSAR screening expired on [DATE]. V19 states once a resident's PASARR screening expires, a new Level I PASARR screening has to be submitted before a resident can receive a Level II PASARR screening. V19 states he was just made aware of this information and submitted a new PASARR screening for R223 today on [DATE]. Facility policy dated [DATE] titled PASSAR Screening of Residents with Mental Disorder of Intellectual Disability documents in part, Policy: It is the facility's policy to ensure that residents with Mental Disorder and those with Intellectual Disorder will receive PASSAR Screening within the timeframe allowed.

Based on observation, interview and record review, the facility failed to follow physician order policy for prescribed gastrostomy tube feeding rate. This failure affected one (R4) resident reviewed for tube feeding in a sample of 35. Findings Include: On 05/14/24 at 01:26 PM, observed R4 lying in bed with HOB/head of bed elevated, and tube feeding infusing. Observed 1.2-liter (L) bottle of Jevity 1.2 hung with label listing date (05/14/24) and hang time (9:00 AM). Observed tube feeding infusing at 55 milliliters (ml) per hour (hr.). On 05/14/24 at 01:57 PM, V15 (Registered Nurse) stated V15 knows R4 well and has taken care of R4 before. V15 stated V15 follows R4's tube feeding orders listed in R4's electronic health record (EHR) ordered by R4's physician. V15 stated R4 is NPO (nothing by mouth) and receives Jevity 1.2 at 55 ml/hr via gastrostomy tube. V15 stated V15 hung R4's tube feeding bottle at 9:00 AM this morning and set the rate at 55 ml/hr. On 05/14/24 at 02:00 PM, surveyor went with V15 to view R4's tube feeding rate and R4 stated R4's tube feeding was infusing at 55 ml/hr with Jevity 1.2. On 05/14/24 at 02:04 PM, V15 reviewed R4's orders in R4's EHR and stated R4's tube feeding rate was changed on 05/10/24 to 75 ml/hr. V15 stated 75 ml/hr is what R4's current order is and this is the rate R4 should be receiving. On 05/15/24 at 12:56 PM, V3 (Director of Nursing) stated the nurses follow the orders in the resident's EHR. V3 stated if R4's tube feeding order says the rate should be run at 75 ml per hour then that is what the rate should have been set at. V3 stated it was an oversight and that nurse V15 (Registered Nurse) is a good nurse. On 05/16/24 at 8:52 AM, V34 (Registered Dietitian) stated for residents who are NPO they receive one hundred percent of their nutrition via a tube feeding and if a resident receiving tube feeding is losing weight, V34 would make a recommendation to adjust the tube feeding volume to provide to more calories. V34 stated the nurses should be following the doctor's order for the tube feeding rate and if the rate was not followed as ordered this would affect their total calorie intake. V34 stated R4 has had a significant weight loss over three-month period from (2/2024) to (5/2024). V34 stated R4 weighted 162.8 pounds in (2/2024) and currently weights (5/2024) 150 pounds. V34 calculated that this is a 12.8-pound weight loss or -7.9% weight change in three months. V34 stated due to R4 losing weight V34 recommended to increase the rate of R4's tube feeding from 55 ml/hr to 75 ml/hr to provide more calories. R4 has diagnosis including but not limited to Gastro-Esophageal Reflux Disease Without Esophagitis, Presence Of Aortocoronary Bypass Graft, Gastrostomy Status, Schizoaffective Disorder, Bipolar Type, Dysphagia, Oropharyngeal Phase, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Hypertension, Chronic Obstructive Pulmonary Disease, Unspecified Atherosclerosis Of Native Arteries Of Extremities, Bilateral Legs, Congenital Stenosis And Stricture Of Esophagus, Other Iron Deficiency Anemias, Deficiency Of Other Vitamins, Ventricular Tachycardia, Xerosis Cutis, Pressure Ulcer Of Right Buttock, Stage 2, Pressure Ulcer Of Sacral Region, Stage 2, Diverticulosis of Intestine, Part Unspecified, Without Perforation Or Abscess With Bleeding. R4's Order Summary Report dated 05/14/24 documents in part, diet NPO (nothing by mouth) dated 01/26/24 and enteral feed order Jevity 1.2 rate 75 ml/hr x23 hours and infuse until total volume of 1725 ml is reached per day dated 05/10/24. R4's Enteral Feeding care plan documents in part R4 requires enteral feedings as the primary source of nutrition due to malnutrition. R4's Nutrition care plan documents in part, provide tube feed prescription Jevity 1.2 @/at 75 ml/hr x 23 hours and infuse until 1725 ml total volume reached per day. R4's Tube Feeding care plan documents in part, provide enteral feeding as ordered. R4's MDS (Minimum Data Set) from 04/08/24 BIMS (Brief Interview for Mental Status) was 0 indicating R4 is rarely/never understood. Section K - Swallowing/Nutritional Status documents in part nutritional approaches - feeding tube and proportion of total calories the resident received through tube feeding 51% of more. R4's Medication Administration Record dated 05/01/24-05/31/24 documents in part, enteral feeding order(G-tube) start date 05/10/24 Jevity 1.2 rate 75 ml/hr x23 hours and infuse until total volume of 1725 ml is reached per day signed off on by V15 on 05/11/24, 05/12/24, 05/13/24, 05/15/24 day shift. R4's Weight/Tube Feeding assessment dated [DATE] completed by V34 documents in part, weight loss is unintentional and undesirable since BMI (Body Mass Index) is underweight for advanced age and recommending to increase Jevity 1.2 from 55 to 75 ml/hr x 23 hours. R4's Monthly Weight Report printed 05/14/24 at 17:40 documents R4's weight [DATE].8 lbs (pounds) and May 2024 150 pounds. Facility policy titled, Physician Orders dated 07/28/23 documents in part it is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders and the facility shall ensure to follow physician orders as it is written in the POS. Facility policy titled, Enteral Tube Feeding Care dated 07/28/23 documents in part as procedure nurse will check the POS/MAR the order for enteral feeding interventions: feeding formula, type: bolus/continuous, rate and duration. Facility Job Description titled Registered Nurse dated 08/24/18 documents in part, will administer medications within the scope of practice of the R.N. Licensure.

Based on observations, interviews and records review, the facility failed to follow their policy on controlled drug count by failing to accurately count and reconcile controlled medication record/log for three (R220, R492, R211) of six residents in a sample of 35 reviewed. Findings include: R220 current face sheet documents R220 is a [AGE] year-old individual with medical diagnoses that include but not limited to: bipolar disorder, current episode mixed, severe, without psychotic features, attention-deficit hyperactivity disorder, unspecified type, generalized anxiety disorder, osteomyelitis, unspecified. R220's POS (Physician Order Sheet) documents Active 10/11/2023 - Lyrica Capsule 150 MG (Pregabalin) -Give 1 capsule by mouth two times a day for Nerve pain related to chronic pain syndrome Active 10/11/2023-clonazePAM Oral Tablet 0.5 MG (Clonazepam) -Give 1 tablet by mouth three times a day related to generalized anxiety disorder Active 04/17/2024-Adderall Oral Tablet 20 MG(Amphetamine-Dextroamphetamine) - Give one tablet by mouth three times a day for. R492 current face sheet documents R492 is a [AGE] year-old individual with medical diagnosis that include but not limited to: other specified arthritis, multiple sites, other low back pain, other low back pain. R492's POS documents: Active 5/11/2024 -Pregabalin Oral Capsule 75 MG (Pregabalin) Give 1 capsule by mouth two times a day for pain. R211's current face sheet documents R211 is a [AGE] year-old individual with diagnosis that include but not limited to: schizoaffective disorder, bipolar type, dementia in other diseases classified elsewhere, severe, with psychotic disturbance, and her POS (Physician Order Sheet) documents: admitted to Unity Hospice 8/3/23. Review of R211's POS does not document an order for Morphine Sulfate 200mg/ML solution. On 5/14/2024 at 11:48am during medication cart and storage room inspection on first floor with V17(Licensed Practical Nurse-LPN), the medication narcotic count logbook was observed not signed off as given for R220 for medications administered: Lyrica Capsule 150 MG (Pregabalin), was not signed off as given, and medication counted at hand was 5 tablets remaining but narcotic sheet showed 6 tablets remaining and last signed as given on 5/13/2024 at 5pm , clonazepam Oral Tablet 0.5 MG (Clonazepam) count was 19 tablets, narcotic sheet showed 20 tablets remaining and was last signed as given on 5/13/2024 at 5pm, Adderall Oral Tablet 20 MG(Amphetamine-Dextroamphetamine)remaining 16 tablets, narcotic sheet showed 17 tablets remaining and last signed as given on 5/13/2024 at 5pm. V17 stated she gave the medications to R220 this morning, but did not sign the medications as given on the narcotic count book. V17 stated she should have signed off the medications as soon as she gave them to keep a true count of the medication to prevent confusion and to monitor the controlled medications. R492's Pregabalin Oral Capsule 75 MG (Pregabalin) count was five tablets on the bingo card, while the medication count sheet/log documented six tables on hand. The narcotic sign off sheet documented the medication was last signed off as given on 5/13/2024 at 5pm. V17 stated she gave the medication this morning but not sign it off yet. V17 said she is supposed to sign off the medications as given as soon as she gives it. On 5/14/2024 at 12:44pm, V4(Assistant Director of Nursing-ADON) said all controlled medications should be signed off on the narcotic book by the nurse who administered the medication as soon as they are given to prevent medication being given again and to prevent the medication from being misused. V4 stated signing the narcotic as soon as given helps prevent misuse and keeps proper counts of the medications. On 5/15/2024 at 12:47pm during inspection of 3rd floor medication carts and medication storage room with V30(Registered Nurse-RN), observed in the medication fridge was R211's medication Morphine Sulfate 200mg/ML solution. The medication bottle was open and in the bottle was 5mL of medication in the bottle. V30 stated R211 was V31(Registered Nurse-RN) resident for the day. During review of R211 narcotic log with V30 showed the narcotic log was not completed, there was no documentation of how much of R211's medication was remaining and R211's medication Morphine Sulphate was observed opened, and in the bottle was 5ml of the medication in the bottle. V30 stated there is no log R211 has received the medication. On 5/15/2024 at 12:50pm, V31 said she has not administered to R211 any Morphine Sulfate during her shift. V31 stated medications such as morphine sulphate should be monitored to prevent misuse. V31 stated she does not know if R211 has been prescribed morphine sulfate. On 5/15/2024 at 1:35pm, V4 (ADON) and surveyor observed R211's medication and medication sheet. V4 stated all controlled medications are supposed to be logged in the medication log sheet and if the medication is discontinued, it should be discorded/wasted to prevent medication errors, medication being misused. V4 stated she did not know why R211's morphine was opened, yet R211's morphine was discontinued and R211 is no longer on the medication. V4 stated if the medication is open and not logged in the narcotic book, it is not known what the contents in the medication bottle is since there is no way of tracking the medication, and this can lead to medication errors and misuse. Facility policy titled Controlled medications count, dated 7/27/2023 documents: -After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication was taken. -After administration of the controlled medication, the nurse will sign off the eMAR. -If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication.

Based on interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects two (R1, R5) residents out of seven residents reviewed for abuse. As a result of this failure, R2 hit R1 in the face with a shoe on 02/28/2024 resulting in R1 sustaining a facial laceration, being sent to the hospital, and requiring four sutures; facility failed to protect R5 from physical abuse by R4. Findings includes: Facility reported incident/FRI dated 02/28/2024 documents that the facility reported an altercation between R1 and R2. FRI documents that R1 reported R2 hit R1 with a shoe. R1's face sheet dated 03/26/2024 documents that R1 is a [AGE] year-old male with diagnoses not limited to: wernicke's encephalopathy, laceration without foreign body of other part of head, subsequent encounter, dysphagia, oral phase, epilepsy, unspecified, not intractable, without status epilepticus, major depressive disorder, recurrent, severe with psychotic symptoms, other hyperlipidemia, history of falling, basal cell carcinoma of skin of left lower eyelid. R1's MDS/Minimum Data Set, dated dated dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental Status score of 9/15, indicating that R1 is moderately cognitively impaired. R1's hospital records dated 02/28/2024 documents that R1 was seen in the hospital and diagnosed with a facial laceration requiring four sutures. On 03/26/2024 at 12:07 PM observed R1 alert and responsive. Noted R1 with a scar on top of his nasal bridge/forehead. R1 said that he got stitches after his roommate (identified as R2) hit R1 with his own shoe. R1 states that the incident occurred in the facility. R1 states that R2 told R1 that he stunk and if R1 didn't get out of his bedroom, R2 and R1 were going to get into a fight. R1 states that staff were present but does not recall the staff's name. R1 states that R2 removed R1's shoe and swung it at R1 and then R2 was choking R1. R1 states that the staff member removed R2 away from R1. R1 remembers he then went to the hospital. R1's Nurse's notes dated 2/28/2024 23:45 Note Text: On this day, the writer received the resident via transport and 2 assistants. The resident received discharge papers from the hospital stating that he received a CT/computerized tomography without any additional findings and that the resident needs to follow up with MD/medical doctor as soon as possible. After assessment, it was found that the resident had received 4 sutures to the left side of his forehead. The writer called back to the hospital and spoke to the charge nurse. The charge nurse stated that he did not receive any medication and no discharge orders. The resident did not complain of pain and was seen laying comfortably in bed. Will endorse to AM nurse to follow up with appointment. R2's face sheet dated 03/26/2024 documents that R2 is a [AGE] year-old male with diagnoses not limited to: other spondylosis, lumbar region, other psychoactive substance abuse with unspecified psychoactive substance-induced disorder, major depressive disorder, recurrent, mild, generalized anxiety disorder, other insomnia, essential (primary) hypertension. R2's MDS/Minimum Data Set, dated dated dated [DATE] documents that R2 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R2 is cognitively intact. R2's general progress note dated 2/28/2024 23:01 documents Note Text: R2 displayed verbal and physical aggression towards roommate. Roommate was sent out due to facial injury. R2 placed on 1:1 supervision. Doctor informed with order to send him to the hospital for psych evaluation with petition. Order noted and carried out. Report given to psych intake at hospital. R2 made aware going to hospital for psych evaluation. R2 emergency contact #1 informed. Ambulance informed of transportation. R2's social service note dated 2/28/2024 21:40 documents Note Text: On 2/28/24, a peer alleged that R2 tossed a shoe across the room and it brazed peer's face. Both residents were immediately separated by staff. R2 was placed on 1:1 monitoring until sent to the hospital for psych evaluation. Administrator, MD, and family member were notified. Police Department was also notified. Initial report was sent to state agency with final report to follow. R2's Medical Professional Progress note dated 3/1/2024 12:43 documents Note Text: Notified by nursing staff that on 2/28 nighttime, R2 displayed verbal and physical aggression towards his roommate. Roommate was sent out due to facial injury. R2 presented with verbal aggression toward staff and medication non-compliance. R2 was sent to the hospital for psychiatric evaluation and admitted with dx of aggressive behavior. The facility issued an IVD/involuntary discharge. R2 should not return to facility due to his behaviors and requires elsewhere placement. R2's nurse's notes dated 1/3/2024 08:14 documents Behavior: R2 is verbally abusive towards the writer because he was asked not to dump water inside the garbage can in the hallway. R2 is very demanding, wants everything his way and if it is not done R2 gets mad and ready to curse the staff out. Sometimes R2 is cussing his roommate, demanding the roommate to shower, because he claimed that he did not see the roommate when he took his shower, even though roommate took shower on the scheduled day. If he does not want any resident as a roommate R2 may pour water in the bed or spray the room just to make the roommate to be uncomfortable. Non-Pharmacological Interventions: Educated and encouraged R2 that he needs to be calm and be nice to staff and to his roommate, Social Worker made aware. Pharmacological Interventions: Summary/Outcome remarks: R2 is unable to be redirected. R2's care plan dated 02/28/2024 documents in part that R2 is care planned for presence of abuse and neglect factors . care plan documents A peer alleged that R2 tossed a shoe across the room and it brazed peer's face. R2's care plan dated 04/18/2023 documents in part that R2 act(s) in self-defeating ways and engages in behavior to attempt to intimidate, antagonize, and provoke others. Behavioral symptoms include Acting territorial and not allowing peers in certain areas . He has behaviors of not getting along with roommates and will confabulate stories. R2's abuse assessment dated [DATE] written by V7 (Social Worker) does not document that R2 has a history or presence of behaviors such as aggression, disrespect, and/or abrasive/inappropriate behavior. R2's involuntary discharge form dated 02/28/2024 documents R2 was discharged from the facility due to the safety of individuals in the facility being endangered. On 03/26/24 at 1:52 PM V4 (Social Worker) states that he was on the 5th floor, walking down the hallway when V4 heard a commotion. V4 states that he opened the door which was slightly cracked opened and V4 saw R1 right in front of the door, bleeding from his face. V4 states that he observed R1 with his right shoe off. V4 stated that he saw R2 also inside the room next to R2's bed. V4 stated R1 and R2 were already separated. V4 stated it is a 4 bedroom, R1's bed is bed four, R2's bed is bed three. V4 states one of the other roommates was not in the room. V4 states that he does not remember if the 4th roommate was in the room. V4 states that there were no staff in the room. V4 states that he then yelled out for help. V4 states that when R1 and V4 were walking to the nurse's station, V4 asked R1 what happened and V4 states that R1 responded that he got hit with a shoe. V4 states that he observed the nurse cleaning R1's wound. V4 states that he called the administrator to report the allegation. V4 states that the administrator is the abuse coordinator. V4 states 911 was called. V4 states that he called the facility's security and V4 states that R2 was brought to the first floor for 1:1 with the security guard. V4 states that he did not witness the altercation between R1 and R2. On 03/26/24 at 2:11 PM surveyor inquired to V4 what would happen if a resident's abuse assessment were not accurate. V4 states that this would lead one to think that the resident has no behaviors present. V4 states that this can lead to an incident or a situation that could have been prevented. On 03/26/2024 at 2:41 PM V7 (Social Worker) states she made rounds on the floor and met with R1 to follow up on what had happened the night before. V7 states that R1 informed her that R2 came to R1 and told R1 that he smelled. V7 states that V7 asked R1 how he got the injury and V7 states that R1 informed her that R1 told R2 to go away, and that is when R2 tossed a shoe at R1. V7 states that R2 is usually verbally aggressive towards staff and V7 states that R2 always is feeling superior to others. V7 states that one thing R2 does is complains that R2's roommate's smell. V7 states that every time there is a new roommate, R2 complains about the roommate. V7 states that she has had to move two residents for R2 to make him peaceful. V7 states that R2 would say he liked clean people. V7 states she was made aware that R2 sprayed air freshener at his roommates. Facility document dated 07/14/2023, titled Abuse and Neglect documents in part, Policy statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment . Prevention: Have procedures to: Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. 45001 Facility Reported Incidents, date of occurrence 3/15/2024, documents in part: On 3/15/24 at around 8:45pm, R5 reported to V4(Social Worker) that R4 had struck R5 on the left ear. According to R4's face sheet, 3/26/24, R4 is a [AGE] year-old resident. R4's diagnoses include but are not limited to major depressive disorder, chronic obstructive pulmonary disorder, violent behavior, and generalized anxiety disorder. According to R4's MDS (Minimum Data Set) dated 3/13/2024, Brief Interview for Mental Status score indicates R4 is cognitively intact. According to R4's care plan, R4 presents with a difficult or troubled past secondary to severe mental illness, chronic health conditions, hemiplegia, hemiparesis, spinal stenosis, seizures, and paraplegia. R4 presents with risk factors related to acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history, and present mental health symptoms. A peer alleged that R4 was physically aggressive towards the peer. R4 was placed on 1:1 monitoring until sent to the hospital for psych evaluation, 12/7/23. R4 has and has a history of problems with anxiety and severe mental illness and healthcare workers. R4 has been noted with several behaviors related to verbal aggression towards staff when redirected. R4 also has behaviors of videoing staff without their consent or permission, 12/13/23. R4 has a history of criminal behavior. Convictions: aggravated battery/Peace Officer, aggravated battery/nurse. R4 is on adult probation and is currently on parole, 12/10/23. According to R4's Social Services, Abuse, Neglect, Exploitation, Trauma, and Identified Offender assessment, 3/12/2024, R4 presents at risk for being abused or for being an abuser. This is due to R4's behavioral history, substance abuse history, as well as R4's current diagnosis. According to Progress Note, 3/15/2024 22:58, R4 is verbally and physically aggressive towards staff members with an allegation of physical abuse towards one resident. R4 is using inappropriate language and threatening staff. Refused to be redirected. In need of immediate hospitalization to prevent harm to self and others. Placed on 1:1 supervision. Doctor informed with order to send R4 to the hospital on involuntary petition for psychiatric evaluation. Medical Professional Progress Note, 3/18/2024 11:46, documents in part: Notified by staff that resident (R4) was verbally aggressive and loud toward staff. There is an allegation of physical abuse toward a peer resident. R4 was sent to the hospital and admitted with diagnosis of aggression. Due to the safety needs of others, R4 would benefit from elsewhere placement. Behavior Note dated 3/8/2024 18:21, documents in part: Resident (R4) was very abusive towards staff and continue to videotape everyone on the floor, claims that R4 is an advocate to other residents even if the resident is on fluid restriction. They are entitled to give them anything they want. Behavior Note, 1/27/2024 00:31, documents in part: Resident (R4) noted verbally and physically aggressive towards staff. Refused to be redirected. R4 called police on staff. Resident stated, I am going to set the facility ablaze. R4's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, 3/18/2024, reads in part: the safety of individuals in this facility is endangered. According to R5's face sheet, 3/26/24, R5 is a [AGE] year-old resident. R5 diagnoses include but are not limited to obesity, major depressive disorder, generalized anxiety disorder, atherosclerotic heart disease of native coronary artery, asthma, cirrhosis of liver, localized swelling, mas and lump, lower limb, bilateral. According to R5's MDS, 3/6/2024, Brief Interview for Mental Status score, R5 is cognitively intact. According to R5's care plan, R5 presents with a host of medical problems and a psychiatric, substance abuse history. R5 is at risk for becoming a recipient or perpetrator of abuse and/or neglect. R5 alleged that a peer was physically aggressive towards R5, 9/9/22. According to R5's Social Services, Abuse, Neglect, Exploitation, Trauma, and Identified Offender assessment, 3/7/2024, R5 is at risk for being abused or for being the abuser, this is due to R5's medical diagnosis as well as R5's behavioral history. Health Status Note, 3/15/2024 22:06, documents in part: Resident (R5) alleged that a peer struck R5 on the left ear. Both residents were immediately separated by staff. Full body assessment done, no injury. No changes in ROM/range of motion. No loss of consciousness. Denied pain. R5 stated, I am fine. Vital Signs stable. Police Department notified. On 3/26/24 at 1:54 PM, V4 (Social Worker) stated I was not on the 2nd floor when the incident happened. V8 called me and said we have a situation and asked for my help. When I arrived on the 2nd floor, security was talking to R4. I talked to R5. R5 alleged R4 was upset and hit R5. R5 said R4 hit R5 on the head like a punch. R5 said, I want R4 arrested, I already called police. I did not speak to R4 before R4 left the facility. I gave the involuntary petition to the ambulance. The ambulance transported R4 to the hospital. On 3/26/24 at 3:00 PM, V11 (Social Worker) stated I have been the social worker for the second floor for four years. I was not here when the incident happened. From what I heard there was an alleged altercation between R4 and R5. R4 was sent to the hospital. I was informed R4 will not be returning to the facility. R4 was involuntary discharged . I got reports of R4 being verbally aggressive towards staff, using gender and racial slurs. I did not get reports from residents of any issues with R4. R4 was sent out before for verbal aggression toward staff. R5 does not have behaviors. R5 is polite and gets along with residents and staff. R4 and R5 never really interacted, they were not in the same room. On 3/26/24 at 3:52 PM, R5 was observed in room sitting in a wheelchair with R5's mother visiting. R5 stated, on 3/15, R4 was screaming and cussing at the nurse (V12) regarding another resident being in pain. R4 was calling V12 every name in the book including b###h. V12 took medication into the resident's room and R4 followed V12. R5 went to the nursing station to get security, I said call 911. V10 (Registered Nurse) was at the nursing station. R5 called 911. Facility security came to the floor. R5 said R4 hit R5 two times on the left ear. R5 did not feel pain at the time. R5 noticed ringing in the left ear after everything had calmed down. R4 was recording everything. I saw the video on the internet. On 3/26/24 at 4:12 PM, V10 (Registered Nurse) stated V10 heard R5 screaming that R5 was attacked by R4. I was passing medications on the other side of the unit. I tried to put my body between R4 and R5 to protect R5 from R4. R4 is stronger than R5. R5 is in a wheelchair. R4 can walk. R5 was screaming R5 was already hurt three times by R4. R4 was saying it doesn't matter if R4 goes to jail because R4 already killed a man. R4 was filming with a cell phone. V10 stated V10 did not see R5 get hit. R4 was sent to the hospital. V10 stated R4 has a behavior problem. This was not the first time they had an altercation. On 3/26/24 at 5:00 PM, V8 (Nursing Supervisor) stated I did not witness anything. I was told R4 was verbally and physically aggressive toward V12 (Registered Nurse). I saw R4 with aggression, so I removed R4 and put R4 on 1:1 with security. I called the ambulance to send R4 out for aggressive behavior. The police came and I told them I got an order from the doctor to send R4 out for aggressive behavior. Later, R5 alleged R4 struck R5. On 3/26/24 at 8:15 PM, V12 (Registered Nurse) stated one of my patients shares a room with R4. I was going to assess my patient in the room. I wheeled the patient into the room. I was inside the room. R4 was verbally abusive following me and forcefully closed the door on me. R4 was outside of the room. I don't know why R4 was cussing at me and verbally abusive. R4 said R4 was recording this. I did not pay R4 no mind. I was not looking at R4, so I did not see R4 recording. After I finished with my patient I went and told V8 that R4 was verbally abusive and banged the door on me. Someone called the ambulance and R4 went to the hospital. I'm not sure why R4 went to the hospital it might be because R4 was verbally abusive to me. Both R4 and R5 were my patients that evening. On 3/27/24 at 9:20 AM, V13 (Certified Nursing Assistant) stated I'm always working on the second floor. I heard the argument between both of them (R4 and R5). I was in a resident room with a total care resident. They were on the other side of the unit. I could hear loudness, arguing. I know their voices. I went to get security after coming out of the room. I told them R5 and R4 were getting loud and to come diffuse the situation. Security came up and I went about my business to finish my resident. On 3/27/24 at 3:15 PM V1 (Administrator) and V2 (Assistant Administrator) stated V1 is the abuse coordinator. In the event I'm not available V2 gets the calls. We just had abuse training in January. Any instance of abuse staff should report immediately to us. Then we report to the State Agency within two hours. V4 said there was an alleged physical abuse toward R5 from R4. R5 told V4 that R5 was hit in the ear. The nurse assessed R5. R5 refused to be sent to hospital. R4 and R5 were separated immediately. R4 was sent to the hospital for behavior. R5 called the police. Ambulance also came. R4 was IVD (Involuntary discharged ) due to behavior toward staff. In general, if a resident is verbally aggressive or abusive toward staff, it is possible for them to become aggressive to other residents. Facility policy Abuse and Neglect, 7/14/23, documents in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Types of abuse: 1. physical, 2. verbal, 3. mental, 4. sexual, 5. neglect (including medical neglect), 6. theft/misappropriation of property/financial abuse, 7. Involuntary seclusion, 8. exploitation, 9. injury of unknown origin.

Based on observations, interviews and review of records, the facility failed to protect a resident's right (R15) to be free from physical abuse and failed to address continuing abusive behaviors of a resident (R4). These failures affected 2 residents (R4 and R15) out of 5 residents (R4, R9, R10, R11, and R15) reviewed for abuse. These failures resulted to R4 requiring hospitalization for psychiatric evaluation and R15 being transferred to local hospital after sustaining skin tear on left eyebrow. Findings include: R4 is [AGE] years old, initially admitted on [DATE]. R4 has diagnoses of seizure, and schizoaffective disorder bipolar type. R4's minimum data set assessment dated [DATE] shows R4 scored 15 indicating that R4's cognition is intact. On 10/31/2023 at 11:38 AM, R4 was seen sitting in his wheelchair talking to himself. R4 agreed to talk in his room and was able to answer questions within topic. R4 stated that he sometimes has disagreements with other residents but cannot remember who those other residents were. R4 was noticed to get easily agitated during conversation. R4 insisted R4 be wheeled down to the first floor. V5 (Licensed Practical Nurse) stated that R4 had verbal altercation with R15 about an ice cream. V5 said that R4 said to R15, I want your ice cream. R15 was seen alert, answered only with a few words and unable to elaborate what happened. At 12:23 PM, V3 (Social Service Director) stated that he was not familiar with R4 and was not aware of any incident that happened. On 11/1/2023 at 10:17 AM, V6 (Assistant Social Service Director) stated that it was V7 (Certified Nursing Assistant) who informed him about the incident between R4 and R15. V7 told him that R15 had a laceration on his left eye. When I spoke to R15 he pointed to R4, and said ice cream, ice cream. I (V6) right away informed V3 about the situation. R4 has history of multiple behavioral problems including physical and verbal aggression. V3 (Social Service Director): Notes dated 2/3/2023, documents that R4 was verbally and physically aggressive towards staff with delusional and paranoid behavior. Notes dated 5/2/2023, documents that R4 was verbally and physically aggressive hitting staff. Notes dated 6/14/2023, by V15 (Psychiatry/Nurse Practitioner) documents that R4 present history was outburst. R4 has loud, and aggressive thought process, delusional, anxious, and blunted. Notes dated 3/28/2023, by V15 (Psychiatrist/Nurse Practitioner) documents that R15 Spanish speaking and poor historian. On 11/3/2023 at 12:21 PM. V15 (Psychiatry/Nurse Practitioner) stated, I really think that R4 is cognitively impaired and does not know right from wrong. Present history means that during that time nurses reported that he has an outburst. R15 Spanish speaking and poor historian mean that R15 having long mental illness may affect his ability to perform during conversation. I cannot tell you if R4 and R15 are a good fit on being roommates. I don't think anyone is a good fit for R4. Then on 6/29/2023, notes of V6 (Assistant Social Services Director) documents that R4 and R15 had altercation that led to R4 being transferred to hospital for psych evaluation. R15 went to ER (emergency room ) for evaluation of injury (notes of V8 / Licensed Practical Nurse dated 6/29/2023). During the duration of review, R4 and R15 are on the same floor. R4 has access to R15 by using his wheelchair as a means of locomotion. R15 is [AGE] years old, initially admitted on [DATE]. R15 has diagnoses of dementia, schizoaffective disorder bipolar type. R15's BIMS (brief interview for mental status) dated 5/10/2023 noted by V6 (Assistant Social Service Director) document that R15 score was 7 with significant cognitive impairment. On 11/2/2023 at 9:48 AM, V7 (Certified Nursing Assistant) stated during lunch time while doing rounds, V7 went inside room where R4 and R15 were. V7 stated that she observed R15 had a wound that was moderately bleeding on his eyebrow. V7 stated that when she asked R15 what happened? R15 pointed to R4 and said, Ice cream! Ice cream! R15 cannot talk to you during conversation. R4 likes food too much and is very loud. At 10:54 AM, with V1 (Administrator) and V2 (Assistant Administrator), V1 stated that there was no particular reason why R4 and R15 were placed in the same room. V2 stated that it could have happened to anyone. V1 and V2 were asked given that R15 cannot verbalize very well and R4 has history of physical and verbal aggression was there any precautions initiated? V2 stated that it could happen to anyone. V2 said, It could happen to you and me. At 1:10 PM, V6 stated that R15 cannot tell you or make his need known. V6 said that he needs to talk in Spanish just to make R15 understand better and R4 does not speak Spanish and would have a hard time communicating with R15. When asked what interventions facility did to address verbal and physical aggressive behavior, V6 said, Care plan should address recent behavioral problems like physical and verbal aggression. At 11/2/2023 at 2:45 PM. Police report was requested, V2 stated that the incident on 6/29/2023 was not reported because not all physical abuse incidents are reported to law enforcement agency. Per notes dated 6/29/2023 by V6, documents that R15 has skin tear above his left eye. Hospital records provided by V2 regarding R15's CT (Computed Tomography) scan results indicate that R15 sustained left maxillary subcutaneous soft tissue edema or swelling on or near the left eye. Abuse policy dated 7/14/2023, reads: It is the policy of the facility to provide profession care and services in an environment that is free from any type of abuse. The facility must identify, correct, and intervene in situation in which abuse, neglect, exploitation, and/or misappropriation of resident property, is more likely to occur.

Based on interviews and records reviewed, the facility failed to report and initiate an investigation of an injury of unknown source in the time frame required resulting in the delay of the investigation. This failure affected 1 resident (R3) out of 15 residents reviewed. Findings include: On 11/01/2023 at 1:15 pm V2 (Assistant Administrator -AADM) states R3 was sent to the hospital due to lethargy; it was the nurses and the CNAs and the supervisor who found out that she was lethargic, and R3 was sent to the hospital in the same day. On 11/01/23 at 1:17 pm V1 (Administrator) states when we were reviewing the hospital paperwork, we saw the diagnosis. The liaison updated us on the 9/8/23 about the hospital diagnosis based on the CT scan results. Based on this information received, we initiated the investigation. On 11/01/23 at 1:19 pm V2 (AADM) says Once we learned about the diagnosis on 9/8/23, we started interviewing staff to see if there was a fall. R3 was on 1:1 supervision after she came back from the hospital in April due to the fall incident. Staff said there was no fall between April and September. The staff who did the 1:1 is always the same people and we interviewed all of them. We have the radiologist summary from the hospital with the findings. When R3 was in the hospital in April due to the fall, they sent her back right way and we were monitoring her, but they had the CT negative. Our believe is the hematoma was related to the fall that happened in April, subdural takes some time to develop. R3's doctor said with the aging, this can happen. R3's doctor could not make an explanation other the aging condition. Prior the fall, R3's dementia was getting bad. Progress notes dated 9/2 23 reads: Note Text: Followed up with (local hospital) regarding resident status spoke to ER-Nurse/C . with response resident is admitted diagnosis-Sepsis and Subdural Hematoma. Belongings kept in resident closet, medication kept in med room for pharmacy return, kitchen aware of resident's transfer. This note was signed by V12 (Registered Nurse -RN). On 11/2/23 at 8:51 am V12 (Registered Nurse/RN) states I don't know if subdural hematoma is reportable. That's why I didn't do anything. I have to inform the administrator regarding the incident, if its reportable. Surveyor asked if V12 knows what to report to the administrator in which he answered, If there is abuse, I have to report to the administrator, nothing else. Asked about an injury of unknown origin, he says, It depends on the nature of injury. If the resident has wounds, cuts, fractures, change of condition, we report it. Then says I just wanted to confirm R3's diagnosis and they (hospital) told me it was subdural hematoma. I did not mention to anybody. I didn't think it was an issue. That's what happened. Now that I understand what subdural hematoma is, yes, it needs to be reported to the administrator. Facility Reported Investigation (FRI) initial and final reviewed and documents facility initiated the investigation on 8/23, 6 days after facility had been informed of R3's diagnosis by the ER nurse to V12 (RN). On 11/02/23 at 11:39 am V1 and V2 presented to surveyor a sheet dated 9/9/23 of education on abuse policy and has V12's name and a signature. V2 says V12 was educated on injury of unknow origin. V2 states I agree 100% it was not reported on the time frame because they didn't understand that subdural hematoma is an injury. They thought it was reportable only if something is physically visible, such as bruises, cuts, fractures. Facility's abuse policy and procedure reads: Type of abuse: 9- Injury of unknown Origin. Unobserved/Unexplained injury requiring transfer to a hospital for examination. 7 steps in abuse prevention: VII - reporting/response All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee. All allegations of abuse will be reported to the state agency immediately not exceeding 2 hours after the initial allegation is received. A final investigation report will be submitted to the state agency within 5 working days.

Based on interviews, and record reviews the facility failed to ensure R1 is free from abuse in a sample of 3 residents reviewed for abuse. This failure resulted in R1 acquiring two dental (teeth) fractures and a cut on the nose that required hospital evaluation and 7 stitches between upper lips and nostrils. Findings include: Facility's incident reportable regarding R1 documents in part: On 4/26/23, staff observed R1 with some blood on her linens. Nurse immediately assessed R1 and noted that she had a cut on her nose. The third roommate alleged both roommates, R1and R2 bumped into each other, and R1 lost her balance and fell . Both residents were immediately separated by staff. R1 was sent to the hospital for medical assessment via 911. R2 has been placed on 1:1 monitoring until sent to the hospital for psych evaluation. R1's history and physical report (4/26/23) from the hospital emergency room documents in part-R1 arrives to emergency department from nursing home facility, with reports of being assaulted by her [R1] roommate. R1's head was slammed against the wall and heating apparatus, C-Collar in place upon arrival, nasal packing to R1's right nostril. R1's sustained a laceration over right nares and nasal philtrum, frontal left incisor with [NAME] two dental fractures. R1's face-sheet documents medical diagnosis of dementia unspecified with other behavior disturbance, mild cognitive impairment. R1's Minimum Data Set [MDS] Brief Interview Mental Status score= 02, indicates R1 is severely cognitively impaired. Facility's reported incident report dated 4/26/23 initial and final investigation. R1's Facility's Abuse Risk assessment dated [DATE] document in part R1 may be at risk for abuse due to her mental status. After Care Visit form the emergency room documents in part: dated 4/26/23 Reason for Visit - Facial Laceration, and Assault Victim Diagnosis: Assault, Facial Laceration-initial encounter. Follow up with primary care physician for Suture removal in ten days. R1's Care plan dated 4/20/2019-R1 may be at risk for abuse related to diagnosis for dementia and the inability to communicate effectively and at risk; R1 will remain safe, free of mistreatment R1's (4/26/2023) progress notes documented in part: R1 was observed by the nurse with some blood on her linens. R1 was immediately assessed and noted with a cut on her nose. A peer [R4] alleged that [R1] and another peer[R2] bumped into each other, and R1 lost her balance and fell . [R1] was sent to the hospital for medical investigation. Administrator, MD, and emergency contact made aware. Initial has been sent to IDPH [Illinois Department of Public Health] with final report to follow. R1's (4/26/2023) progress note documents in part: Around 4pm, R1 was noted in room laying in her bed in stable condition. During rounds approximately at 6pm, this writer observed [R1] with blood on her linens. Immediately on assessment, [R1] was noted with a linear cut on her base nose. Pressure and ice pack applied to the site with bleeding controlled. VS taken with BP [Blood Pressure] 102/70, HR [Heart Rate] 78, R [Respirations]17, T [Temperature] 97.7, O2SAT [Oxygen Saturation] 96% room air, 911 called. V8 [Nurse Practitioner] notified. Supervisor [V5], Administrator [V1], Director of nursing [V3] made aware. R1 was transferred to the hospital in stable condition. Call placed to Guardian with response to call back. Returning call received from Guardian with confirmation notification. R1's (4/27/2023) progress note documents in part: R1 was back to facility per stretcher accompanied by two paramedics (ambulance) with DX [diagnosis] of Assault, facial laceration, and dental injury. [R1] Noted with 7 stitches between upper lips and nostrils. Alert, oriented x(times) 1-2. Verbally responsive not in respiratory distress. BP 140/77 P-74 R-18 T-97.4. R2's face-sheet, medical diagnosis schizophrenic disorder bipolar type, schizophrenia, hypertension, and altered mental status. R2's [MDS] Brief Interview Mental Status score= 07, indicates R2 is mildly cognitively impaired. Physician orders dated 4/16/23, R2 's Behavior Tracking documents Y [Yes] if resident have behaviors- noted several times 4/19/23 thru 4/26, agitation and refusal of medications. R2's Care plan dated 3/6/23- R2 has behavior which is disruptive, disrespectful to staff and peers. R2 has behavior of inappropriate boundaries touching and bumping into others. R2 will refrain from verbally or physically aggressive behaviors; if R2 becomes verbally or physically abusive attempt to calm her by explaining that ladies do not behave like this We do not touch other people. R2's (4/26/2023) progress notes documented in part: A peer [R4] alleged that R2 and another peer [R1] bumped into each other. Both residents were immediately separated by staff. R2 has been placed on 1:1 monitoring until sent to the hospital for psych evaluation. Administrator [ V1], doctor and family member made aware. Initial investigation sent to IDPH with final report to follow. R2's (4/26/2023) behavior note documents: Per nurse on duty [V6-Licensed Practical Nurse] R2 noted with physical aggression towards roommate [R1]. Both residents were separated immediately. R2 placed on 1:1 monitoring. Non-Pharmacological Interventions: Placed on 1:1 monitoring. Pharmacological Interventions: Summary/Outcomes: Per nurse on duty [V6] R2 noted with physical aggression towards roommate [R1]. Both residents were separated immediately. R2 placed on 1:1 monitoring. Doctor informed with order to send resident to hospital for psych eval Order noted and carried out. Report given to psych intake at hospital. Ambulance informed of transportation. R2's emergency contact informed as well asV3 and V2 notified. R2's (4/27/2023) Progress Note documents in part: followed up with the hospital regarding resident status with response that resident [R2] is admitted with diagnosis aggressive behavior. On 5/23/23 at 1:20 PM, V7 [Certified Nurse Assistant-CNA] stated, I was the C.N.A. for R1 and R2 on 4/26/23 3PM-11PM shift. I made rounds and noticed R1 and R2 in their room as usual. V7 stated I went down to another floor to refill ice. Once I came back to the floor the nurse called me to the room. I saw R1 was bleeding from the nose and the nurse was dressing the nose area. I am not sure what caused R1's nose to be cut opened. On 5/23/23 at 3:15 PM, V6 [Licensed Practical Nurse] stated, I was the nurse on 4/26/23, I was making rounds and I saw R1 standing in her room hold linen up to her face with blood covering her mouth. R1 could not tell me what happened. R4 [Roommate] told me that R1 and R2 bumped into each other. I cleaned her nose and stopped the bleeding. I asked R2 what happened, she said to ask R1 what happened and R2 walked away. V5 [Nurse Supervisor] sent R2 to the hospital for physical aggression. R2 has behavior issues of being verbally and physically aggressive in the past throwing items at the nursing stations towards staff. R2 is not easily redirected, R2 will go then come back again with behaviors until she [R2] tired herself out. I did not witness the incident; I do not know what happened. On 5/23/23 at 3:45PM V5 [RN Supervisor] stated, I've been working here for ten years. I am the evening supervisor. I was here when the incident occurred. I was not on the unit and did not witness anything. I completed the documentation on the progress notes because V6 had medication to administer. I documented only what V6 told me. I did not ask R2 what happened. I called 911 for R1 and R2 was monitored by security. I do not know if R2 has behaviors. I do not remember, please refer to my documentation. On 5/23/23 at 1:23 PM, V4 [Social Worker] stated, I received a call from R1 and R2's nurse who stated the two residents bumped into each other and R1 feel down. R1 was sent to the emergency room for further treatment due to her nose was cut and bleeding. R2 was sent out to the emergency room for psych evaluation due to the allegation of abuse. I am not familiar with R1 or R2, I was the person that sent in the reportable to Illinois Department of Public Health [IDPH]. You need to speak to the third-floor social worker [V9]. On 5/23/23 at 3:00 PM V9 [Social Worker] stated, I've been working for 4 years. I was not here in the building when the incident occurred. The next working day of the incident I was made aware that R2 bumped into R1 and R1 fell . I went to see R1 the next day, she was sleeping well. During safety follow up visits, she [R1] was doing fine, hanging out in the day room eating her snacks, and back to her usually self. R1 is alert to self only, unable to verbalize what happened. R1 did not have any past aggressive behaviors. R1 would wander into other resident's room and fiddle with their items. R1 is at risk for abuse because others could take advantage of her. V9 stated R2 does have a history of aggressive behavior. R2 would yell at staff and get in people's personal space, being verbally aggressive. I have not witnessed R2 throwing items at the nursing station being physically aggressive. I have not been told about any times R2 was physically aggressive. On 5/23/23 at 2:19PM, V8 [Nurse Practitioner] stated, I believe nursing staff called me and said, R2 bumped into R1 and caused the cut on R1's nose and R1 fell . R2 has a history of physical and verbal aggressive behavior here at this facility in the past. R1 is confused with a cognitive impairment, she is a kind resident. R1 could not tell me what happened when I assessed her on 4/27/23. R1 did not have any aggressive behaviors. R1 is very calm, and usually sits in her [R1] room and sometimes pace the hallways. R1 was sent to the hospital for further evaluation. R1 returned to the facility with seven sutures to her nose area. CT (computerized tomography) scan of her [R1] head were negative. R2 did not return back to the facility. On 5/23/23 at 3:35 PM, V3 [Director of Nursing] stated, I was not there at the time of the incident, the nurse called me, and stated that R2 bumped into R1 and R1's nose was cut and bleeding. I have no idea how R1's nose was bleeding. I don't know what happened. R1 is alert x1 and is a wander on the unit. R2 was not physically aggressive in the past, she just talked to much, very delusional, and very excited. I assisted with the investigation. R4 statedd that R1 and R2 bumped into each other. R1 was sent out to the hospital for evaluation. R2 was sent to another hospital for a psych evaluation. R1 returned to the facility with seven sutures. R2 was sent to the hospital for a psych eval because we really did not know what happened between R2 and R1. R2 would not say, what happened she said to ask R1 what happened. R2 did not have previous physical aggression, like hitting other residents or staff. R2 would yell out at times. R2 decided not to return to the facility after she was sent to the hospital for psych evaluation. On 5/23/23 at 4:11 PM, V2 [Assistant Administrator] stated, I was notified that R1 and R2 bumped into each other, V6 assessed R1, gave first aide and called 911 for R1 to be sent out to the hospital for further evaluation. All parties the doctor, the family member was notified. R2 did not say nothing other than she [R2] was owner of this facility. R2 did not know what was going on. During the investigation, the allegation was not substantiated. Due to, not having any proof that abuse occurred. R4 stated R1 and R2 bumped into each other. Also, the staff did not see R2 in the room during the time of the incident. R1 did not have any bruises, only the cut on her [R1] nose. R2 did not have any blood on her at the time she was assessed. They have been roommates for several months and there were not any issues with R1 and R2. On 5/23/23 at 4:15 PM, V1 [Administrator] stated, All new hires receive abuse training during orientation. All staff receive abuse training annually and as needed. The most recent all staff abuse training was on 4/27/23 and 4/28/23. Abuse and Neglect Policy dated 1/17/22 documents in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment

Based on interviews, and records review, the facility failed to provide adequate fall prevention and monitoring for one resident (R2) of 3 residents reviewed for falls. This failure resulted in R2 sustaining a fall with injuries requiring R2 to receive stitches on the forehead and R2 sustaining a fracture on the right hand. Findings include: Facility reported incident report dated 12/25/2022 documents: on 12/25/2022 at 02:35am, floor nurse heard a noise coming from the east shower room. Staff went to investigate and observed R2 on the shower room floor, face down. R2 was observed to have a laceration to the forehead with minimal amount of bleeding and a small cut to the left upper lip area. R2 stated I fell and hit my head. R2 was assessed R2's physician was notified and R2 was sent to a nearby hospital for further evaluation. R2 is a [AGE] year-old admitted to the facility on [DATE]. R2's Brief Interview for Mental Status (BIMS), dated [DATE], document R2's BIMS as 15/15. R2's Functional Status dated [DATE], document R2 needs limited assistance with bed mobility, locomotion on unit, personal hygiene, toilet use, and R2 needs extensive assistance with walking in room and corridor, with one person assist. R2's medical diagnoses includes but not limited to multiple sclerosis, restless legs syndrome, history of falling, presbyopia, age related nuclear cataract, bilateral, unspecified mononeuropathy of right lower limb, diplopia, mild cognitive impairment of unclear or unknown etiology. On 01/07/2023 at 11:53am V6 (Assistant Director of Nursing-ADON) stated that residents have shower days and shower times, and residents are not supposed to be showering on the 11pm-7am shift for safety and supervision reasons. V6 stated shower schedules are from 7am to 3pm and from 3pm to 11pm, depending on a resident scheduled shower time. V6 stated R2 was taking a shower on 12/25/2022 at 02:35am, without staff supervision or knowledge when R2 fell trying to reach for something on the floor of the shower. V6 stated R2 was sitting on the shower chair and the chair tipped over. V6 stated R2 did not call for assistance but staff heard a noise coming from the east shower room. V6 stated staff went to check and found R2 on the bathroom floor, face down. V6 stated R2 was bleeding and had a laceration on the forehead, and R3 complained of right shoulder pain. V6 stated R2 gait is unstable and uses a wheelchair because R2 has multiple sclerosis. V6 stated none of the three staff members (2 CNAs and 1 nurse) saw R2 wheel herself (R2) from R2 room all the way to the east side shower room. V2 stated R2 passed by the nursing station as R2 went to the east side shower room, but no staff member saw R2. V2 stated staff should always monitor residents to keep them safe. V6 stated staff should have seen R2 as R2 wheeled self to the east side shower. V6 stated R2 was taken to the hospital and had 5 stitches on forehead and a right-hand fracture. Hospital records dated 12/25/2023 at 09:45am document: on 12/25/2022 R2 was at the hospital related to fall with head laceration. R2 was diagnosed with closed displaced fracture of the surgical neck of the right humerus, unspecified fracture morphology, and facial laceration. On 1/07/2022 at 12:48pm V2 (Director of Nursing-DON) stated V2 was not here when R2 fell . V2 stated R2 fell at 02:35am on Christmas day. V2 stated maybe staff were taking care of other residents when R2 fell . V2 stated R2 should have been given health teaching and education on how to use the call light if R2 needed to shower. V2 stated the nursing station where the nurses do documentation faces the side wall and cannot see residents as they pass by. V2 stated the nurses might not have heard or seen R2 as R2 was passing by the nursing station. Nursing notes dated 12/25/2022 at 0:35am document: writer heard a noise coming from the shower room and ran to see what happened and R2 was seen on the floor face down. R2 stated I fell and hit my head. R2 observed with laceration on the Lt (left side) of the forehead and two small cuts on Lt (left side) upper lip with moderate amount of bleeding. On 1/7/2023 at 13:34pm, V7 (Licensed Practical Nurse-LPN) stated if resident who needs assistance with showering or activities of daily living/ADL care, the CNA is supposed to assist. V7 stated if a resident insists on showering in the middle of the night, the staff should monitor that resident as the resident showers to make sure the resident is safe, because anything can happen, and staff should be on the lookout to assist if the resident needs help. V7 stated residents should be monitored 24 hours a day in the facility to keep them safe. V7 stated the CNAs (certified nurse's assistants) are supposed to be on each side of the hallway monitoring residents. Facility fall policy titled: Fall Occurrence, dated 7/28/2021 documents: -It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. -Those identified as high risk for falls will be provided interventions to prevent falls.

Based on interview and record review the facility failed to protect a resident rights to be free from physical abuse for 1 (R1) of 6 (R2, R3, R4, R5, R6) residents reviewed for abuse. This failure resulted in R1 sustaining a laceration to the left arm and left leg, requiring hospital evaluation, 7 sutures to the left lower leg, 2 sutures to the left arm and a subsequent hospitalization due to an infection to the left leg laceration. Findings Include: R2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) section C - Cognitive Patterns document R2 BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. Progress note dated 07/24/22 document in part: Social Service Note: R2 was involved in a physical altercation with another resident. R2 was placed on 1:1 monitoring until sent to the hospital for psych evaluation. Progress note dated 07/24/22 Social Service Note: R2 was involved in an altercation with another resident. R2 has been displaying paranoid and delusional behavior. R2 has a dx (Diagnoses) of [CONDITION(S)] Disorder, Anxiety Disorder, Suicidal Ideation's and has been refusing medication. R2 is difficult to redirect. R2 has been placed on 1:1 monitoring and requires immediate hospitalization to prevent harm to self/others. Progress note dated 07/25/2022 document in part: General Progress Note: R2 has been presented with an IVD (Involuntary Discharge) for endangering the safety of others. R2 was accused of cutting another resident while in the facility. Progress note dated 07/25/22 document in part: General Progress Note: Writer called hospital psych intake to follow up on R2's status, per RN (Registered Nurse), R2 is admitted for Aggressive behavior. Progress note dated 07/26/22 document in part: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to R2's condition, instability, and physical treat to those at the facility, alternative placement has been recommended. Care Plan document in part: Presence of Abuse and Neglect Factors: R2 may also minimize his mental health and psychosocial issues. R2 was involved in an altercation with another resident. R2 Hospital Medical Record dated 07/24/22 document in part: Presents to Emergency Department after being petitioned due to aggressive behavior. Per petition R2 got in a physical and verbal argument with another resident in the nursing home and was unable to be redirected. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) section C - Cognitive Patterns document R1 BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. Progress note dated 07/24/22 document in part: This writer was called by the 5th floor nurse regarding an altercation from the floor between two residents. Upon assessment resident was observed with superficial laceration to R1's left arm and small laceration on R1's left lower leg with minimal amount of bleeding. Progress note dated 07/24/22 document in part: Social Service Note: R1 alleged that there was an altercation between him (R1) and another resident. R1 was sent to the hospital. Progress note dated 07/24/22 document in part: Change of Condition Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: for evaluation of left arm laceration and left leg laceration. Other relevant information: altercation. Summarize your observations and evaluation: resident was observed with laceration to his left leg and left arm after attacked by another resident. Progress note dated 07/24/22 document in part: R1's return from ER (emergency room ) with stitches to the left upper arm and left leg and [MEDICATION(S)] 875/125 mg (Milligram) every 12 hours for 7 days. Progress note dated 07/25/22 document in part: Skin/Wound Note: R1 was assessed S/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note dated 07/26/22 document in part: Medical Professional Progress Note: Altercation; laceration to LL (Left lower) arm and leg. R1 is seen following an altercation with another resident on the floor. R1 sustained injuries and was sent to ER. R1 states that he (R1) sustained laceration with sutures to left lower arm and lower leg. Progress note dated 07/31/22 document in part: Send to emergency room for left leg wound evaluation. Comments: Resident left lower leg was observed swollen despite use of oral antibiotic. Progress note dated 07/31/22 document in part: Antibiotic Note: Date of infection: left leg wound Site of infection: Comment: R1 remains on ABT (Antibiotics) po (By mouth) for left leg and left arm wound. Left leg noted swollen and c/o (Complaint of) pain. Dr. (Doctor) paged with order to send to ER for evaluation. Progress note dated 07/31/2022 document in part: Discharge Summary: R1 admitted into Hospital with the Dx (Diagnoses) Wound Infection and leg [CONDITION(S)]. Care Plan document in part: Presence of Abuse and Neglect Factors: R1 was involved in an altercation with another resident on 7/24/22. R1 sustained minor lacerations to his left arm and left leg. R1 was assessed by nursing and sent to the hospital. Care Plan document in part: R1 has a history that indicates that R1 has experienced serious trauma during his (R1) lifetime. R1 experienced violence, on July 24th R1 was physically hurt by another resident. Date Initiated: 07/25/22. Care Plan document in part: R1 is on Antibiotic Therapy to prevent infection to R1's lacerated wounds (sutured) on left arm and left lower leg. Date Initiated: 07/26/22. Care Plan document in part: 07/26/2022 R1 has sutured lacerated wound on left arm and left lower leg. Document titled After Visit Summary dated 07/24/22 document in part: [MEDICATION(S)]-Clavulanate ([MEDICATION(S)]) 875-125 mg (Milligram), R1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Order Review Report document in part [MEDICATION(S)] Oral Tablet 875-125 MG (Milligram) give 1 tablet by mouth every 12 hours for prophylaxis for 7 days, order date 07/24/22, start date 07/25/22. Treatment Administration Record dated 07/01/22 - 07/31/22 document in part: Apply [MEDICATION(S)] to left arm suture site one time a day. Apply [MEDICATION(S)] to left lower leg suture and cover with dry dressing until it's healed, one time a day. On 08/02/22 at 09:29 V2 (Assistant Administrator) stated there was no communication, no fight or anything between the two residents (R1, R2). R1 stated that he (R1) was sitting down chilling and R2 cut him (R1). On 08/02/22 at 11:36 AM V2 (Assistant Administrator) stated there is no video surveillance of R1 and R2's incident. The video just copies over itself, and the nurse station has no monitor to see at the nurse station. On 08/02/22 at 12:44 PM V7 (Licensed Practical Nurse) stated on 07/24/22 a little after 3:00 PM at the change of shift I heard R1 scream and call out. R1 yelled out twice. I think R1 said stop it, which alarmed us. R1 was sitting in a chair on the east side of the building around the corner from the nurse station on the 5th floor and stated R2 cut me (R1). There was blood on R1's left arm and left leg. I could visibly see the blood and there was a skin tear to R1 left arm, but the left leg was bleeding worse. The left arm had a nice size gash. R1 pulled up his (R1) jogging pants and the blood was draining/trickling to R1 shoe. The cut was to R1's left outer calf. There were two other staff members that got to R1 before me. I cannot recall what R1 was cut with. In my opinion that was physical abuse when someone is physically injured. On 08/02/22 at 01:10 PM V8 (Licensed Practical Nurse) stated we were at the nurse station and R1 was saying I'm sorry, I'm sorry, please, please. R2 was standing close to R1 and R1 was sitting in a chair. I did not witness the incident, R2 was still at the scene of the event but I did not see R2 drop the knife and the knife was close to him (R2). The knife had a metal handle and was silver. That is physical abuse. I saw blood coming from R1 left arm and left leg. R1 and R2 were sent to the hospital. I do not know where R2 got the knife from. On 08/02/22 at 02:23 PM V4 (Assistant Director of Nursing) stated on Sunday 07/24/22 it was close to the end of the shift when I was paged from the 5th floor. V7 (Licensed Practical Nurse) notified me that there was an incident and I have to come. I took the elevator and when I got off, I saw R1 sitting in front of the elevator. V7 told me that R1 had a laceration so I went in the medication room to get supplies then cleaned the lacerations with normal saline and wrapped them with kerlix. The police came and made a report. I did not see the incident. I was told that staff heard a scream from the other side of the wing and R1 was bleeding. The police and the social service director attempted to interview R2 and R2 declined to respond. After I dressed R1's wounds R1 was escorted back to the second floor. R1 was sitting in a chair at the time of the incident. V7 told me and showed me the knife that R2 used. I don't know what happened to the knife, it was placed in an empty gloves box on top of the medication cart inside of the nurse's station. It was a knife bent in a L shape. It looked like a butter knife, but the end was a little sharper than a butter knife. That was the first time I saw that knife and I have no idea where R2 got the knife from. The knife was taken by the police. On Monday 07/25/22 I visited R1 in his (R1) room. R1 stated that he (R1) was sitting near room XXX on the 5th floor, when R2 came from the washroom and just cut him (R1). R1 does not know the reason. When I asked R1 why he (R1) was on the 5th floor R1 stated that he (R1) was just visiting but would not tell me a specific person's name. R1 stated I had not experienced R2 with any aggressive or abusive behavior. R1 stated when a resident goes on a pass security checks the residents' belongings when they come back from their pass. The resident bags are checked but there is no pat down search. R1 never had any aggressive or abusive behavior. R2 went out for a psych evaluation and did not return. R1 was sent to the hospital and returned to the facility with 2 sutures to left middle lower arm and the lower left outer lateral leg had 7 sutures. The lower arm laceration was superficial and gapping, the lower leg laceration looked smaller than the arm but looked deep. I did not get a chance to measure the lacerations and there was no active bleeding at the time that I saw them. R1 came back from the hospital on ([MEDICATION(S)]) an oral antibiotic. When I worked on Sunday 07/31/22 a week after the incident between R1 and R2, R1 had no wound dressing on the left lower leg. R1 stated that he (R1) removed the dressing to the left lower calf area. The left lower leg was swollen. The Doctor was called and stated, have R1's wound evaluated at the hospital. R1 was admitted to the hospital on 07/31/22 with a wound infection. There was no drainage, it was just swollen which might be from the wound laceration that is infected to the left lower leg. R1 did not have any other wounds to the left lower leg that I know of. R1 is a diabetic and diabetics are more prone to infections. V1 (Administrator) was made aware that there was a knife that was used. On 08/02/22 at 03:07 PM V11 (Licensed Practical Nurse) stated I walked in when R1 was going out to the hospital. R1 was alert and oriented x 3, ambulatory without assistance, non-compliant, always sleeping in hallway and argumentative. R1 had no altercation with any other residents and was a resident on the second floor. On 07/24/22 when R1 returned from the hospital R1's leg was covered with a clean dry dressing and the arm was open to air with 8 or 9 sutures. The night before 07/31/22 R1's legs were not swollen and R1 had no other wounds other than the laceration to the left leg. On 07/31/22 I contacted the hospital and R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/02/22 at 03:41 PM V12 (Registered Nurse) stated on 07/25/22 I called the hospital and R2 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/02/22 at 03:47 PM V13 (Certified Nurse Assistant) stated we were at the nurse station and heard someone screaming for help. When we got there R1 was sitting in the chair, R2 saw us and immediately left and went into his (R2's) room. I did not notice R2 holding anything, but it was a bent sharp object on the floor. The nurse was trying to treat R1 and picked up the knife with a glove. The knife is nothing like what we have in the facility. The nurse took R1 to the nurse station, called 911, treated R1 and sent R1 to the hospital. On 08/02/22 03:58 PM V14 (Certified Nurse Assistant) stated we were looking for the schedule when R1 was saying help, help, help. R1 was sitting in a chair and R2 was standing in front of R1. We saw a sharp object on floor and the nurse picked it up with the gloves. R1 was from the second and I never saw R1 and R2 aggressive with one another. On 08/02/22 04:14 PM per telephone interview V5 (Social Service Director) stated on 07/24/22 security called me and said there was an alleged allegation that R1 and R2 had a situation. R2 did not have a lot of interactions but had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 is alert and oriented x3, has Delusions and Auditory Hallucinations as well. R1 has no aggression or abusive behavior to my knowledge. On 08/02/22 at 04:25 PM V2 (Assistant Administrator) responded to the request for R1's wound care notes by stating There are no wound care notes for R1 and normally when nothing is wrong there is nothing documented about the wound. On 08/02/22 at 04:26 PM V1 (Administrator) stated when I got the call about the altercation between R1 and R2 that R2 may have cut R1 I was not in the building, and I stated to make sure both R1 and R2 are separated. I was told there was something sharp used. R1 was sitting in a chair on the 5th floor. The allegation was unsubstantiated due to there not being any history of behaviors by R2. Something did happen and R1 was injured with a laceration to the left arm and left leg. Being that there was no intent that would not be considered as abuse. R1 being cut was not intentional and I have no way of knowing that it was intentional. R1 was not doing anything just sitting there and then began yelling for help and three staff went running to R1. I do not know where the sharp object came from. R2 does go out on pass and security checks the bags when they return but security do not do an actual pat down. The Police came and filed a report. The Police just do the basics, they did not pursue any criminal charges. What I found working here the police rarely want to do anything. I am aware that R1 had to receive sutures and was on oral antibiotics. On 07/31/22 wound infection is what the hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/03/22 at 08:27 AM V16 (Security/Receptionist) stated I was called for assistance on the 5th floor. When I went up R1 was sitting in a chair in front of the elevator. I noticed the cut on R1's left arm and there was a small amount of bleeding. When I was working a few weeks ago R2 went out on pass and came right back. When a resident goes out on pass their bags are checked. I did not see any weapons. On 08/03/22 at 09:11 AM per telephone interview V6 (Social Worker) stated on Sunday 07/24/22 I got a call from the nurse supervisor to go to the 5th floor. R1 was sitting in a chair. R2 just attacked R1 with no reason. R2 would not talk to me or the police. When the surveyor questioned V6 about the Progress note documented on 07/24/22 reading in part: R2 has been displaying paranoid and delusional behavior. R2 has been refusing medication. R2 is difficult to redirect. V6 stated R2 was paranoid and mentioned that people are looking at him (R2) and trying to do things to him (R2). On 08/03/22 at 10:24 AM per telephone interview V17 (Licensed Practical Nurse) stated on 07/24/22 when R1 came back from the hospital R1's left arm was open to air, had no drainage, with 7 sutures and the left leg was covered with a dry dressing. I removed the dressing to clean the left leg and there was dried blood with 2 sutures and no signs of infection. 08/04/22 at 02:16 PM per telephone interview V15 (Nurse Practitioner) stated I received a call on 07/24/22 and was told that there was an altercation. After a few days I saw R1 and R1 had stitches to the left arm and left leg. The left arm was open to air with multiple stitches. I did not see the left leg because it was wrapped with a dressing. The laceration was done with something sharp, but I do not know what type of tool was used. I recently spoke with the Director of Nursing and was told R1 left leg wound was infected. R1 came back to the facility today (08/04/22) with continuous IV (Intravenous) infusion, antibiotic IV piggyback. I believe the infection was from the laceration that was on the left leg. Document Titled Facility Reported Incident/Abuse Report Initial Form dated 07/24/22 document in part: Type of Abuse: Physical. Alleged Victim: R1, Alleged Perpetrator: R2. On 07/24/22 V16 (Security/Receptionist) reported to V5 (Social Service Director) that R1 alleged that there was an altercation with R2. R1 was assessed by nursing and noted a cut on the left leg and arm. R1 was sent to the hospital. Document Titled Abuse Report Final Form dated 07/24/22 document in part: R1 reports that he (R1) was sitting in a chair on the 5th floor hanging out when R2 came up to him (R1) and cut him (R1) on the arm and leg. The staff working on the floor all report being at the nursing station and hearing R1 yelling. R1 was seated in the chair bleeding from his (R1) left leg and arm. Policy: Titled Abuse and Neglect reviewed 01/17/22 document in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention.

Based on interview and record review, the facility failed to follow facility protocol and monitor a resident every two hours. This failure affected one resident (R1) of three residents reviewed for supervision. The facility failure resulted in R1 observed in R1's room hanging, unresponsive and pronounced dead. Findings include: R1's Admission Record documents, in part, that R1 was a [AGE] year-old resident with a diagnosis of [CONDITION(S)] Disorder [CONDITION(S)] Type and an admitted to the facility of [DATE] from a hospital stay of [DATE] to [DATE]. Facility Reported Incident of [DATE] at 6:45 am documents in part R1 was observed hanging and unresponsive by the assigned CNA (V20) on duty. Code blue initiated, R1 was eased down, CPR (Cardiopulmonary Resuscitation) started, 911 was called. Paramedics arrived and took over the code. R1 was pronounced dead at 7:59am. The body was released to the medical examiner's office. R1's death certificate was reviewed. R1's cause of death was indicated as Asphyxiation and Hanging while the manner of death was indicated as suicide. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, that R1's Brief Interview for Mental Status (BIMS) score was a 14 which indicates that R1 is cognitively intact. In R1's psychiatric hospital records, dated [DATE], V31 (Psychiatric Hospital Advanced Practice Nurse) documented, in part, that R1 was brought in the ER (emergency room ) after being found 'completely naked' and acting bizarre and psychotic in the community. V31 documented that R1 was recently maintained on ([MEDICATION(S)]), ([MEDICATION(S)]), and ([MEDICATION(S)]) long acting injectable, but has been noncompliant. R1's Census List documents, in part, that on [DATE], R1 was admitted to a room in the facility, and on [DATE], R1 had a room change to a different room on a different floor. On [DATE] at 8:15 am, V5 (Licensed Practical Nurse, LPN) documented, in part, in R1's progress note, This morning around 6:45 am, (R1) was observed hanging and unresponsive by the assigned CNA (V20, Certified Nursing Assistant, CNA) on duty. Code Blue initiated. (R1) was eased down. CPR (Cardiopulmonary Resuscitation) was started. 911 was called . (R1) was pronounced dead at 7:59 am. Facility daily nursing schedule, dated [DATE], documents that for the 11:00 pm to 7:00 am night shift, V5 (LPN) was the primary nurse assigned to R1 and that V4 (CNA) and V20 (CNA) were the CNA's on R1's floor. On [DATE] at 1:57 pm, V4 (CNA) stated that V4 was assigned to the first side of the second floor and that V20 was assigned to R1 on the second side. V4 stated that V4 makes rounds on V4's assigned residents on the first side and that V20 makes rounds on V20's second side. V4 stated that V20 needed my help with performing care for R2 and R5 who were roommates of R1. V4 stated that on [DATE] around 6:30 am, V4 entered R1's open door to the room, and R1 was hanging from the ceiling. V4 stated that V20 then entered R1's room and then immediately notified V5 (LPN). When asked if V4 had made rounds on R1 during the night shift prior to seeing R1 hanging from the ceiling, V4 stated, No, (V4) had not went in (R1's) room with (V20) before on that night. We (V4, V20) did not make rounds together. V4 stated that V4 did not perform vital signs for R1. V4 stated, (V4) makes rounds every two hours. As a CNA, we check on them (residents) to see if they are wet, if they are, okay? (V4) come close to the bed to see them (residents), see if they are sleeping or see if breathing. When asked if V4 does documentation for performing the resident rounds every two hours, V4 stated, No. If we see something wrong during rounds, we have to tell the nurse that there is a problem. On [DATE] at 3:00 pm, V20 (CNA) stated that V20 was R1's CNA on [DATE] from 11:00 pm to 7:30 am. V20 stated that V20 first made rounds on [DATE] at 11:30 pm and observed R1 in R1's room. V20 stated, It was the first-time meeting (R1). V20 stated that R1 was in the room by (R1's) bedside and walking around. V20 stated that V20 introduced herself to R1 and said, If you (R1) need anything from me, push the (call) light and I (V20) will come. V20 stated that V20 encouraged R1 to lay down to sleep. V20 then stated, The next time I (V20) see (R1) was around 3:00 am ([DATE]). V20 stated that R1 was standing in the room, and V20 asked R1 again, Aren't you (R1) sleepy? V20 stated that R1 replied, Don't worry yourself, I (R1) will go. V20 stated, I (V20) told (R1) that I (V20) need to worry. V20 stated that V20 responded to R1 by saying, I (V20) see you (R1) standing there, and you (R1) are not sleeping. V20 stated that on [DATE] around 6:30 am, V4 and V20 were getting ready to go into R1's room to render care for R2 and R5. V20 confirmed that V4 entered R1's room first and that V20 heard V4 screaming. V20 stated that V20 went into R1's room and see (R1) hanging by the ceiling with blue chair on the bed. V20 stated that V20 went to notify V5 (LPN) and called a Code Blue to R1's room. When asked of how often V20 conducts rounds on V20's assigned residents, V20 stated, Every two hours. V20 stated that resident rounds consist of going into each room and checking if resident is breathing or wet or had a BM (bowel movement). V20 stated that for the [DATE] night shift, V20 did not perform vital signs for R1. On [DATE] at 3:13 pm, V5 (LPN) stated that on [DATE], V5 worked on R1's floor on the 3:00 pm to 11:00 pm shift and the 11:00 pm to 7:00 am shift. V5 stated that from 3:00 pm to 11:00 pm, R1 wasn't my (V5's) patient, but that V5 met R1 for the first time at the nurse's station at 3:00 pm. V5 stated, The next time I (V5) see (R1) is around 11:00 pm that Saturday ([DATE]) at the nurse's station and that R1 was using the telephone at the nurse's station at that time. When asked when the next time was that V5 sees R1 during the night shift, V5 stated, I (V5) don't see (R1) again until 6:45 am because the CNA makes the rounds on the floor. V5 stated that on [DATE] at 6:45 am, V5 is moving the medication cart down the hallway and heard V4 saying, Oh My God. V5 stated that V5 went towards R1's room, asked V20 What's wrong? and that V20 was just mumbling. V5 stated that V5 then entered R1's room where R1 was hanging from the sprinkler with a ligature around R1's neck. When asked if V5 received any report about R1 from the CNA's (V4, V20) who worked the night shift on [DATE], V5 stated, No. If something is wrong, they will tell me. If everything's right, they won't say anything. This surveyor informed V5 that V20 had stated that R1 was awake during V20's rounds on [DATE] at 3:00 am and was walking in R1's room. This surveyor asked V5 if V20 had reported this to V5 after the round, and V5 stated, No, I (V5) was not made aware that (R1) was awake. V5 was asked if V5 made any rounds on R1 from 11:00 pm to 7:00 am on [DATE], and V5 stated, No, I (V5) did not round on (R1). I (V5) let the CNA do that. When asked if V5 performed an assessment of R1 or checked R1's vital signs during this same night shift, V5 stated, No. V5 stated that V5 did go through my meds due and do my monitoring, but R1 did not have any medications due during this night shift. On [DATE] at 3:00 pm, V21 (Assistant Director of Nursing, ADON) stated that rounds are done every two hours on residents. V21 stated that the nurses will closely monitor residents for the first 72 hours (three days) after an admission to observe for any feelings of being isolative, anxious or any general concerns. R1's completed physician order, with the start date of [DATE] on the 3:00 pm to 11:00 pm shift, documents, Vital signs every shift x 3 days upon admission/readmission for the order type of Monitoring Record. R1's Monitoring Record, dated [DATE], for the night shift on [DATE], V5 (LPN) documented BP (Blood Pressure) ,d+[DATE], Temp (Temperature) 97, Pulse 70, Resp (Respirations) 20, O2 Sats (Oxygen Saturation) 97. V4 (CNA), V5 (LPN) and V20 (CNA) confirmed with this surveyor that they did not perform vital signs on R1 on [DATE] from 11:00 pm to 7:00 am. On [DATE] at 4:56 pm, V11 (Nursing Supervisor) stated, We check on them (residents) every two hours. We go room to room to check if they are breathing, not in distress and are not wet. Check vital signs once a shift. On [DATE] at 11:38 am, V16 ([CONDITION(S)] Nurse) stated that staff will monitor resident's hourly or every two hours depending on diagnosis. V16 stated that staff do monitoring every two hours to make sure if anything goes wrong and to intervene at the appropriate time. V16 stated that when residents are new admissions to the facility, adjusting to the change of environment is different for everyone. When asked if a resident displays not sleeping at night, V16 stated, If you're not sleeping, it could be because you are worried or bothered with something. Is something occurring? When asked if not sleeping should be reported, V16 stated, It depends. If residents verbalized, they are not sleeping or keep waking up then we will relay to the doctor. On [DATE] at 12:07 pm, V15 (Psychiatric Rehabilitation Services Coordinator, PRSC) stated that a nursing home is an adjustment for a new admissions like R1. When asked if a resident is staying awake at night, would V15 find this concerning? V15 stated, I (V15) would wonder why they are not going to sleep. Why do they have trouble sleeping? CNA needs to communicate to the nurse and to doctor to (let doctor) know about having trouble sleeping. On [DATE] at 1:41 pm, V2 (Director of Nursing, DON) stated that when a resident is admitted into the facility, nurses will perform the full assessment, and within the first 72 hours, nurses will do vital signs and monitor them (residents) closely. V2 stated that the nurse and CNA will round every two hours on residents on their specific sides of the floors. When asked what rounds consist of, V2 stated that staff will knock on the residents' door, check to see if the residents are awake. V2 stated that if residents are asleep, the staff must lay eyes on each one of the residents. When asked where nurses and CNA's will document rounds every two hours, V2 stated, Nowhere, it's a given thing. We automatically have to do rounds every two hours. On [DATE] at 2:35 pm, when asked the purpose for rounding every two hours on residents, V2 (DON) stated, The purpose is that we have to know the resident's condition. Assess their needs to be met. R1's psychiatric hospital document, dated [DATE] and titled Medication Reconciliation Patient Discharge Summary, documents, in part, that R1 was to continue taking the following medications of [MEDICATION(S)], [MEDICATION(S)] [MEDICATION(S)], and [MEDICATION(S)]. This indicates that R1 was initiated on new antipsychotic medications during R1's hospital stay from [DATE] to [DATE]. On [DATE] at 2:15 pm, V8 (Psychiatrist) stated that while in the [DATE] to [DATE] psychiatric hospital stay, R1 was changed from [MEDICATION(S)] and [MEDICATION(S)] to the new antipsychotic medications of [MEDICATION(S)] and [MEDICATION(S)] [MEDICATION(S)]. V8 stated when asked V8 (Psychiatrist) if V8's expectation of the facility staff is to follow their protocol to monitor residents, V8 stated, Yes. R1's Care Plan (Interim), dated [DATE], documents, in part, that the focus of R1 on [CONDITION(S)] medications with interventions to monitor behavior while on medication, monitor for adverse or allergic reaction; call MD (doctor) for any changes in condition and monitor for any ill effects related to medication. On [DATE], this surveyor requested a facility policy for supervision of residents. On [DATE] at 1:52 pm, V3 provided the following policy, General Care, and stated, We use this 'General Care' policy for supervision. Facility policy dated [DATE] and titled, General Care, documents, in part: Policy Statement: It is the facility's policy to provide care for every resident to meet their needs. Procedures: 1. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs . Psychological needs would include but are not limited to areas of mental and psychosocial well-being. 2. The facility will assist the resident to meet these needs. Facility job description dated [DATE] and titled, Registered Nurse, documents, in part: . Reports to: Director of Nursing and Assistant Director of Nursing . Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse (R.N.) plays a critical role in providing superior customer service and nursing care to all Guests and guests. The R.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: . 1. Provides quality nursing care to Guests/guests . 2. Provides supervision to C.N.A.'s and all subordinate staff which includes checking their work to ascertain that assignments have been completed . 8. Carry out direct contemporaneous charting in your shift . 9. Responsible for all nursing care of assigned Guests while on duty. Facility job description dated [DATE] and titled, Licensed Practical Nurse, documents, in part: . Reports to: Director of Nursing and Assistant Director of Nursing . Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Licensed Practical Nurse (L.P.N.) plays a critical role in providing superior customer service and nursing care to all Guests and guests. The L.P.N provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: . 1. Provides quality nursing care to Guests/guests . 2. Provides supervision to C.N.A.'s and all subordinate staff which includes checking their work to ascertain that assignments have been completed . 8. Carry out direct contemporaneous charting in your shift . 9. Responsible for all nursing care of assigned Guests while on duty. Facility job description dated [DATE] and titled, Certified Nursing Assistant, documents, in part: . Reports to: Floor Nurse/Nursing Supervisor/Director of Nursing . Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing customer service and nursing care to all Guests. The C.N.A. safeguards the health, safety and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: . 1. Provides quality nursing care to Guests . 2. Provides individualized attentions, which encourages each Guest's ability to maintain or attain the highest practical physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to follow the current care plan interventions for an agitated resident by attempting to physically restrain the resident for 1 of 3 residents (R1) reviewed for behaviors. This failure resulted in R1 increasing agitated behavior and in the process obtaining lacerations to 4 fingers in his right hand, which required R1 to be sent emergently to the hospital and obtaining 14 stitches to the right hand. Findings include: On 11-13-19 at 12:55pm, R1 stated, one day (10-26-19) in the afternoon I wanted to go down to buy a soda. I asked V4 (Certified Nursing Assistant, C.N.[NAME]) if I can go downstairs to buy a soda and he told me no. I was by the elevator on the 4th floor when the elevator door opened and I went in. V3 (chef) was in the elevator and he told me I need to get out otherwise he will lose his job. I tried to get to the elevator buttons but he did not allowed me by blocking them. I went out of the elevator because V4, (C.N.[NAME]) and V12, (Activity Person) were pulling on me. I grabbed the elevator door to open it up, then V12 grabbed me from behind, holding my pants and dragged me out of the elevator. When V12 dragged me my fingers got cut by the sharp metal edge from the elevator door. I went to the hospital and my fingers were sutured. On 11-13-19 at 12:15pm, V3 (Chef) stated, I was delivering a salad and I held the elevator door open in the 4th floor. I was the only one in the elevator. I stopped the elevator by pulling the stop button, R1 came into the elevator and was reaching for the elevator button. The male C.N.[NAME] (V4) and (V12) activity person came to redirect him. He eventually went out of the elevator. I released the stop bottom from the elevator, the elevator door was closing, and from the outside the patient grabbed the door with both hands. I pushed the stop bottom again. R1 was screaming and using profanity. R1 was being held by a staff member. I could not see the person behind R1. The next thing I saw was blood all over the place. On 11/13/2019 at 2:11pm, V12, Activity Aide, stated, R1 gets along with me and I told R1 to let go of the elevator door. In the mean time I was holding R1 from his waist and pulling him to stop him from going back into the elevator and I observed R1 with blood in his hand. The care plan interventions we need to use with R1 are talking to him to deescalate his behavior, to re-direct R1 to a quiet area but not to put our hands on the patient. On that day R1 was not listening to anyone because his goal was to go downstairs. The security talked to him and took him down to smoke after the nurse bandage his hand. On 11/13/19 at 3:10pm, V10 (Security Guard) stated, On 10-16-19 at about 7:00pm I was called from the 4th floor because R1 was agitated. I talked to him and re-directed him and I took him down for a smoke break. R1 has a history of giving staff trouble. R1 wants to go to the elevator and down to the first floor. R1 is in the locked unit and R1 needs staff supervision when he leaves the floor. R1 goes to the elevator and pushes people around when he wants to go into the elevator. I am not able to put my hands on anyone, the best way to calm a patient is talking to the patient. Per Nurses notes, dated 11/14/19, reads R1 went to theER on [DATE]. Per Hospital records, dated 10-26-19, reads R1 Laceration/ hand injury. Care Plan, dated 9-20-2019, reads R1 under focus: R1 verbally aggressive behavior when agitated. Interventions; R1 becomes verbally or physically abuse attempt to calm R1, talk to him in a calm manner and walk with him to a quiet area to discuss concern. In-service validation form, dated 10-17-19, Title customer service, and outlines approaches on how to deal with residents with aggressive behaviors to be able to calm them down. 0n 11-13-19 at 2:20pm, V2 (director or nursing) stated we follow the nonviolent crisis interventions (CPI). We do verbal de-escalation with the patient, no staff is to physically hold or restraint the patient when they are aggressive or agitated. Nonviolent crisis intervention foundation course workbook reads on page 39, using a physical approach, staff may accelerate the individual's behavior rather than decelerate it.

Based on interview and record review the facility failed to follow their Abuse and Neglect policy to provide an environment that is free from any type of abuse for one of three residents (R1) reviewed for abuse. As a result of the abuse, R1 was sent to the local hospital and diagnosed with [REDACTED]. Findings include: On 10/15/19 at 10:01 AM, R1 stated I was assaulted by a real strong man. He pulled my shoe and he hit me. I don't know his name but I told V5 (CNA - Certified Nurse Aide). On 10/15/19 at 10:17 AM, V4 (LPN - Licensed Practical Nurse) stated she asked R1 what happened but he refused to say. I assessed him and I saw the bruise on his chest. On 10/15/19 at 10:24 AM, V5 (CNA) stated around 8:30 [NAME]M. on 9/25/19 I woke (R1) up and he was in pain. I called the nurse. I didn't see anyone attack him. On 10/15/19 at 10:25 AM, V6 (RN - Registered Nurse) stated On 9/25/19 I was told (R1) said his roommate grabbed him by the shoes and forced him to fall. R1 never told me personally. R1 complained of left hip pain and had bruising to his chest. I notified social service and the Nurse Practitioner. On 10/15/19 at 12:27 AM, V7 (Social Worker) stated On 9/25/19 (R1) told me he had fallen, his roommate grabbed his shoe and caused him to fall. On 10/15/19 at 1:24 PM, V11 (Nurse practitioner) stated R1 had redness and pain to the left to hip and bruising on his chest. He told me that he was hit. I was also told he fell and his shoes got caught in wheel chair, I don't know who witnessed it. I have never seen him out of the wheel chair. On 10/16/19 at 9:24 AM, V1 (Administrator) said I was told R2 was upset because he asked R1 to flush the toilet. R2 was covered in BM (Bowel Movement) R1 told him to get a CN[NAME] This was the night before on 9/24/19. They separated R1 and R2 by placing R2 in another room. R1 was assessed and didn't say anything until the morning. R1 said his shoe was pulled causing him to fall. R1 didn't say R2 was on top of him. R1 was sent to the hospital. A police report was made. On 10/16/19 at 10:44 AM, R2 denies doing anything to R1 and doesn't know why he was moved out of the room. R2 said he could get up, then he said he lives in the wheelchair. R2 is able to lean forward and reach out. V14 (CNA) said I only saw him stand one time, because he was upset. Electric Medical Records dated 9/25/19 at 10:00 AM reads, R1 reported that another resident (R2) grabbed his shoe last night and it caused R1 to fall to the ground. R1 was admitted to a local hospital. R1's hospital Physician History documentation dated 9/25/19 at 6:10 P.M. (18:10 hours) reads: Patient states he was assaulted at his nursing home sustained multiple [MEDICATION NAME] traumatic injuries. R1's hospital record dated 9/26/19 at 10:53 [NAME]M. Physician Documentation indicated, Male battery from nursing home, found with a left 2nd - 5th rib fractures and a mid-sternum fracture. Physician notes dated 9/26/19 reads R1 has a small sternal fracture. R1 discharge order from hospital dated 9/27/19 has R1 ordered for outpatient physical and occupational therapy with a [DIAGNOSES REDACTED]. Policy titled Abuse and Neglect dated (MONTH) 7, 2019 It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property exploitation, neglect, or mistreatment. Abuse is a willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse.

Based on interviews and record reviews, the facility failed to develop an individualized care plan, re-evaluate and revised/update care plan interventions in preventing accidents for one (R1) of five residents reviewed for accidents and supervision. This deficiency resulted in R1 sustaining a laceration on left eyebrow and acute nasal bone fractures. Findings include: R1 is a [AGE] year old, male admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R1 has moderately impaired cognition in making decisions regarding tasks of daily life, according to MDS (Minimum Data Set) dated 06/13/2018 under Section C. Per MDS also, the following were documented under Section E: E0200 - Other behavioral symptoms not directed toward others: R1's behavior of this type occurred 1 to 3 days E0500 - R1 is at significant risk for physical illness or injury; significantly interfere with care and significantly interfere with participation in activities and social interactions. E0800 - Reject evaluation or care that is necessary to achieve the resident's goals for health and well-being: R1's behavior of this type occurred 1 to 3 days. R1's POS (physician's orders [REDACTED].>08/20/18: (MONTH) wear head helmet daily as tolerated for safety. Skin check daily, remove helmet for shower, care and any activities. 08/05/18: Behaviors: Monitor for the following: (Violent Behavior). Click Y if behavior was observed and N if No behavior and choose chart code No behavior intervention codes: (1) orient to reality (2) redirect/reorient (3) provision of therapeutic milieu (4) set limits (5) counseling (6) therapy behavior reinforcement +/- (7) referral to activities (8) therapeutic communication (9) refer to social services for evaluation (10) refer to Psychiatrist/pertinent medical practitioner (11) encouragement/reinforcement (12) non-stimulating environment (13) pharmacological intervention every shift. Additional behaviors to be monitored: spitting, throwing objects. Care plan dated 06/18/18 indicated that R1 has a behavior of hitting head on the wall/floor/bed/wall rails, attempts to hit staff, threw computer on the ground, knocked off maintenance cart, places himself on the floor and rolling off, physically aggressive/agitated, crawls on the floor, refuses to go back to bed, threw urine at staff, threw a chair/milk/linens/water/tables/objects/wet diapers/utensils at staff. Interventions: analyze key times, places, circumstances, triggers, and what de-escalates behavior and document; complete a cognitive assessment; evaluate for side effects of medications. Care plan dated 06/19/18 documented that R1 is at risk for ineffective coping behaviors specifically a mood problem, related to [DIAGNOSES REDACTED]. Interventions: Active-listen and identify perceptions of what is happening; administer medications as ordered. Monitor/document for side effects and effectiveness; Monitor/record mood to determine if problems seem to be related to external causes, that is, medications, treatments, concern over diagnosis. Care plan dated 06/19/18 documented that R1 has impaired cognitive function/dementia or impaired thought processes which is related to or as evidenced by [DIAGNOSES REDACTED]. Interventions: Administer medication as ordered; Ask yes/no questions in order to determine needs; break tasks into one step at a time. Post incident investigation report date completed 07/26/18 documented that on 07/20/18, R1 threw himself on the floor after incontinence care, sustained a small laceration to left side of forehead with minimal bleeding. R1 was transferred to a local hospital for further evaluation and treatment. R1 came back into the facility on [DATE]. Post incident investigation report dated 08/19 18 documented that R1 was observed with discoloration on right lower eyelid. Per report also, R1 has a behavior of intentionally putting self on the floor and banging head on the headboard. R1 is exhibiting maladaptive behavior. Facility's Incident Report dated 08/27/18, documented that R1 was observed sitting on the floor, noted blood on the face and there were traced amount of blood on the wall at 4:50 AM. According to the report also, R1 was interviewed stating that he hit his head intentionally on the wall because he wanted to die. R1 sustained a 1-inch laceration on left eyebrow and noted some bleeding and later was stopped. R1's roommates were sleeping when incident happened according to the report. R1 was transferred to the hospital as ordered. Hospital's Record dated 08/27/18 at 6:59 AM, documented that R1 presented to the emergency room with complaint of laceration on the left eyebrow. Triage notes indicated that R1 was cooperative, appeared disoriented and confused. Per hospital's report also, under Clinician History of Present Illness, R1 is a poor historian due to dementia, however, according to EMS (emergency medical services) crew that R1 was witnessed to be hitting his head intentionally against the wall that morning of 08/27/18 and found R1 to have a laceration on the left side of his head prompting to be transferred to the hospital emergency room as ordered. Hospital Records dated 08/27/18 revealed the following: Physical Examination: General - Elderly adult male, non-toxic appearing, no acute distress, alert, oriented x 1 and cooperative. (R1) looks demented, no acute distress. HEENT (Head, Eyes, Ears, Nose, Throat) - Big laceration over the left eyebrow, about 4cm (centimeters), hematoma, left eyelid. ENT - Left supraorbital laceration 4 x 1 cm. in length. Mild ecchymosis to left medial border of eye. No battle sign. No raccoon eyes. Progress notes: CT scans are positive only for nasal bone fracture. Hospital's Patient Discharge Transition Record dated 08/27/18 indicated that R1's facial laceration on the left eyebrow was repaired with five sutures. Hospital's Discharge Instructions under addendum notes indicated that R1 was having nose bleeding; R1 was assessed and treated with drug swabbing and nasal packing. Per addendum notes also, R1's bleeding was controlled. R1 was later transferred to another acute hospital. Under Emergency Department (ED) documentation dated 08/27/18 at 4:12 PM, R1 was transferred to ED as trauma transfer as nose bleed started after R1 was banging his head and was agitated. Physical examination indicated that R1 had a packing in right nares. R1's CT scan of head or brain without contrast dated 08/27/18 time stamped 4:41 PM documented: Impression: Acute nasal bone fractures, with hemorrhagic fluid within the nasopharynx. On 01/16/19 at 1:52 PM, V6 (Registered Nurse) was interviewed regarding R1's incident on 08/27/18. V6 stated, It was reported to me by V23 (CNA) that he (R1) was on the floor. It was between 4 to 5 in the morning. I went to his (R1) room and found him (R10) sitting on the floor close to the bathroom door and had an inch laceration on the left eyebrow. There was blood on the wall outside the bathroom. He (R1) stated he (R1) hit his head on the wall because he (R1) wanted to die. He was not wearing any helmet at the time. I did head to toe assessment and asked V23 monitored him (R1) and do one on one. He (R1) was later transferred out to the hospital as ordered. Prior to this, every 30 minutes I go to his (R1) room to check him (R1). When I did my rounds on him before the incident, he (R1) was lying on bed, awake and calmed. His (R1) room mates were all asleep at that time. The interventions that I do in order to prevent any accidents on him (R1) are close monitoring by me and the assigned CNA every 30 minutes to one hour; make sure floor mats are placed on the floor on each sides of the bed; his head helmet should be on at all times. There were no documentation on progress notes dated 08/27/18 that R1 was exhibiting behavior issues and unable to tolerate the use of helmet. There was also no progress notes dated 08/26/18 documented in R1's medical record regarding behavior issue and use of helmet. On 01/15/18 at 1:23 PM, V25 (LPN) was asked regarding R1. V25 stated, He (R1) has behavior issues like paces the unit, pushing staff, yelling, banging on the table, refused medications sometimes and resistive to care. He (R1) is alert and oriented x 1 to 2, depends on his mood - sometimes, he would be angry and cursed at staff, spit at staff, throw something at staff, put himself on the floor and laid on the floor. He doesn't usually bang his head on the floor but on the wall when he is sitting on his wheelchair. He needs to wear a helmet which he takes off but staff monitors and put it back on his head. He has the helmet on during the day, his bed is always on the lowest position at night and had floor mats on both sides. For him, I usually redirect him and if he has PRN (when necessary) medication for his behavior, I give it but that would be the last thing I would do. V4 (Assistant Director of Nursing) was also asked regarding R1. On 01/15/19 at 2:46 PM, V4 stated, He (R1) is basically behavioral the first day he was admitted into the facility. Not even 24 hours yet, he (R1) was sitting in the wheelchair, he (R1) pushed the wheelchair and put himself onto the floor. He (R1) will spit on us and very agitated. He was placed on monitoring every 15 minutes. Close monitoring when he is up on the chair and he was placed by the nurses' station. The incident on 8/27/18, it was a behavior issue that he (R1) woke up at 4:50 AM and stated he wants to die. V6 reported to me that resident was sleeping throughout the night, then at 4:50 AM, he got up, went to the bathroom and found him outside bathroom door sitting, bleeding, walls noted to have blood while roommates were sleeping. On 01/15/19 at 3:30 PM, V28 (RN) was interviewed regarding R1. V28 stated, He (R1) has a couple of behavior (spitting/hitting/putting himself on the floor) One time, he banged himself on the floor, we just put pillows. At times, we give medications, it helps. We do close monitoring. He is not wearing a helmet. I don't remember him wearing one. But we place landing mats on the floor. If he takes his helmet off, he has the landing mats on the floor in the room by the bed. V2 (Social Services Director) was asked regarding R1 on 01/16/19 at 11:24 AM, stating, He had some behavioral issues like screaming, yelling and had to be removed from the dining room, very difficult to redirect. I work with V5 (Psychiatrist) about behavior. I know he would not benefit from group or 1:1 because of confusion and cognitive impairment. On 01/16/19 at at 2:30 PM, V35 (Care Plan/MDS Coordinator) was asked regarding care plan revisions and updates. V35 stated, Care plans are being done upon admission, quarterly, significant change and annually. I don't do behavior care plans but when residents are on [MEDICAL CONDITION] medications, I do the care plan. My responsibility is to remind each department: Social Services for behavior; Restorative for ADLs (activities for daily living) and Nursing for medical: that care plans need to be initiated, revised and updated. We revised and update care plans when residents readmitted back into the facility and when additional [DIAGNOSES REDACTED]. Any planned interventions from the previous care plan that were not effective will be discussed in the meeting and care plan will be revised or updated if there is a need and will be coordinated to the staff per departments for implementation. On 01/17/19 at 2:15 PM, V26 (Restorative Nurse Assistant) was asked regarding interventions in preventing accidents on R1. V26 stated, He (R1) has a behavior that can't be redirected, so he needs to use a helmet. But he cannot tolerate helmet that should be on at all times even while sleeping. When I'm there, if he wants to remove it the helmet, I take it off, sits with him for 20-30 minutes and then put it back and he is okay with that. He has no assistive devices and makes no sense if he use it. He needs close monitoring because when he stands up and walk, staff needs to bring him back to bed or wheelchair. On 01/17/19 at 4:30 PM, V5 was interviewed regarding behavior management and care plan interventions. V5 stated, With regards to behavior issues, behavior interventions like counseling; communicate each other and talk about issues could be used. It is how you approach the residents. Another is de-escalation: If there is conflict, separate the residents and find out what is happening. Isolation of residents and engaging them in activities could also help in managing behavior issues. Understand the situation, like there is a reason why resident is exhibiting the behavior could be applied, if their needs are met met at the time; is there something else going on here why behaving that way. Medically speaking, I order laboratory examinations to find out underlying conditions that can contribute to behavior. In the Psychiatry world, behavior is managed by medications; care plan development and implementation- the social worker discussed the care plans with me. Care plans should be revised and updated if interventions are not effective. It should be done when needed. And care plan should be individualized to be effective. Facility's policy titled, Care Plan revised date (MONTH) 28, (YEAR), stated in part: Policy Statement: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Procedures: 5. These will be periodically reviewed and revised by a team of qualified person after each assessment.

Based on interview and record review, the facility failed to protect and prevent the physcal assault of 1 of 4 residents R2 reviewed for physical assault. This facility failure resulted in R4 physically assaulting and punching R2 in the eye requiring enucleation (removal of the eye) of the left globe (eyeball) due to [MEDICATION NAME] facial trauma). The facility also failed to prevent injury of unknown origin to a dependent resident (R3) also reviewed for injury of unknown origin. This failure resulted in R3 sustaining a [MEDICAL CONDITION] with no known mechanism of injury. Findings include: 1) Review of facility's final incident report of 07.20.2018 documents: (V9, CAN-Certified Nursing Assistant) reports walking into room after (R4) alerted him in the hallway at around 6:15 A.M. that he had an altercation with someone. (R4) informed (V9) that (R2) was moving his covers while he was sleeping, and (R4) punched (R2). (V9) followed (R4) to the room and observed blood on (R2's) face as well as a red eye. Review of R2's hospital record documents: -07.15.2018 at 9:12 AM (page 11): Pt (patient) via ambo (ambulance) from (Nursing Home) . pt was assaulted at NH (Nursing Home) by other resident s/p (status [REDACTED]. Pt has visible hematoma (bruise) on lf (left) eye, no blood thinners. Also rt (right) arm skin tear, and possible missing tooth d/t (due to) dried blood in pts mouth. Pt's lf eye, visibly reddened and swollen, possibly ruptured . -07.15.2018 at 12:16 PM (page 10): Spoke to (nursing) supervisor, at (Nursing Home) .During the night 11p-7a shift, patient got up and went to his roommate's bed who is sleeping and started folding linens on top of him. His roommate got upset and punched him. His roommate told the nursing staff that he punched him because he was disturbing his sleep. CT (Computed Tomography) Head (07.15.2018, page 21) documents: Rupture of the left ocular globe with lens dislocation. Supra and infraorbital soft tissue swelling and hematoma. CT (Computed Tomography) Facial bones (07.15.2018, page 22) documents: Rupture of the left ocular globe with lens dislocation. Physician Discharge Summary (page 123) documents: [MEDICATION NAME] facial trauma (physical trauma to a body part, either by impact, injury or physical attack) with ruptured left globe (ruptured eyeball) s/p (status [REDACTED]. Review of R2's ambulance run sheet of 07.15.2018 documents: (Ambulance) was assigned to an emergency assault call. Upon arrival to the scene patient was found standing up in his room. Upon observation, patient appeared to be in pain. He was covering his left eye with one hand. He had bruises on his left face. He had a laceration on his jaw and on the upper left side of his left eye .Patient's nurse stated that the patient accidentally slept on (in) his roommate's bed, and his roommate was upset and physically beat the patient up while he was sleeping. Due to the assault, the patient had a bruised face, a laceration, and injuries to the mouth . Review of R2's MDS (Minimum Data Set, 07.05.2018) documents the following: Diagnoses: [REDACTED]. -BIMS (Brief Interview for Mental Status): not completed. -Cognitive Skills for Daily Living: 2 (Moderately impaired). V9 (CNA-Certified Nursing Assistant, 07.26.2018 at 11:31 AM and 2:00 PM) said R4 approached him between 6:20 Am and 6:30 AM telling V9 come, come to my room. V9 said he saw blood on R2's head and clothing. V9 said R4 told him that R2 was in his bed (R4's) and was trying to pull the covers away from him. R4 told V9 that he (R4) fought with R2. V7 (CNA, 07.27.2018 at 10:48 AM and 10:59 AM) described R2 as little violent. He would stand up like he wanted to fight me when I would try to change his (incontinent product). V20 (CNA, 07.27.2018 at 2:54 PM) said R4 admitted to her that he struck R2 afer R2 urinated on the floor and then laid down in R4's bed. V11 (LPN-Licensed Practical Nurse, 07.26.2018 at 3:04 PM) said that he was notified (at approximately 6:00 AM) by V9 that R4 had a fight with R2. Review of R4's hospital record (07.15.2018, page 1) documents: Pt (patient) became angry at his roommate this morning and punched his roommate. Review of R4's MDS (07.13.2018) documents the following: -Diagnoses: [REDACTED]. -BIMS: 10 (moderately impaired). -Physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that puts others at significant risk for physical injury. Current behavior status is worse compared to prior assessment. 2) Review of the facility's initial incident report of 07.14.2018 documents: Resident (R3) was noted with swollen right hip, sent to (local hospital) for evaluation. Staff followed up with resident at (local hospital), spoke with the charge nurse and staff was informed that an x-ray was done and revealed fracture of right femur. Review of Radiology Results Report (Date of Service: 07.12.2018) for x-ray of R3's right femur documents: Impression: Acute distal femoral fracture (broken thighbone just above the knee joint). Review of R3's medical record (MDS-Minimum Data Set, 06.28.2018) documents the following: Diagnoses: [REDACTED]. BIMS (Brief Interview for Mental Status): 4 (severely impaired). Bed Mobility, Transfer: 3/3 (Extensive assistance/Two plus persons physical assist). V4 (CNA-Certified Nursing Assistant, 08.02.2018 at 11:21 AM) said she does not know how R3 sustained a femur fracture. V4 said R3 is dependent on staff for transfers and repositioning, requires mechanical lift for transfers and doesn't walk. V13 (Registered Nurse Supervisor, 07,27.2018 at 3:42 PM) said she does not know how R3 sustained a femur fracture. V3 (CNA, 08.02,2018 at 1:05 PM) and V15 (Registered Nurse, 08.02.2018 at 1:16 PM) both said that they heard that R3 fell . V23 (LPN-Licensed Practical Nurse, 07.27.2018 at 3:50 PM) said after receiving R3's x-ray results, she immediately interviewed the CNA who denied any issues for the resident. V24 (LPN, 08,02.2018 at 3:21 PM) said V2 (Director of Nursing) called her and asked her if R3 had fallen on her shift. I asked the CNAs if she fell , they said no. I would know if she fell on my shift. V22 (Physician, 07.31.2018 at 11:23 AM) said he was concerned that a bedbound resident sustained [REDACTED]. He said he spoke with a nurse at the facility who was not able to tell him what happened; there was no injury, no loss of consciousness, no [MEDICAL CONDITION] activity. V10 (Physician, 08.01.2018 at 9:59 AM) said: (regarding the mechanism of injury for R3's femur fracture) We don't know for sure. It's usually caused by a fall or twisting injury.

Based on observation, interview and record review, the facility failed to ensure that safety interventions were in place by not securing a window for 1 resident (R1) out of 4 residents reviewed for safety in a sample of 4. This failure led to R1 falling out a window resulting to a head injury and subsequent death. Findings include: R1 ' s [DATE] Physician order [REDACTED]. According to R1 ' s medical record, prior to R1's admission to this nursing facility, R1 was homeless and lived in shelters. R1 was treated at a local hospital between the dates of [DATE] to [DATE] due to sudden onset of confusion and disorientation and then was admitted to the facility on [DATE]. The [DATE] Minimum Data Sheet documents R1 ' s BIMS score to be 8 out of 15 indicating that R1 is moderately impaired. R1 was placed in the facility ' s locked unit because according to E2 (RN-MDS Coordinator), R1 " has dementia which qualifies (R1) to be placed in this unit. " As documented on the incident report and nurses notes on [DATE] at 11:00 am, R1 was found lying on the parking lot ground outside the facility. On [DATE] at 10:00 am, E9 (ADL Coordinator) stated, "I heard a very loud 'boom' while I was on the basement." E9 recalled that she had looked out the window, saw someone on the ground and called R14 (Registered Nurse) for help. E9 stated that all other staff rushed to the scene, cardiopulmonary resuscitation was initiated and 911 called at 11:05 am. E9 further states that the paramedics arrived at 11:09 am, took over and brought R1 to a local hospital. On [DATE] at 2:30 pm, E1 (Administrator) stated that an investigation was conducted and an incident report was sent the department. "(R1) jumped out of the window in what appears to be an escape attempt." E1 stated that no one saw R1 jump but a staff was in the basement and heard a sound from outside the building saw R1 lying on the ground and reported immediately to the nursing staff. E1 stated that immediately the staff responded, 911 called and R1 was brought to the hospital. E1 stated that all the staff that he interviewed stated that R1 was his usual self that morning and that there were no indications of elopement or suicide. E1 added that R1 was last seen at about 10:30 am. On [DATE] at 10:57 am, E8 (Licensed Practical Nurse) was interviewed regarding the incident. E8 described R1 to be " alert and oriented to person, calm and pleasant and talked about religious things, was delusional, talking about Jesus all the time but not agitated. " E8 stated that R1 did not express indications of any suicidal ideation or leaving the facility. E8 was the nurse on duty on the day of the incident. E8 stated that R1 took medications, including scheduled psychotropic medications that morning as usual. E8 stated that was sitting in the activity room at 10:00 am. E8 also added that she and E7 (Certified Nursing Assistant) were at R1's room between 9:45 am to 10:15 am attending to another resident who was sent out to the hospital and that R1 was not in the room during these times. E8 stated that at 11:00 am at the time of the incident, she did not hear any sound coming from R1's room as she was sitting at the desk doing paper work when she was alerted by E11(Special Unit Director). On [DATE] at 11:11 am, E7 stated that at the time of the incident, she was the assigned certified nursing assistant. E7 stated that R1 was also his usual self on that day. E7 stated that R1 was friendly, never angry, agitated or depressed. E7 stated that, " I give (R1) the dress and (R1) dresses himself and do everything on his own. " E7 stated that " R1 never told me that he wanted to go home nor did (R1) try to run away. " E7 states that she was at R1's room at 9:45- 10:15 am assisting E8. E7 stated that the last time she saw R1 was when Z2 (Phlebotomist) took R1 to a resident ' s room which she could not recall, to have a blood draw. E7 was in another room fixing the bed at the time of the incident and did not hear any sound coming from R1's room. E11 (Special Care Unit Director) stated that she had seen R1 at 9:00 am the day of the incident. E11 stated that R1 was his usual self and that there was no indication of any suicidal ideation nor did R1 try to escape from the facility. At 11:00 am, E11 was in a meeting and that they were called when the incident happened. On [DATE] at 11:28 am, E10 (ADL Coordinator) stated that on the day of the incident, R1 got up, went to breakfast, to washroom and then to activities as usual. At 10:35 am, while E10 was charting on the east side hallway, R1 greeted E10. E10 stated that this was the last time she had seen R1. At the time of the incident, E10 stated that she was in the dayroom located at the west side of the hallway and could not hear noise coming from R1's room. On [DATE] at 12:18 pm, E12 (Activity Aide) stated that R1 never showed any sign of trying to escape or having suicidal ideation. On the day of the incident, E12 and E13 (Activity Aide) both stated that R1 was his usual self, participating in an activity in the day room and about 10:30 am, Z2 brought R1 out of the dayroom to have a blood draw. R1 did not return to the activity room. E12 and E13 did not hear any sound coming from R1's room as they were in the activity room at that time. On [DATE] at 2:40 pm, E2 (RN/MDS/Care Plan Coordinator) stated that R1 was assessed to be alert and oriented x1, cooperative, had bouts of anxiousness, confusion, forgetfulness and delusions. E2 stated that R1 did not have any attempts or history of wandering, elopement or suicide. R1 was not on any special precautions but because R1 had dementia, he was placed on a locked unit for monitoring. E2 stated that because elopement was not triggered in the MDS, there was no care plan for elopement monitoring. R1 was not identified to be placed under elopement precautions. On [DATE], between 10:00 am - 3:00 pm in the conference room, E2, E8 and E11 confirmed that R1 was not on any special precautions. E2, E8, E11 stated that when a resident is on elopement precaution, "they have wander guards, they would be on close monitoring, staff specifically knows where they are at a given time." R1 did not have a wander guard. E2, E7, E8, E11 stated that " staff monitored residents including R1, every 1 hour. Nurses monitor residents on the even hours and CNAs have to do their rounds on the odd hours. In addition, staff is stationed on the hallways to monitor residents. " The facility's "Policy and procedure for special care unit on wandering/high risk of elopement" document in part that, "A. Staff will be made aware of those residents at high risk for elopement. B. Staff will monitor resident at ,[DATE] minute intervals to ensure resident's safety. C. Staff will redirect resident to activity area several times ...and attempt to give him/her in some type of activity." Review of hospital records indicated that during hospitalization prior to nursing home stay, R1 was placed on elopement precautions and was being monitored for safety. According to E2, during R1's stay in the nursing facility, R1 was not identified as at risk for elopement and therefore was not monitored according to facility special unit policy on residents with high risk for elopement. On [DATE] at 3:10 pm a phone interview was conducted with Z1 (Psychiatrist). Z1 stated that prior to R1 ' s admission in the nursing facility, R1 was in a local hospital due to sudden changes and decline in mental status. Z1 diagnosed R1 with Dementia. Z1 stated that during his stay in the nursing facility, R1 did not cause any behavioral or management problem and was compliant to treatment. Z1 stated that R1 "did not try to kill himself but fell out of the window when he tried to escape." It was also documented on Z1 s notes that R1 "tries to elope through the third floor window and fell through the window during his escape, found by RN on his back, 911 called ...pronounced dead at hospital. " On [DATE] at 2:25 pm, a phone interview with conducted with Z3 (Physician). Z3 stated that R1 lived in a shelter and was seen in a physician's office and noted to be confused and was not taking care of himself and was stabilized in a hospital. Z3 stated that R1 was being managed medically due to seizure disorder and was for psychiatric management more than for medical management in the nursing facility. Z3 stated that " (R1) was homeless, lived in a shelter and possibly wanted to get out of the facility." Z3 stated that R1 did not have any history of elopement or suicidal ideation. On [DATE] at 11:00 am, tour of the facility, including R1 ' s room, was conducted with E1 (Administrator). E1 stated that all of the windows on the third floor, which is a " locked unit " have latches and are screwed in, as noted during the tour in R1 ' s room 304 as well as in rooms 321, 307, 321. During the tour, the windows in the room where R1 was have been screwed in and cannot be opened. A tour of the rooms on the second floor was then conducted. E1 pulled a window in room 216, which E1 stated is the same type of window in room 304. The opening measured 12 inches. E1 and E3 stated that windows on the third floor should be "screwed in shut." E3 (Maintenance Supervisor) stated that the windows measure about 3 feet x 2 feet and can be pulled opened to about a foot and a half. E3 also stated that the windows are checked once a month especially on the third floor and during cold days. E1 stated that "there used to special screws securing the window which can be taken out only by a special tool but they are not available so we use these (round top) screws in the third floor to secure the windows ...apparently (R1) opened the window in his room or the window was not screwed shut as it should have been ...(R1) jumped out of the window and died . There are a lot of things that needed to be checked and this is one of those things." E1 stated that all windows on the third floor have been checked and screwed in. E1 stated that he is not aware where the screws are or whether screws were present in the windows during the time of the incident. According to the hospital records, R1 "came via EMS after fall/jump from window of nursing home, arrived not breathing, with no pulse, and with blood pouring out of bilateral ears." It was documented on the record that R1 sustained a blunt head injury and subsequently pronounced dead at 11:30 am due to cardiac arrest.