Every finding on record at Countryside Nursing & Rehab CTR

Based on interview and record review, the facility failed to implement and follow their Abuse Prevention Policy and Procedures by failing to protect a resident (R1) from physical and verbal abuse, failed to immediately report allegations of abuse to the state agency, failed to initiate a timely investigation, and failed to take immediate actions to ensure resident safety. These failures resulted in psychosocial harm of R1 who is fearful and scared of another altercation with V5 and fearful he will be abused again. Failure of the facility not following their abuse policy puts all 147 residents at risk of being abused.The Immediate Jeopardy began on 07/05/2026 when R1 and V5 were involved in a physical altercation in the facility. V1 (Administrator) was notified on 07/20/2026 at 3:00 PM of the Immediate Jeopardy.The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 07/23/2026, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1 is [AGE] years of age. Current diagnoses include but are not limited to Dementia with Other Behavioral Disturbance (diagnosed 10/01/2022), Type 2 Diabetes Mellitus, Chronic Kidney Disease with Heart Failure, Major Depressive Disorder, Unspecified Psychosis, Neuromuscular Dysfunction of Bladder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Parkinson's Disease.R1's comprehensive assessment section C Cognitive Patterns dated 05/18/2026 documents a BIMS (Brief Interview for Mental Status) score of 11. R1 has moderate cognitive impairment.R1's Physician Order Report dated 06/09/2026 - 07/09/2026 states in part R1 is prescribed the following medications for Psychosis: Divalproex Delayed Release 250mg (milligrams) 1 tab oral three times a day and Haloperidol 5mg 1 tab oral once a day.R1's care plan dated 02/16/2026 states in part: R1 may display episodes of aggression, of hitting staff and peers which pose a risk to self and/or others and interferes with care provision and social interactions. Goal: R1's aggression triggers will be minimized through proactive staff intervention. Approach: 02/16/2026 Redirect to safe, calming activity when agitated. Discipline: All Disciplines, C.N.A, Nursing.Problem start date 02/16/2026 Psychosocial Well-Being: R1 may exhibit agitation vulnerabilities such as low esteem, confusion, and easily being misled/or misguided by others which may put him at risk for abuse due to his diagnosis of Dementia. On 11/19/25 a peer made allegations that the above resident was physically aggressive towards him. Goal: R1 will be free from any forms of abuse and neglect daily by next review. Approach start date 02/16/2026: 11/18/25 1:1 counseling on respecting others and privacy. Re-educated to call light for staff to use when staff assistance is needed. Allow R1 time to vent and positive feedback given. Added to 72hr well-being check. 1:1 behavior monitoring until calm. Room change completed 11/18/25 and 11/19/25. R1 will be redirected by staff as needed to ensure the safety of himself and others. Staff will intervene when R1 appears to need redirection or assistance with a task. Review of incident witness statements document in part: On 07/05/2026 during the 11PM - 7:30 AM between 5 AM - 6 AM, staff witnesses observed a physical altercation between R1 and V5 C.N.A Certified Nurse Assistant at the entrance to R1's room. On 07/08/2026 at 10:09 AM, R1 is alert and oriented to person. R1 is ambulatory with a rolling walker. R1 was inquired of being abused by V5 CNA. R1 said, I didn't obey her (CNA) and she threw me on the ground, my hip hurt. I peed on the floor and asked for a towel, and she got mad at me. I hit her because I had to, I didn't mean it. It was this week.On 07/08/2026 at 11:55 AM, V8 RN (Registered Nurse) was inquired of her progress note on 7/5/2026 regarding R1's behavior. V8 said, I got report from V9 LPN (Licensed Practical Nurse) and she said she heard some loud speaking down the hall; the CNAs were in front of R1's room. R1 was agitated. I didn't see any agitation from him.On 07/08/2026 at 1:18 PM, V10 PRSC was inquired of her 7/6/2026 observation note regarding R1. V10 said, I was told not to complete that note in the computer, that's why it's still open. I don't recall who told me not to complete it. I was told to do it because there was an incident with a resident and staff member R1 and a CNA, but I don't know her name. It happened on overnight shift. I came in at 9AM. I was told a resident was physically aggressive with a staff member. I attempted to speak with R1, but he talked around it. It was around 10 or 11 AM, he didn't appear to be in distress. I tried to speak with him after the incident, but he wouldn't tell me what happened. He has a behavior of praying loud in the shared bathroom and ignoring staff often. He doesn't follow directions from staff. I didn't speak with the staff, I never see third shift, they leave before I get here in the morning.On 07/08/2026 at 1:48 PM, V9 LPN Licensed Practical Nurse was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V9 said, I wasn't aware of what happened, I got there towards the end. I was at the nurse's station watching over the fall risk residents. I heard a noise from the hallway. Three CNAs were with them. Everything ended by the time I got there. Another nurse came in and interviewed R1. One of the residents was trying to get up so I ran back to the nurse's station. I wasn't R1's nurse that night, can't remember who was. His nurse was on break.V11 RN is written as assigned to A wing on the 07/05/2026 schedule.On 07/08/2026 at 1:55 PM, Call placed to V11 RN Registered Nurse with no answer, unable to leave a message.On 07/08/2026 at 1:57 PM, V12 CNA was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V12 said, I was in the hall, it started in the hallway. I heard V5 CNA giving R1 commands to put his clothes on then I heard them arguing back and forth about water being on the floor. Then I heard the altercation going on. I got to the room, and they were in each other's arms. My back was turned so I don't know who started it. V5 was tussling back and forth with R1. V5 said, I look 12, but I'm not 12! I called for assistance and got them apart. The nurse and another new CNA came, I don't know their names. R1 said he was OK. He wanted to get a towel. V5 came back in the room, and I told her to leave. She went to the security desk. It happened after 5 AM.On 07/08/2026 at 2:14 PM, V14 CNA was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V14 said, I heard commotion in the hallway. When I got there staff were pulling them (R1 and V5) apart. V5 was the CNA. There were two aides that broke it up and a nurse came. I didn't know what happened. R1 was asking for a towel and some pants. I went to finish my rounds.On 07/08/2026 at 2:26 PM, V17 LPN was called to inquire of the Sunday 07/05/2026 incident between R1 and V5 CNA, message left to return the call.On 07/08/2026 at 2:43 PM, V18 LPN was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V18 said, I went to lunch a little bit before 5AM. There was an incident with a resident and staff. I was told V2 Assistant Administrator was informed. I didn't speak to staff. I was done.On 07/09/2026 at 9:07 AM, V5 CNA was inquired of the Sunday 07/05/2026 incident with R1. V5 said, I was doing patient care, he (R1) became aggressive asking for pants. I called for assistance from any CNA to help redirect and de-escalate. He (R1) scratched my arm and wrist. The CNAs came and de-escalated it. He (R1) calmed down and apologized. I couldn't find a nurse on my side, so I went to the other side. I made V9 LPN aware and wrote a statement. V2 Assistant Administrator came up here. I was off the schedule one day for the investigation. V2 called me back the next day and told me he (R1) admitted to what happened so I could come back.On 07/09/2026 at 10:00 AM, The state agency reportable incidents were reviewed from the past six months. There is no reportable incident noted for the 07/05/2026 altercation between R1 and V5 C.N.A. V1 Administrator was inquired of the incident for review. Abuse policy requested from V1 related to concerns identified with employee witness statements of the incident. V1 Administrator came into the conference room and said, I just sent in this reportable for abuse.On 07/09/2026 at 10:22 AM, V2 Assistant Administrator was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V2 said, It was reported that staff said a resident attacked a CNA, so she called to report it. I told her I was on my way and to have all staff on that wing to stay so I could obtain statements. The CNA was not to return to the wing. Have the nurse check the resident and make sure the staff was safe. It was R1 and V5 CNA. When I got here, I went to the wing to check on R1. I saw V9 LPN and asked for statements. I called V1 Administrator. I witnessed all the statements and read them. I let V1 know I was in the building and what was going on. I interviewed R1 and he was apologetic, he said he hit her because he had to and was sorry. He said he was alright and wasn't in pain. R4 is R1's roommate. R4 can talk with hand movements, but he didn't wanna talk. I talked to V5 C.N.A, V15 Anonymous , V12 C.N.A, V14 C.N.A, V9 LPN and V17 LPN about what happened. Staff said they heard hollering for help and when they got there V5 and R1 were on the floor. V15 Anonymous wrote in her statement R1 and V5 were on the floor. After they were separated, staff told security. V5 should have left the area when R1 became aggressive and got assistance. She shouldn't have still been in there. It should have been reported to the state then because they were tussling with each other on the floor. V9 LPN should have immediately assessed R1 and checked for safety. Separate CNA and write the statement. Document the incident and assessment. The on-coming shift shouldn't have documented on the incident, V9 should have done it. A call to the doctor should have been made to ask if R1 should go out for assessment. Family should have been called. It should have been called to the state, and we should have started our investigation.On 07/09/2026 at 10:22 AM, V2 was inquired of witnessing R4's statement and R4 saying leave me alone. V2 said, I filled out the top of his witness statement, but V20 LPN did it. R4 can't verbalize, he has a communication board. He'll nod yes or no.On 07/09/2026 at 11:22 AM, V1 Administrator was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V1 said, V2 Assistant Administrator contacted me that morning saying she was already on her way, it was reported to her between a resident and staff. She said she'd get the details. She called back and said R1 struck V5. V2 said R1 said he hit V5 and V5 didn't. She said she'd get statements from everyone. I read the statements the next day. I saw it as V5 was in self-defense, but the statements say they were in a struggle. V5 should have stepped away from the resident when he was aggressive and waited for help. R1 is care planned for aggression. His admitting diagnosis was behavior disturbance. This should have been reported.On 07/09/2026 at 11:55 AM, V1 was inquired of the incident report, R1 assessment, doctor and family notification documentation not being completed. V1 said, I looked for the progress note or incident. I didn't find anything from the nurse that worked the shift.On 07/09/2026 at 2:01 PM, V21 Anonymous was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V21 said, R1 has never acted like this, it doesn't make sense. V17 LPN and I called my boss. V5 came up to the desk after it happened and said, Motherfucker's think I'm [AGE] years old. I'm not fucking playing this. I dragged his motherfucking ass. What happened to R1 isn't what's really being said. I went to the room to check on R1 after it happened. I took pictures of his shirt, it was ripped. R1 said, All I did was ask for a towel because I peed on the floor and the CNA got mad at me and threw me down. I told V5 CNA to write the statement, and she argued with me. I have my first statement written and they told me I couldn't write that. They told me to rewrite my statement.On 07/09/2026 at 2:50 PM, V1 Administrator was inquired of the cameras observed in the hallways and common areas for video footage on Sunday 07/05/2026. V1 said, I have cameras, but they don't record anything. It's just live feed. Once it passes it doesn't record.On 07/09/2026 at 2:52 PM, V20 LPN was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V20 said, I worked the night shift, I was on the other side. The CNAs were talking about the incident. I was told V11 RN was on break. V9 LPN was there when I got there. I went over there to check on R1. V9 was at the nurse's station. I asked R1 if he was OK, he said he hit the CNA because he had to. I looked at his hands, face, and body. I went back to my side. I didn't document anything. I was asked to write a statement. I wasn't his nurse; I was just concerned. He's normally calm and cool. I've never had an issue with him. I've never heard of him (R1) having an issue with any other resident.On 07/09/2026 at 3:01 PM, R4 was inquired of hearing or seeing anything while in the room on Sunday 07/05/2026 between R1 and V5. R4 is nonverbal and shook his head from side to side indicating No. R4 was asked if he was asleep during the incident. R4 nodded his head up and down indicating Yes.On 07/13/2026 at 10:07 AM, Timecards were reviewed from all staff present during the incident on 7/5/26. V11 RN clocked out at 3:07 AM and returned at 4:17 AM. V9 was the only nurse on left on the A/B wing. Further calls made to speak with R11 with no answer or ability to leave a message.On 07/13/2026 at 10:31 AM, V5's personnel file was reviewed, abuse and dementia training completed. V23 Human Resources was inquired of V5 CNA completing CPI (Crisis Prevention Intervention) training. V23 said, V5 didn't have CPI training yet. We try to get them in within the first 60 days of hire. We offer the training every two weeks, but it can only take ten people.On 07/13/2026 at 10:36 AM, V2 Assistant Administrator was inquired of V11 RN not having a statement written and not working since 07/04/2026. V2 said, I didn't see V11 when I came in that morning. I didn't call her because staff said she was on break and wasn't there when it happened. V9 LPN was there.On 07/13/2026 at 11:41 AM, V4 ADON Assistant Director of Nursing was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V4 said, I wasn't here that day. V2 Assistant Administrator told me there was an incident on Monday (07/06/2026). I helped with witness statements and contacting staff. I talked to V5 CNA over the phone on Monday. She was trying to redirect R1 and he became aggressive and hit her. I talked to V20 LPN, she said she heard a commotion and went to assess R1. We had V5 CNA take a leave while investigating, everything else was done by administration.On 07/13/2026 at12:01 PM, V24 Family Member was inquired of being notified of the Sunday 07/05/2026 incident between R1 and V5 CNA. V24 said, I was told he (R1) made contact with staff and scratched her on the arm. He's never been violent towards anyone ever. I'd like to know more about what happened.On 07/13/2026 at 12:43 PM, V3 DON Director of Nursing was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V3 said, I was on vacation the day it happened. I returned on Monday and was made aware. The investigation was already assigned to other staff; I wasn't a part of it. When there's an incident the nurse should make sure everyone is safe, assess the resident, complete the observation form for the body and pain, notify the doctor and family, then notify administration immediately, and do a progress note. Document so you can see if something comes up, you may not be able to remember so document everything. It's to cover you as a nurse. If there's no documentation, I'd try to find out why it wasn't done. Technically if there's no documentation, it wasn't done. We train the nurses on incidents and if anything happens after hours they can contact me at any time. V4 ADON was available, and all nurses have her phone number. V4 and I are responsible to make sure all the documentation is in place. I didn't look into the documents for it (incident report) because staff said they did the investigation. I should have followed up and looked at everything.On 07/13/2026 at 1:21 PM, V21 Anonymous contacted this surveyor regarding the Sunday 07/05/2026 incident between R1 and V5 CNA. V21 said, V5 came to the desk talking about what happened and said, Who came up here being messy, I don't like nobody being messy. I asked V5 why didn't she yell code white in the hall? Why did you drag him (R1) back in the room? V5 said, I knocked his ass out. I've done this on second shift, and they don't say nothing about it, why people on this shift messy.On 07/13/2026 at 3:19 PM, R1 was inquired of his shirt being ripped during the incident with V5 CNA and how he feels while V5 is in the building working. R1 said, She (V5) pulled me and ripped my shirt. She hasn't worked with me since then. I think she's gonna fight me again. I'm scared.On 07/13/2026 at 3:28 PM, V1 Administrator was inquired of the incident investigation process and V5 CNA. V1 said, Overall myself and V2 (Assistant Administrator) are responsible for the investigation. V5 CNA was off for one day then came back in. It was concluded as a resident to staff incident. I'm the abuse coordinator. I'm responsible for making sure the investigation is completed. I do interviews with residents and staff, and anyone present having information regarding it. Assessments of staff and residents if needed. Coordinate any other actions if needed, contacting doctors and family. Review statements. Come to a conclusion with the information provided. Each investigation is individual; I can't give a time frame. V5 returned to work on July 6th.On 07/13/2026 at 3:35 PM, V3 DON Director of Nursing was inquired if C.N.As are able to go anywhere else in the building other than their assigned unit while working. V3 said, C.N.A's can go to other units to get supplies or if helping other staff.On 07/14/2026 at 12:24 PM, This surveyor was asked into V1 Administrator's office related to questions about the investigation. V1 said, Can you tell me who called in this investigation? V1 wanted this surveyor to tell him if it was staff and who it was. V1 said, I have some staff I need to get rid of. I know it's staff because state has been in the building for a few months and every time they (state) come in they have specific information that only staff would know. I just want to talk to them to clear up some of the information being reported to state. This surveyor told V1, According to your abuse policy anyone in this building can report an allegation of abuse.On 07/14/2026 at 12:44 PM, V10 PRSC (Psychiatric Rehab Services Coordinator) was inquired of the facility having emergency codes. V10 said, Yes, we do. It's on the back of our ID's (Identification). Code white means combative resident. V10 showed this surveyor the back of her ID badge with a list of emergency codes. Code white = combative resident.On 07/14/2026 at 1:02 PM, V2 Assistant Administrator was inquired of the facility having emergency codes and training. V2 said, The emergency codes are on the back of our badges. V2 turned her ID badge over to the back, there is a list of emergency codes. V2 said, All staff have training on the emergency codes in orientation. Surveyor requested a copy of the emergency codes for review.On 07/14/2026 at 1:18 PM, V23 HR Human Resources provided V5 CNA's signed copy of the emergency code training dated 05/28/2026 with a copy of the emergency codes.On 07/15/2026 at 12:03 PM, R4's room was reviewed for his communication book. R4's communication book is on the nightstand in his room. There are multiple pages of pictures with written descriptions listed. There is no documentation of the phrase leave me alone on any of the pages in the communication book.V8 RN Registered Nurse was inquired of R4's communication and book. V8 said, R4 is nonverbal and uses a communication book. He can demonstrate by pointing at things to call your attention. He can hear and understand what you say and nod his head. He's had the book since I've been working with him from April of this year. There aren't any pictures or words that say leave me alone.On 07/15/2026 at 12:06 PM, V8 RN was inquired of the report she received on 07/05/2026 and her documentation. V8 said, V9 LPN gave me report that morning. She said R1 was having behaviors early that morning around 5AM. V4 ADON Assistant Director of Nursing told me to do 72 hour behavior charting; we do that to see if R1 had any changes. I don't know of him ever hitting or being aggressive with staff since I've been here. V4 asked me to call V25 Physician. I called V25, but he didn't answer so I left a message. V4 said R1's family was already called. When I looked in his (R1's) notes, there wasn't anything documented from V9 about the incident calling V25, the doctor or family. I documented he (R1) didn't have behaviors for my shift.Interviews were conducted with staff on 07/15/2026 between 12:48 PM - 2:02 PM. All staff did not recall R1 having any aggressive behaviors of hitting or yelling at staff to their knowledge.On 07/15/2026 at 12:56 PM, R1 was inquired how the incident started with V5 C.N.A. and how he ended up on the floor. R1 said, She (V5) swung at me first, then I swung back at her. She didn't wanna give me the towel and she got mad. She swung at me because I pissed on the floor. That's what it was about. That's why she got mad. I got on the floor cause she threw me down.On 07/15/2026 at 1:29 PM, V30 Plant Operation Manager of Housekeeping and Laundry was inquired of R1's behavior. V30 said, I've been here two years, and I work on all units. I've never seen or heard him (R1) ever be aggressive. I've never seen him hit or yell at anyone. He does urinate on the floor sometimes because he doesn't understand when he has to use the bathroom. It's usually an accident. He'll come and ask for pants.On 07/15/2026 at 1:42 PM, V32 MDS LPN was inquired of R1's behavior care plan. V32 said, R1 has Dementia with behavior disturbance since 2022 from his face sheet. His care plan for aggressive behavior was reviewed 2/16/26, but it didn't just start. For their (residents') annual care plan review we update the start dates. His progress notes from 2/16/26 say he went out to the hospital for cellulitis, and we picked him up because he needed skilled care and therapy. It wasn't for behavior.On 07/15/2026 at 1:54 PM, V33 LPN was inquired of R1's behavior. V33 said, I've been here seven years. I'm familiar with R1. He's compliant. He sings and talks to himself. He's not one to have behaviors, he doesn't act out. He's kind and respectful. He'd have to be triggered to have a behavior like that.On 07/15/2026 at 2:11 PM, V35 PRSC Psychiatric Rehab Services Coordinator was inquired of R1's behavior. V35 said, I've been here nine years, he's (R1) on my caseload. He's calm but can be agitated sometimes. I haven't seen him hit anyone, staff or resident. He'll say leave me alone. Sometimes he'll yell in the room, but I'm familiar with him. I can calm him down. I've never had to do a code white for him or ask staff to do anything. He's only upset if he doesn't get his money.On 07/15/2026 at 2:31 PM, V12 CNA was inquired of the Sunday 07/05/2026 incident. V12 said, I've been here six months. I was in the hallway getting linen and going in and out my residents' rooms. V5 and R1 were in the hall in front of R1's room. I believe it was about 5 in the morning. I didn't see it start. I heard her (V5) yelling about clothes. I heard a commotion and saw them in each other's arms. I was going towards them to break it up and I turned my head to call for help. They both fell into the room. I didn't hear him (R1). He (R1) can get anxious about his clothes, but he's normally calm. I haven't seen him aggressive or yelling at anyone.On 07/15/2026 at 2:41 PM, V14 CNA was inquired of the Sunday 07/05/2026 incident. V14 said, I was in a room when it happened. I heard a commotion in the hall and peaked my head in the hall. I heard someone say let go. I came down to the room, two staff were there breaking it up, V12 and V15. I've never seen him (R1) have any behaviors. I don't know of him ever hitting anyone. He can yell in his room when he doesn't want to get up.On 07/15/2026 at 3:08 PM, V5 CNA was inquired how the incident started with R1. V5 said, I was in his (R1) room helping with incontinent care. I was putting towels on the floor in the room. I thought it was water. He (R1) was in the bathroom. R1 told me it was pee (urine), he said he had an accident. I was redirecting him to put on his pants because he was going in the hall in his underwear and he wasn't listening. He was fidgeting. I don't remember who grabbed who first, but my arm was scratched. I said help. He became resistant and we began struggling. We lost our balance and fell. A couple of people came to help; I didn't know their names. I'm not scheduled to work on his side. I didn't get any training when I came back to work. I haven't' had CPI (Crisis Prevention Intervention) training yet.On 07/15/2026 at 3:30 PM, V20 LPN was inquired of assessing R1 after the incident, the lack of documentation, and of V11 RN. V20 said, I didn't ask him (R1) how he got on the floor. I'm not sure why V11 left, I just thought she was at lunch. I didn't see her. I just went there (A unit) to make sure he (R1) was OK because I work with him a lot. I was asked to write a statement. His nurse V11 wasn't here so they (administration) asked us to write a statement. He (R1) was sitting on the bed; he wasn't in distress. I didn't get vital signs. I didn't like stepping on anyone's toes. V9 LPN was at the desk. If an incident happens, I'd step in and act as the nurse. I'd check the resident, handle the emergency, do the assessment and vital signs and tell the nurse when she comes back.On 07/15/2026 at 6:05 PM, V15 Anonymous returned an interview regarding the Sunday 07/05/2026 incident between R1 and V5 CNA. V15 said, I've been there three to four years. I know him (R1). He (R1) prays loud in his bathroom. He'll pee on the floor but will help clean it up then he'll ask for clothes. He's a cool person, laid back. I've never seen him aggressive or hit anyone. I worked that night and saw two people fighting in the doorway of his (R1) room. V12 CNA said we need help down here. When I got there, it was R1 and V5 CNA. They were thrashing with each other and fell on the floor. V5 was pulling him (R1) into the room. We (V12 and V15) were trying to pull him (R1) away from V5. V5 said, I'm not no little kid. You peed on the floor; I'm not helping you no more! R1 looked shocked, his shirt was ripped in the front. It was blue. We separated them. A nurse came and asked what happened, but I don't know her name. I went and told V21 Anonymous Staff and V17 LPN, V5 just beat the mess out of R1. She was trying to pull him in the room. V5 said, I dragged him. I told V5 why didn't you leave the room. You could've came and got one of us to help him. V5 was wrong for what she did. V2 Assistant Administrator came and asked us to write statements. V2 said to put down he (R1) was aggressive but he wasn't. I usually work his set. V2 said, I don't want V5 to lose her license. On 07/16/2026 at 11:06 AM, V4 ADON was inquired about further details of the Sunday 07/05/2026 incident between V5 CNA and R1. V4 said, I didn't come in on Sunday. V2 (Assistant Administrator) called me about the incident between 5 - 7AM. I didn't come in until Monday. I called V25 Physician. I left a message because he didn't answer. I said R1 had some aggression and to call the facility to speak with the nurse or myself. V24 Physician came and rounded on Monday (7/6/26). She wrote a note on 7/7, but it didn't talk about the incident. V24's progress note was reviewed in R1's electronic medical record with V4. The nurse should have followed up with the call. V11 RN Registered Nurse was his nurse that night. V9 LPN Licensed Practical Nurse was working on the side with her. I didn't see any note about the incident. V2 just said R1 was having behaviors. I didn't speak to V9 LPN on Sunday because there were two nurses and a nurse manager there. V2 didn't ask me to come in. I spoke with V8 RN Monday. I told her to check on R1, check if he was having behaviors, and do an event which is a behavior assessment. She didn't see any display of aggression on her shift. The night shift nurse should have contacted me to call the doctor and petition R1 out. V20 LPN did his assessment but didn't document anything in his medical record. I saw she wrote she assessed him (R1) in her statement. She should have done a progress note at minimum, the assessment tab and incident note. She said he (R1) didn't have any injuries. V3 DON Director of Nursing and I called V5 CNA Certified Nurse Assistant . We asked her statement, did a one on one and told her how to be safe and remove herself from the situation. It wasn't documented, it was just verbal.On 07/16/2026 at 11:39 AM, V3 DON was inquired of updates to R1's care plan following the incident. V3 said, I wasn't a part of the conclusion, so I'd have to ask V1 Administrator. His (R1) care plan says to redirect to safe, calming activities when agitated. We automatically update the care plan on this situation. His care plan is reflective of his behavior. V5 CNA had Dementia training in orientation, but she hasn't had CPI (Crisis Prevention Intervention) training yet. What should be done was to back away, redirect, have someone else take over for that resident especially if the aggression is towards them because you don't want to aggravate the resident more or have any negative situation happen.On 07/16/2026 at 12:11 PM, V2 Assistant Administrator was inquired about further details of the Sunday 07/05/2026 incident between V5 CNA and R1. V2 said, Once I got to the building I found out V11 RN had left. V9 LPN said V11 went on lunch. She (V11) wasn't seen when I got there. As a nurse, V9 LPN should have done what she was supposed to do per her managers. She (V9) should have known what her duties were. When V11 RN left, V9 was in charge of the unit. V5 CNA was sent home because of the incident with R1. I told her she's being sent home due to the investigation and would be called back upon completion. Her department heads were responsible for calling her back. I don't know if V5 received any training.On 07/16/2026 at 1:09 PM, 24 Physician was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V24 said, Someone was on call, maybe a partner took the call. I know he (R1) had a history of aggression. When I rounded, he was calm and cooperative. Our NP (Nurse Practitioner) typically works sees him. She's on leave so I'm covering for her. This was my first time seeing him (R1). None of the nurses or ADON (Assistant Director of Nursing) said anything about him having behaviors. I always talk to staff before seeing the residents. I'd like to have known about the incident, was it physical or verbal aggression. How often and what happened. What was said, if there were any falls, level of fall, medications, or obvious injury. Any pain, loss of consciousness. I'd want him evaluated and sent out also to have psych (psychiatry) see him. Was it new staff ? Is there a root cause? Is this a pattern? I'd like to ask the nurse more detailed questions. I'd have them monitor and document behaviors, draw labs, and order neurological checks after a fall. They should have put in a incident report to know what happened. Agitation is something that makes you feel upset and is redirectable. Aggres[TRUNCATED]

Based on interview and record review the facility failed to provide care and services according to accepted standards of practice by not following their charting and documentation policy and the Licensed Practical Nurse Job Description. The facility failed to document an altercation between R1 and V5 C.N.A (Certified Nurse Assistant) in R1's medical record and complete an incident report per the facility policy. This failure to document the staff and resident altercation caused a lack of investigation into the incident and report of suspected abuse to the state surveying agency by administration. This failure affects one (R1) resident of four reviewed for charting and documentation of incidents. Findings include:R1 is [AGE] years of age. Current diagnoses include but are not limited to Dementia with Other Behavioral Disturbance (diagnosed 10/01/2022), Type 2 Diabetes Mellitus, Chronic Kidney Disease with Heart Failure, Major Depressive Disorder, Unspecified Psychosis, Neuromuscular Dysfunction of Bladder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Parkinson's Disease.R1's comprehensive assessment section C Cognitive Patterns dated 05/18/2026 documents a BIMS (Brief Interview for Mental Status) score of 11. R1 has moderate cognitive impairment.R1's Physician Order Report dated 06/09/2026 - 07/09/2026 states in part R1 is prescribed the following medications for Psychosis: Divalproex Delayed Release 250mg (milligrams) 1 tab oral three times a day and Haloperidol 5mg 1 tab oral once a day.R1's care plan dated 02/16/2026 states in part: R1 may display episodes of aggression, of hitting staff and peers which pose a risk to self and/or others and interferes with care provision and social interactions. Goal: R1's aggression triggers will be minimized through proactive staff intervention. Approach: 02/16/2026 Redirect to safe, calming activity when agitated. Discipline: All Disciplines, C.N.A, Nursing.Problem start date 02/16/2026 Psychosocial Well-Being: R1 may exhibit agitation vulnerabilities such as low esteem, confusion, and easily being misled/or misguided by others which may put him at risk for abuse due to his diagnosis of Dementia. On 11/19/25 a peer made allegations that the above resident was physically aggressive towards him. Goal: R1 will be free from any forms of abuse and neglect daily by next review. Approach start date 02/16/2026: 11/18/25 1:1 counseling on respecting others and privacy. Re-educated to call light for staff to use when staff assistance is needed. Allow R1 time to vent and positive feedback given. Added to 72hr well-being check. 1:1 behavior monitoring until calm. Room change completed 11/18/25 and 11/19/25. R1 will be redirected by staff as needed to ensure the safety of himself and others. Staff will intervene when R1 appears to need redirection or assistance with a task. Review of incident witness statements document in part: On 07/05/2026 during the 11PM - 7:30 AM shift between 5 AM - 6 AM, staff witnesses observed a physical altercation between R1 and V5 C.N.A Certified Nurse Assistant at the entrance to R1's room. On 07/08/2026 at 10:09 AM, R1 is alert and oriented to person. R1 is ambulatory with a rolling walker. R1 was inquired of being abused by V5 CNA. R1 said, I didn't obey her (CNA) and she threw me on the ground, my hip hurt. I peed on the floor and asked for a towel, and she got mad at me. I hit her because I had to, I didn't mean it. It was this week.On 07/08/2026 at 11:55 AM, V8 RN (Registered Nurse) was inquired of her progress note on 7/5/2026 regarding R1's behavior. V8 said, I got report from V9 LPN (Licensed Practical Nurse) and she said she heard some loud speaking down the hall; the CNAs were in front of R1's room. R1 was agitated. I didn't see any agitation from him.On 07/08/2026 at 1:18 PM, V10 PRSC was inquired of her 7/6/2026 observation note regarding R1. V10 said, I was told not to complete that note in the computer, that's why it's still open. I don't recall who told me not to complete it. I was told to do it because there was an incident with a resident and staff member R1 and a CNA, but I don't know her name. It happened on overnight shift. I came in at 9AM. I was told a resident was physically aggressive with a staff member. I attempted to speak with R1, but he talked around it. It was around 10 or 11 AM, he didn't appear to be in distress. I tried to speak with him after the incident, but he wouldn't tell me what happened. He has a behavior of praying loud in the shared bathroom and ignoring staff often. He doesn't follow directions from staff. I didn't speak with the staff, I never see third shift, they leave before I get here in the morning.On 07/08/2026 at 1:48 PM, V9 LPN Licensed Practical Nurse was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V9 said, I wasn't aware of what happened, I got there towards the end. I was at the nurse's station watching over the fall risk residents. I heard a noise from the hallway. Three CNAs were with them. Everything ended by the time I got there. Another nurse came in and interviewed R1. One of the residents was trying to get up so I ran back to the nurse's station. I wasn't R1's nurse that night. His nurse was on break.V11 RN is written as assigned to A wing on the 07/05/2026 schedule.On 07/08/2026 at 2:43 PM, V18 LPN was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V18 said, I went to lunch a little bit before 5AM. There was an incident with a resident and staff. I was told V2 Assistant Administrator was informed. I didn't speak to staff. I was done.On 07/09/2026 at 10:22 AM, V2 Assistant Administrator inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V2 said, It was reported staff said a resident attacked a CNA so she called to report it. It was R1 and V5 CNA. I saw V9 LPN and asked for statements. I called V1 Administrator. Staff said they heard hollering for help and when they got there V5 and R1 were on the floor. V9 LPN should have immediately assessed R1 and checked for safety. Separate CNA and write the statement. Document the incident and assessment. The on-coming shift shouldn't have documented on the incident, V9 should have done it. On 07/09/2026 at 11:55 AM, V1 was inquired of the incident report, R1 assessment, doctor and family notification documentation not being completed. V1 said, I looked for the progress note or incident report. I didn't find anything from the nurse that worked the shift.V8's time sheet reflects working 07/06/2026 7AM-3:30 PM shift. V9's time sheet reflects working 11PM-7:30 AM shift on 07/05/2026. V11's time sheet reflects working 11PM-7:30 AM shift on 07/05/2026.On 07/09/2026 at 2:52 PM, V20 LPN was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V20 said, I worked the night shift, I was on the other side. The CNAs were talking about the incident. I was told V11 RN was on break. V9 LPN was there when I got there. I went over there to check on R1. V9 was at the nurse's station. I asked R1 if he was OK, he said he hit the CNA because he had to. I looked at his hands, face, and body. I went back to my side. I didn't document anything. I was asked to write a statement. I wasn't his nurse; I was just concerned.On 07/13/2026 at 10:07 AM, V9 was the only nurse on left on the A/B wing. Further calls were made to speak with V11 with no answer or ability to leave a message.On 07/13/2026 at 10:36 AM, V2 Assistant Administrator was inquired of V11 RN not having a statement written. V2 said, I didn't see V11 when I came in that morning. I didn't call her because staff said she was on break and wasn't there when it happened. V9 LPN was there.On 07/13/2026 at 12:43 PM, V3 DON Director of Nursing was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V3 said, I was on vacation the day it happened. I returned on Monday and was made aware. The investigation was already assigned to other staff; I wasn't a part of it. When there's an incident the nurse should make sure everyone is safe, assess the resident, complete the observation form for the body and pain, notify the doctor and family, then notify administration immediately, and do a progress note. Document so you can see if something comes up, you may not be able to remember so document everything. It's to cover you as a nurse. If there's no documentation, I'd try to find out why it wasn't done. Technically if there's no documentation, it wasn't done. We train the nurses on incidents if anything happens after hours, they can contact me at any time. V4 ADON was available, and all nurses have her phone number. V4 and I are responsible to make sure all the documentation is in place. I didn't look into the documents for it (incident report) because staff said they did the investigation. I should have followed up and looked at everything.On 07/13/2026 at 3:28 PM, V1 Administrator was inquired of the incident investigation process and V5 CNA. V1 said, Overall myself and V2 (Assistant Administrator) are responsible for the investigation.On 07/15/2026 at 12:06 PM, V8 RN was inquired of the report she received on 07/05/2026 and her documentation. V8 said, V9 LPN gave me report that morning. She said R1 was having behaviors early that morning around 5AM. V4 ADON Assistant Director of Nursing told me to do 72 hour behavior charting; we do that to see if R1 had any changes. When I looked in his (R1's) notes, there wasn't anything documented from V9 about the incident, calling V25, the doctor or family.On 07/15/2026 at 3:30 PM, V20 LPN was inquired of assessing R1 after the incident and the lack of documentation. V20 said, He (R1) was sitting on the bed, he wasn't in distress. I didn't get vital signs. I didn't like stepping on anyone's toes. V9 LPN was at the desk. If a incident happens, I'd step in and act as the nurse. I'd check the resident, handle the emergency, do the assessment and vital signs and tell the nurse when she comes back.On 07/16/2026 at 11:06 AM, V4 ADON was inquired about further details of the Sunday 07/05/2026 incident between V5 CNA and R1. V4 ADON said, V11 RN Registered Nurse was his nurse that night. V9 LPN Licensed Practical Nurse was working on the side with her. I didn't see any note about the incident. V2 just said R1 was having behaviors. I didn't speak to V9 LPN on Sunday. The night shift nurse should have contacted me to call the doctor and petition R1 out. V20 LPN did his assessment but didn't document anything in his medical record. I saw she wrote she assessed him (R1) in her statement. She should have done a progress note at minimum, the assessment tab, and incident note.On 07/16/2026 at 12:11 PM, V2 Assistant Administrator was inquired about further details of the Sunday 07/05/2026 incident between V5 CNA and R1. V2 said, Once I got to the building I found out V11 RN had left. V9 LPN said V11 went on lunch. She (V11) wasn't seen when I got there. As a nurse, V9 LPN should have done what she was supposed to do per her managers. She (V9) should have known what her duties were. When V11 RN left, V9 was in charge of the unit.On 07/16/2026 at 1:09 PM, V24 Physician was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V24 said, This was my first time seeing him (R1). None of the nurses or ADON (Assistant Director of Nursing) said anything about him having behaviors. I always talk to staff before seeing the residents. I'd like to have known about the incident, was it physical or verbal aggression. They should have put in a incident report to know what happened.There is no nursing progress note documenting the altercation between R1 and V5 C.N.A on 07/05/2026. There is no internal incident report documenting the altercation between R1 and V5 C.N.A on 07/05/2026.V9 LPN was the nurse on duty while V11 RN was out of the facility on break when the altercation between R1 and V5 C.N.A took place. V9 did not complete an internal incident report documenting the altercation and did not document the incident in R1's medical record. V20 LPN's employee statement documents an assessment of R1 was completed but there is no documentation in R1's medical record. The Licensed Practical Nurse Job Description states in part: Purpose: the primary purpose of this position is to - Supervise the day-to-day C.N.A services for assigned unit to assure that care is being rendered in accordance with current federal, state, and local standards, guidelines and regulations. Duties/Responsibilities/Function: 4. Closely monitor and supervise all facility residents per facility policies and as warranted by good nursing judgment.6. Make written and oral reports/recommendation concerning the activities of your shift as required. 11. Ensure the appropriate documentation/charting is completed as required and in accordance with established policies and procedures. V9 LPN signed the LPN Job Description on 04/16/2026. V20 LPN signed the LPN Job Description on 10/09/2025.The undated Charting and Documentation Policy states in part:Policy Statemen: All services provided to the resident; or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.Policy Interpretation and Implementation2. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g. RN, LPN/LVN, QMA, physicians, therapists, etc.) in accordance with state law and facility policy. Certified Nurse Assistants may only make entries in the resident's medical chart as permitted by facility policy.3. All incidents, accidents, or changes in the resident's condition must be recorded.

Based on interviews and record reviews, the facility failed to follow their abuse and care plan (comprehensive) policy by failing to revise the care plan approach (interventions) after a physical altercation between R1 and V5 C.N.A (Certified Nurse Assistant) occurred. This failure affects one (R1) resident of four reviewed for care plan revision.Findings include:R1 is [AGE] years of age. Current diagnoses include but are not limited to Dementia with Other Behavioral Disturbance (diagnosed 10/01/2022), Type 2 Diabetes Mellitus, Chronic Kidney Disease with Heart Failure, Major Depressive Disorder, Unspecified Psychosis, Neuromuscular Dysfunction of Bladder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Parkinson's Disease.R1's comprehensive assessment section C Cognitive Patterns dated 05/18/2026 documents a BIMS (Brief Interview for Mental Status) score of 11. R1 has moderate cognitive impairment.Review of incident witness statements document in part: On 07/05/2026 during the 11PM - 7:30 AM between 5 AM - 6 AM, staff witnesses observed a physical altercation between R1 and V5 C.N.A Certified Nurse Assistant at the entrance to R1's room. On 07/15/2026 at 1:42 PM, V32 MDS LPN was inquired of R1's behavior care plan. V32 said, R1 has Dementia with behavior disturbance since 2022 from his face sheet. His care plan for aggressive behavior was reviewed 2/16/26, but it didn't just start. For their (residents) annual care plan review we update the start dates. His progress notes from 2/16 say he went out to the hospital for cellulitis, and we picked him up because he needed skilled care and therapy. It wasn't for behavior.On 07/16/2026 at 11:39 AM, V3 DON was inquired of updates to R1's care plan following the incident. V3 said, I wasn't a part of the conclusion, so I'd have to ask V1 Administrator. His (R1) care plan says to redirect to safe, calming activities when agitated. We automatically update the care plan on this situation. His care plan is reflective of his behavior. V5 CNA had Dementia training in orientation, but she hasn't had CPI (Crisis Prevention Intervention) training yet. What should be done was to back away, redirect, have someone else take over for that resident especially if the aggression is towards them because you don't want to aggravate the resident more or have any negative situation happen.On 07/09/2026 at 10:22 AM, V2 Assistant Administrator was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V2 said, It was reported that staff came and said a resident attacked a CNA, so she called to report it. I called V1 Administrator. It should have been reported to the state then because they were tussling with each other on the floor. V9 LPN should have immediately assessed R1 and checked for safety. Separated CNA and write the statement. Document the incident and assessment. The on-coming shift shouldn't have documented on the incident, V9 should have done it. A call to the doctor should have been made to ask if R1 should go out for assessment. Family should have been called. It should have been called to the state, and we should have started our investigation.On 07/27/2026 at 9:25 AM, V10 PSRC was inquired of R1's aggression care plan and interventions. V10 said, After an incident or behavior the care plan is supposed to be updated, I change the date. I'm not sure if we should be adding anything when we update it.On 07/27/2026 at 9:40 AM, V36 Clinical Director of Social Work was inquired of R1's aggression care plan and interventions. V36 said, We update the approaches and interventions. It should be done with each incident or behavior.R1's MDS Minimum Data Set (Comprehensive Assessment) Section E Behavior reviewed from January 2022 - May 2026 does not document any behavioral symptoms (physical, verbal, or self-directed) identified during assessments. R1's care plan dated 02/16/2026 states in part: R1 may display episodes of aggression, of hitting staff and peers which pose a risk to self and/or others and interferes with care provision and social interactions. Goal: R1's aggression triggers will be minimized through proactive staff intervention. Approach: 02/16/2026 Redirect to safe, calming activity when agitated. Discipline: All Disciplines, C.N.A, Nursing. R1's care plan was last reviewed/revised on 07/06/2026 by V35 PRSC Psychiatric Rehab Services Coordinator but the approach/interventions were not updated to reflect the recent 07/05/2026 physical altercation with staff.On 7/28/2026 at 12:16 PM, V36 Clinical Director of Social Work provided a copy of R1's updated care plan.R1's 07/23/2026 care plan approaches were updated as follows: 1:1 counseling. Allow R1 time to express his feelings and give positive feedback. Talk with a calm tone when speaking with R1. Validate R1's feelings and ensure his safety. It was updated thirteen days after the incident.The Abuse and Retaliation Policy Prevention Program dated 1-2026 states in part:Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, retaliation, misappropriation of property, and mistreatment of residents. In order to do so, the facility as attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment of residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; Identifying occurrences and patterns of potential mistreatment.IV. Establishing a Resident Sensitive EnvironmentThis facility desires to prevent abuse, neglect, exploitation, mistreatment, retaliation, deprivation of goods and services by staff, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers, and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches that would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches regularly and update as necessary.The updated October 2022 Care Plans (Comprehensive) policy states in part:Policy: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident.Policy Specifications:The facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or his/her representative, develops and maintains a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain.The Interdisciplinary Team documents in the CAAs (Care Area Assessment) summary and/or the clinical record: a. the resident's status in triggered CAA area. b. The team's rationale for deciding whether to proceed with care planning. c. Evidence that the team considered the development of care planning interventions for all CAAs triggered by the MDS.Each resident's Comprehensive Care Plan has been designed to:Incorporate identified problem areasIncorporate risk factors associated with identified problemsBuild on the residents' strengthsReflect treatment goals and objectives in measurable outcomesIdentify the professional services that are responsible for each element of careAid in preventing or reducing declines in the resident's functional status and/or functioning levelsEnhance the optimal functioning of the residents by focusing on a rehabilitative program, as neededBe respectful of a resident's health beliefs, practices and cultural and linguistic needsReflect the resident's needs and preferences and align with the resident's cultural identityRecognize the effects of past trauma on residents and collaborate with the resident, family and friends of the resident to identify and implement individualized interventions.Care plans are revised as changes in the resident's condition dictates.

Based on interviews and record reviews, the facility failed to follow their abuse and care plan (comprehensive) policy by failing to develop an individualized plan of care with measurable interventions to address a resident's episode of aggression and failed to implement the care plan interventions for aggression resulting in a physical altercation between V5 C.N.A (Certified Nurse Assistant) and R1. This failure affects one (R1) resident of four reviewed for care plan implementation. Findings include:R1 is [AGE] years of age. Current diagnoses include but are not limited to Dementia with Other Behavioral Disturbance (diagnosed 10/01/2022), Type 2 Diabetes Mellitus, Chronic Kidney Disease with Heart Failure, Major Depressive Disorder, Unspecified Psychosis, Neuromuscular Dysfunction of Bladder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Parkinson's Disease.R1's comprehensive assessment section C Cognitive Patterns dated 05/18/2026 documents a BIMS (Brief Interview for Mental Status) score of 11. R1 has moderate cognitive impairment.Review of incident witness statements document in part: On 07/05/2026 during the 11PM - 7:30 AM between 5 AM - 6 AM, staff witnesses observed a physical altercation between R1 and V5 C.N.A Certified Nurse Assistant at the entrance to R1's room. On 07/08/2026 at 10:09 AM, R1 is alert and oriented to person. R1 is ambulatory with a rolling walker. R1 was inquired of being abused by V5 CNA. R1 said, I didn't obey her (CNA) and she threw me on the ground, my hip hurt. I peed on the floor and asked for a towel, and she got mad at me. I hit her because I had to, I didn't mean it. It was this week.On 07/08/2026 at 1:57 PM, V12 CNA was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V12 said, I was in the hall, it started in the hallway. I heard V5 CNA giving R1 commands to put his clothes on then I heard them arguing back and forth about water being on the floor. Then I heard the altercation going on. I got to the room, and they were in each other's arms. My back was turned so I don't know who started it. V5 was tussling back and forth with R1. V5 said, I look 12, but I'm not 12! I called for assistance and got them apart. The nurse and another new CNA came, I don't know their names. R1 said he was OK. He wanted to get a towel. V5 came back in the room, and I told her to leave. She went to the security desk. It happened after 5 AM.On 07/09/2026 at 9:07 AM, V5 CNA was inquired of the Sunday 07/05/2026 incident with R1. V5 said, I was doing patient care, he (R1) became aggressive asking for pants. I called for assistance from any CNA to help redirect and de-escalate. He (R1) scratched my arm and wrist. The CNAs came and de-escalated it. He (R1) calmed down and apologized. I couldn't find a nurse on my side, so I went to the other side. I made V9 LPN aware and wrote a statement. V2 Assistant Administrator came up here. I was off the schedule one day for the investigation. V2 called me back the next day and told me he (R1) admitted to what happened so I could come back.On 07/09/2026 at 10:22 AM, V2 Assistant Administrator was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V2 said, It was reported that staff said a resident attacked a CNA, so she called to report it. It was R1 and V5 CNA. When I got here, I went to the wing to check on R1. I saw V9 LPN and asked for statements. I called V1 Administrator. I witnessed all the statements and read them. I let V1 know I was in the building and what was going on. I interviewed R1 and he was apologetic, he said he hit her because he had to and was sorry. He said he was alright and wasn't in pain. R4 is R1's roommate. R4 can talk with hand movements, but he didn't wanna talk. I talked to V5 C.N.A, V15 Anonymous, V12 C.N.A, V14 C.N.A, V9 LPN and V17 LPN about what happened. Staff said they heard hollering for help and when they got there V5 and R1 were on the floor. V15 Anonymous wrote in her statement R1 and V5 were on the floor. After they were separated, staff told security. V5 should have left the area when R1 became aggressive and got assistance. She shouldn't have still been in there. It should have been reported to the state then because they were tussling with each other on the floor. V9 LPN should have immediately assessed R1 and checked for safety. Separate CNA and write the statement. Document the incident and assessment. The on-coming shift shouldn't have documented on the incident, V9 should have done it. A call to the doctor should have been made to ask if R1 should go out for assessment. Family should have been called. It should have been called to the state, and we should have started our investigation.On 07/09/2026 at 2:01 PM, V21 Anonymous was inquired of the Sunday 07/05/2026 incident between R1 and V5 CNA. V21 said, R1 has never acted like this, it doesn't make sense. V17 LPN and I called my boss. V5 came up to the desk after it happened and said, Motherfucker's think I'm [AGE] years old. I'm not fucking playing this. I dragged his motherfucking ass. What happened to R1 isn't what's really being said. I went to the room to check on R1 after it happened. I took pictures of his shirt, it was ripped. R1 said, All I did was ask for a towel because I peed on the floor and the CNA got mad at me and threw me down. I told V5 CNA to write the statement, and she argued with me. I have my first statement written and they told me I couldn't write that. They told me to rewrite my statement.On 07/13/2026 at 3:19 PM, R1 was inquired of his shirt being ripped during the incident with V5 CNA and how he feels while V5 is in the building working. R1 said, She (V5) pulled me and ripped my shirt. She hasn't worked with me since then. I think she's gonna fight me again. I'm scared.On 07/15/2026 at 12:56 PM, R1 was inquired how the incident started with V5 C.N.A. and how he ended up on the floor. R1 said, She (V5) swung at me first, then I swung back at her. She didn't wanna give me the towel and she got mad. She swung at me because I pissed on the floor. That's what it was about. That's why she got mad. I got on the floor cause she threw me down.On 07/15/2026 at 1:42 PM, V32 MDS LPN was inquired of R1's behavior care plan. V32 said, R1 has Dementia with behavior disturbance since 2022 from his face sheet. His care plan for aggressive behavior was reviewed 2/16/26, but it didn't just start. For their (residents') annual care plan review we update the start dates. His progress notes from 2/16 say he went out to the hospital for cellulitis, and we picked him up because he needed skilled care and therapy. It wasn't for behavior.On 07/15/2026 at 3:08 PM, V5 CNA was inquired how the incident started with R1. V5 said, I was in his (R1) room helping with incontinent care. I was putting towels on the floor in the room. I thought it was water. He (R1) was in the bathroom. R1 told me it was pee (urine), he said he had an accident. I was redirecting him to put on his pants because he was going in the hall in his underwear and he wasn't listening. He was fidgeting. I don't remember who grabbed who first, but my arm was scratched. I said help. He became resistant and we began struggling. We lost our balance and fell. A couple of people came to help; I didn't know their names. I'm not scheduled to work on his side. I didn't get any training when I came back to work. I haven't' had CPI (Crisis Prevention Intervention) training yet.On 07/16/2026 at 11:39 AM, V3 DON was inquired of updates to R1's care plan following the incident. V3 said, I wasn't a part of the conclusion, so I'd have to ask V1 Administrator. His (R1) care plan says to redirect to safe, calming activities when agitated. We automatically update the care plan on this situation. His care plan is reflective of his behavior. V5 CNA had Dementia training in orientation, but she hasn't had CPI (Crisis Prevention Intervention) training yet. What should be done was to back away, redirect, have someone else take over for that resident especially if the aggression is towards them because you don't want to aggravate the resident more or have any negative situation happen.On 07/27/2026 at 9:25 AM, V10 PSRC was inquired of R1's aggression care plan initiation and interventions. V10 said, He went out to the hospital on [DATE] and he returned 06/25/2025 and he had a significant change, and his care plan was updated. V10 checked R1's progress notes and said, He went to the hospital for hyponatremia, vomiting, and hypochloremia. I'm not sure when this care plan was started, I can't find the date. There could've been more approaches or interventions added for him. When we do his quarterly review, we ask him questions about what he likes. He asks a lot of questions. He goes to activities often. He enjoys listening to music and going on nature walks. He goes to rehab and listens to music too. He also likes smoke breaks. I don't know what his triggers are.R1's MDS Minimum Data Set (Comprehensive Assessment) Section E Behavior reviewed from January 2022 - May 2026 does not document any behavioral symptoms (physical, verbal, or self-directed) identified during assessments. R1's care plan dated 02/16/2026 states in part: R1 may display episodes of aggression, of hitting staff and peers which pose a risk to self and/or others and interferes with care provision and social interactions. Goal: R1's aggression triggers will be minimized through proactive staff intervention. Approach: 02/16/2026 Redirect to safe, calming activity when agitated. Discipline: All Disciplines, C.N.A, Nursing. R1's care plan is not individualized and person centered with measurable interventions as it does not document any triggers to his aggression. The care plan does not identify R1's preferences of activities, hobbies or thoughts on his likes and dislikes to assist with identifying ways to calm R1.V5 CNA did not follow R1's care plan approach regarding his episodes of aggression. V5 continued to engage with R1 triggering an altercation. The updated October 2022 Care Plans (Comprehensive) policy states in part:Policy: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident.Policy Specifications:The facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or his/her representative, develops and maintains a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain.The Interdisciplinary Team documents in the CAAs (Care Area Assessment) summary and/or the clinical record: a. the resident's status in triggered CAA area. b. The team's rationale for deciding whether to proceed with care planning. c. Evidence that the team considered the development of care planning interventions for all CAAs triggered by the MDS.Each resident's Comprehensive Care Plan has been designed to:Incorporate identified problem areasIncorporate risk factors associated with identified problemsBuild on the residents' strengthsReflect treatment goals and objectives in measurable outcomesIdentify the professional services that are responsible for each element of careAid in preventing or reducing declines in the resident's functional status and/or functioning levelsEnhance the optimal functioning of the residents by focusing on a rehabilitative program, as neededBe respectful of a resident's health beliefs, practices and cultural and linguistic needsReflect the resident's needs and preferences and align with the resident's cultural identityRecognize the effects of past trauma on residents and collaborate with the resident, family and friends of the resident to identify and implement individualized interventions.Care plans are revised as changes in the resident's condition dictates.The Abuse and Retaliation Policy Prevention Program dated 1-2026 states in part:Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, retaliation, misappropriation of property, and mistreatment of residents. In order to do so, the facility as attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of neglect, exploitation, retaliation, misappropriation of property, deprivation of goods and services by staff, or mistreatment of residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; Identifying occurrences and patterns of potential mistreatment.IV. Establishing a Resident Sensitive EnvironmentThis facility desires to prevent abuse, neglect, exploitation, mistreatment, retaliation, deprivation of goods and services by staff, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers, and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches that would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches regularly and update as necessary.

Based on interview and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of minimum staffing requirements, failed to follow staffing requirements, failed to schedule adequate Nursing staff, failed to replace scheduled staff when call off/NCNS (No Call No Show) occurs, failed to monitor shower/skin sheets to ensure that required care/skin assessments were provided, failed to document/provide required showers/skin assessments, and failed to ensure that adequate staff were available to meet the needs of three of three dependent residents (R1, R2, R3) reviewed for ADL (Activities of Daily Living) care. These failures have the potential to affect 146 residents residing in the facility. Findings include:The (6/9/26) census includes 146 residents.The (3/2026-3/2027) facility assessment tool states the average daily census is 152 (minimum 144). The ADL Bathe Self section affirms that 0 residents are independent, 83 residents require setup or clean-up assistance, 16 residents require partial/moderate assistance, 26 residents require substantial/maximal assistance, and 28 residents are dependent. The staffing information for unit and shift affirms 9 CNAS and 4 Nurses are required for Nights Shift (therefore a total of 13 staff). The (5/24/26-5/30/26) 11pm-7am facility daily staffing forms were reviewed, and the following concerns were identified: On (5/24/26) four (4) Nurses and two (2) CNAS were documented (6 staff). On (5/25/26) four (4) Nurses and seven (7) CNAS were documented (11 staff). On (5/26/26) four (4) Nurses and five (5) CNAS were documented (9 staff). On (5/27/26) four (4) Nurses and six (6) CNAS were documented (10 staff). On (5/28/26) three (3) Nurses and four (4) CNAS were documented (7 staff). On (5/29/26) four (4) Nurses and five (5) CNAS were documented (9 staff). On (5/30/26) four (4) Nurses and six (6) CNAS were documented (10 staff). Lack of staff was noted daily - per facility assessment staffing requirements.R1's (5/22/26) functional assessment affirms resident requires partial/moderate assistance with showers. R1's (5/22/26) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). On 6/10/26 at 11:15am, surveyor inquired about facility concerns R1 stated Sometimes they (CNAS/Certified Nursing Assistants) say they ain't got enough staff at night, sometimes it's only 2 of them (CNAS) and they can't do all the things they need to do. Surveyor inquired if R1 recently showered R1 responded I (R1) took a shower yesterday and affirmed that staff assisted. On 6/9/26 at 11:29am, surveyor inquired about the current staffing on the C/D unit V8 (Registered Nurse) stated We got 3 CNAS today and 3 Nurses I (V8) think for 46 residents. Surveyor inquired if 3 CNAS assigned to the C/D unit was adequate considering the acuity of the residents V8 responded It will be chaotic sometimes but it's safe for example there will be 2 or 3 behaviors and our (staff) situation will be different but its quiet today. Surveyor inquired about the C/D unit CNA staffing - on night shift V8 replied Sometimes they got 4 but mostly it's 3. R1's (June 2026) bath and skin report sheet (reviewed 6/16/26) affirms refused was documented on 6/11 however no additional showers/skin assessments were documented. On 6/16/26 at 10:46am, surveyor inquired when R1's showers are scheduled V19 (CNA/Certified Nursing Assistant) reviewed the shower schedule and stated His (R1) shower is Thursday morning and Monday evening. Surveyor inquired about R1's showers received V19 reviewed R1's (June 2026) bath and skin report sheet and responded, It says he (R1) refused on 6/11 and affirmed that no additional entries were documented. Surveyor inquired about facility requirements for bath and skin assessments V19 replied You (staff) would put the date, your signature and the Nurse gotta verify the skin was done. On 6/16/26 at 11:13am, surveyor inquired about staff requirements for facility showers V2 (DON/Director of Nursing) stated We (facility) have the shower schedule, they (CNAS) follow the shower schedule. If residents refuse a shower, they (CNAS) let the Nurses know. The Nurses try to encourage them (residents) to take a shower. If they refuse a shower, we (staff) let Social Services know so they can put that in the care plan. The wound care nurse (V18) is supposed to be monitoring the sheets to make sure they are being filled out. On 6/17/26 at 1:10pm, surveyor inquired about staff requirements for bath and skin report sheets V18 (Wound Care Nurse) stated The CNAS are to fill them out after every shower whether the shower is refused or given. If the shower is refused, they (CNAS) let the Nurse know. The Nurse is supposed to encourage them (residents) to take a shower, and if it's still refused, they (Nurse) are to document the refusal. Surveyor inquired about concerns with R1's (June 2026) bath and skin report V18 reviewed the documentation and responded It's only one entry, that lets me (V18) know that they (staff) are not documenting the shower on the assigned shower days and the skin assessment as well. The Nurse is supposed to be documenting a skin assessment during every shower day, twice a week. R2's (4/6/26) functional assessment affirms the resident requires supervision or touching assistance for showers. On 6/9/26 at 3:56pm, surveyor inquired about facility concerns R5 (R2's roommate) stated He (R2) doesn't bathe. He smelled so bad I (R5) had to open both windows. R2's (June 2026) bath and skin report sheet (reviewed 6/16/26) affirms showers/skin assessments were provided/documented on 6/7, 6/13 and 6/16 however only one of three skin assessments were endorsed by the Nurse, and nothing was documented from 6/1-6/6 (6 days). On 6/16/26 at 10:55am, surveyor inquired when R2's showers are scheduled V20 (CNA) reviewed the shower schedule and stated, Tuesday morning and 2nd shift Friday and affirmed that R2's (Tuesday) 6/2/26 and (Friday) 6/5/26 showers/skin assessments were not documented. On 6/17/26 at 1:14pm, surveyor inquired about concerns with R2's (June 2026) bath and skin report sheet V18 (Wound Care Nurse) reviewed the documentation and replied I (V18) see a couple of Nurse signatures that are not there, and it started on the 7th. That tells us, the first week that they (CNAS) didn't document for the showers and affirmed that R2's skin assessments were also excluded from 6/1-6/6. R3's (4/9/26) functional assessment affirms the resident requires supervision or touching assistance with showers. R3's (4/9/26) BIMS determined a score of 14 (cognition intact). On 6/9/26 at 11:33am, surveyor attempted to interview R3 however R3 responded I (R3) don't want you in here (room) and dismissed surveyor. R3's (June 2026) bath and skin report sheet (reviewed 6/16/26) affirms a shower/skin assessment was documented on 6/2 however no additional showers/skin assessments were documented. On 6/16/26 at 10:59am, surveyor inquired when R3's showers are scheduled V20 (CNA) stated Tuesday 2nd shift and Friday morning. She (R3) showers almost every day. Surveyor inquired about R3's showers received V20 reviewed R3's (June 2026) bath and skin report and responded, This one says 6/2, nothing else. V20 inspected the bath and skin binder for additional documentation (for R3) to no avail. On 6/17/26 at 1:17pm, surveyor inquired about concerns with R3's (June 2026) bath and skin report sheet V18 (Wound Care Nurse) reviewed the documentation and responded, She (R3) only has one shower documented. The (5/24/26) 11pm-7am facility schedule affirms that 4 CNAS were scheduled (a minimum of 9 is required - per facility assessment). V17 (CNA) is marked NCNS and V14 is marked C/O (call-off) however no additional staff were added to the typewritten schedule - on this shift. On 6/16/26 at 11:05am, surveyor inquired why only 2 CNAS clocked in on 5/24/26 (11pm-7am) per time sheets received V2 (DON) stated It was one NCNS and one call off that day. Surveyor inquired what the facility implements when scheduled staff call off and/or don't show up V2 responded Usually I (V2) call around and try to get people (staff) to come in or come early. We (facility) also send out text messages to all the CNAS to try and get someone to pick it up or we'll ask the CNAS to stay late. Surveyor inquired if the facility uses Agency staff V2 replied No. Surveyor inquired about the facility (11pm-7am) CNA minimum staffing requirements V2 stated The lowest is like 4 to 7 CNAS however 9 are required - per facility assessment. Surveyor inquired about the current census, V2 responded Today the census is 146. The (5/28/26) 11pm-7am facility schedule affirms that 5 CNAS were scheduled. V14 (CNA) was marked NCNS (No Call No Show) however no additional staff were added to the typewritten schedule - on this shift. On 6/16/26 at 11:20am, surveyor inquired how many residents currently reside at the facility V13 (Scheduler) stated I (V13) believe like 147. Surveyor inquired about the facility (11pm-7am) CNA staffing requirements V13 responded Nighttime we (facility) have 4 to 6 however 9 are required - per facility assessment. Surveyor inquired if the facility is short of CNA staff on the 11pm-7am shift V13 replied No. Surveyor inquired if V14 (CNA) was a NCNS on 5/28/26 (11pm-7am) V13 stated Yes. Surveyor inquired how many CNAS clocked in on 5/28/26 (11pm-7am) per time sheets received V13 responded 4. Surveyor inquired if V14 was replaced by other staff V13 replied No. Surveyor inquired if facility Nurses and/or qualified staff from other departments work as CNAS when scheduled staff call off or don't show up V13 stated Not that I'm (V13) aware of, I'm (V13) not sure. The facility staffing policy was requested on 6/16/26, however, was not received during this survey. The department duty hours, nursing services policy (revised August 2008) states nursing service is provided twenty-four (24) hours per day, seven (7) days a week. There may be occasions when an employee is expected to remain on his/her assignment until appropriate relief is assigned. Departmental work schedules may be revised by the Director of Nursing Services when deemed necessary and appropriate to ensure that each resident's needs are met. The (January 2026) ADL policy states a program of assistance and instructions in ADL skills is care planned and implemented. Showers or baths are scheduled, and assistance is provided when required.The bath (shower) policy (revised 2/2024) includes Policy: To be completed for all residents at least twice weekly based on facility bathing schedule. Procedure: Minimally twice a week, residents will receive shower/bath and hair wash. Resident's skin will be checked. If resident refuses shower, CNA will notify Nurse and will provide interventions or education of the proposed care of treatment. Documentation in clinical record.

Based on interviews and record review the facility failed to follow policy procedures, failed to ensure that (R2's) skin assessments were endorsed by a Nurse, and failed to document and/or provide required showers/skin assessments for three of three dependent residents (R1, R2, R3) reviewed for ADL (Activities of Daily Living) care.Findings include:R1 is [AGE] years old with diagnoses which include COPD (Chronic Obstructive Pulmonary Disease). R1's (5/22/26) functional assessment affirms resident requires partial/moderate assistance with showers. R1's (5/23/26) care plan states the resident is limited in ability to groom self, related to decreased mobility and endurance, interventions: provide set up with supplies as needed. Provide assistance with grooming. R1's (5/22/26) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). On 6/10/26 at 11:15am, surveyor inquired about facility concerns R1 stated Sometimes they (CNAS/Certified Nursing Assistants) say they ain't got enough staff at night, sometimes it's only 2 of them (CNAS) and they can't do all the things they need to do. Surveyor inquired if R1 recently showered R1 responded I (R1) took a shower yesterday and affirmed that staff assisted. R1's (June 2026) bath and skin report sheet (reviewed 6/16/26) affirms refused was documented on 6/11 however no additional showers/skin assessments were documented. On 6/16/26 at 10:46am, surveyor inquired when R1's showers are scheduled, V19 (CNA/Certified Nursing Assistant) reviewed the shower schedule and stated His (R1) shower is Thursday morning and Monday evening. Surveyor inquired about R1's showers received V19 reviewed R1's (June 2026) bath and skin report sheet and responded, It says he (R1) refused on 6/11 and affirmed that no additional entries were documented. Surveyor inquired about facility requirements for bath and skin assessments V19 replied You (staff) would put the date, your signature and the Nurse has to verify the skin was done. On 6/16/26 at 11:13am, surveyor inquired about facility showers V2 (Director of Nursing) stated We (facility) have the shower schedule, they (CNAS) follow the shower schedule. If residents refuse a shower, they (CNAS) let the Nurses know. The Nurses try to encourage them (residents) to take a shower. If they refuse a shower we (staff) let Social Services know so they can put that in the care plan. The wound care nurse (V18) is supposed to be monitoring the sheets to make sure they are being filled out. On 6/17/26 at 1:10pm, surveyor inquired about staff requirements for bath and skin report sheets V18 (Wound Care Nurse) stated The CNAS are to fill them out after every shower whether the shower is refused or given. If the shower is refused, they (CNAS) let the Nurse know. The Nurse is supposed to encourage them (residents) to take a shower, and if it's still refused, they (Nurse) are to document the refusal. Surveyor inquired about concerns with R1's (June 2026) bath and skin report V18 reviewed the documentation and responded It's only one entry, that lets me (V18) know that they (staff) are not documenting the shower on the assigned shower days and the skin assessment as well. The nurse is supposed to be documenting a skin assessment during every shower day, twice a week. R2 is [AGE] years old with diagnoses which include bipolar disorder and major depressive disorder.R2's (4/6/26) functional assessment affirms the resident requires supervision or touching assistance for showers.On 6/9/26 at 3:56pm, surveyor inquired about facility concerns R5 (R2's roommate) stated He (R2) doesn't bathe. He smelled so bad I (R5) had to open both windows. Somebody got him (R2) and made him take a shower.R2's (June 2026) bath and skin report sheet (reviewed 6/16/26) affirms showers/skin assessments were documented on 6/7, 6/13 and 6/16 and refused was documented on 6/10 however only one of three skin assessments were endorsed by the Nurse. On 6/16/26 at 10:55am, surveyor inquired when R2's showers are scheduled V20 (CNA) reviewed the shower schedule and stated, Tuesday morning and 2nd shift Friday. Surveyor inquired about R2's showers received V20 (CNA) reviewed R2's (June 2026) bath and skin report and responded He (R2) had one today. He (R2) refused 6/10 and affirmed that on 6/7 and 6/13 showers were also documented however from 6/1-6/6 (6 days) nothing was documented. On 6/17/26 at 1:14pm, surveyor inquired about concerns with R2's (June 2026) bath and skin report sheet V18 reviewed the documentation and replied I (V18) see a couple of Nurse signatures that are not there, and it started on the 7th. That tells us, the first week that they (CNAS) didn't document for the showers and affirmed that skin assessments documented by a Nurse were also excluded from 6/1-6/6. R3 is [AGE] years old with diagnoses which include unspecified psychosis and anxiety disorder. R3's (4/9/26) functional assessment affirms the resident requires supervision or touching assistance with showers. R3's (7/27/24) care plan states resident may require staff assistance for completion of ADLS related to chronic obstructive pulmonary disease exacerbation, intervention: staff to provide required level of assistance with care. R3's (4/9/26) BIMS determined a score of 14 (cognition intact). On 6/9/26 at 11:33am, surveyor attempted to interview R3 however R3 responded I don't want you in here (room) and dismissed surveyor. R3's (June 2026) bath and skin report sheet (reviewed 6/16/26) affirms a shower/skin assessment was documented on 6/2 however no additional showers/skin assessments were documented. On 6/16/26 at 10:59am, surveyor inquired when R3's showers are scheduled V20 (CNA) stated Tuesday 2nd shift and Friday morning. She (R3) showers almost every day. Surveyor inquired about R3's showers received V20 reviewed R3's (June 2026) bath and skin report and responded, This one says 6/2 nothing else. V20 inspected the bath and skin binder for additional documentation (for R3) to no avail. On 6/17/26 at 1:17pm, surveyor inquired about concerns with R3's (June 2026) bath and skin report sheet V18 reviewed the documentation and responded, She (R3) only has one shower documented. The (January 2026) ADL policy states a program of assistance and instructions in ADL skills is care planned and implemented. Showers or baths are scheduled, and assistance is provided when required.The bath (shower) policy (revised 2/2024) includes Policy: To be completed for all residents at least twice weekly based on facility bathing schedule. Procedure: Minimally twice a week, residents will receive shower/bath and hair wash. Resident's skin will be checked. If resident refuses shower, CNA will notify Nurse and will provide interventions or education of the proposed care of treatment. Documentation in clinical record.

Based on observations, interviews, and record reviews, the facility failed to follow its enhanced barrier precautions policy and don appropriate PPE (personal protective equipment) prior to entering resident rooms with enhanced barrier precautions and providing wound care treatments. This failure affected three residents (R4, R5, and R6) out of three reviewed for infection control in a sample of 6.Findings include:On 5/1/26 at 10:00 AM, this surveyor observed V10 (wound care nurse) perform wound treatments for R4. The signage on R4's door notes EBP (enhanced barrier precautions) and there is an isolation cart next to R4's door with PPE (personal protective equipment). V10 nor V7 CNA (certified nurse aide) donned PPE prior to entering R4's room to perform wound care treatment for R4.R4's care plan, initiated 10/2/25, notes R4 requires enhanced barrier precautions due to open wound.On 5/1/26 at 12:07 PM, the surveyor observed V10 perform wound treatment for R5. The signage on R5's door notes EBP and there is an isolation cart next to R5's door with PPE. V10 nor V12 NP (wound care nurse practitioner) donned PPE prior to entering R5's room to perform wound care treatment.R5's care plan, initiated 6/17/25, notes R5 requires enhanced barrier precautions due to open wound.On 5/1/26 at 12:44 PM, the surveyor observed V10 perform wound treatment for R6. The signage on R6's door notes EBP and there is an isolation cart next to R4's door with PPE. V10 nor V12 NP (wound care nurse practitioner) donned PPE prior to entering R6's room to perform wound care treatment.R6's care plan, initiated 3/3/26, notes R6 requires enhanced barrier precautions due to open wound.On 5/1/26 at 2:35 PM, when questioned what enhanced barrier precautions on a resident's door refers to, V10 responded that it refers to hand hygiene. When questioned if PPE needed to be worn when performing wound care, V10 responded that she would need to check into that.The facility's enhanced barrier precautions policy, dated 3/21/24, notes enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents at increased risk of MDRO (multi-drug resistant organisms) acquisition (e.g., residents with wounds). Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gown and gloves. High contact resident care activities include in part: wound care: any skin opening requiring a dressing.

Based on interview and record review, the facility failed to follow their policy in notifying resident representative of a cognitively impaired resident of changing the resident's room for one (R4) of three residents reviewed for resident rights in a sample of five.Findings include:R4 is an [AGE] year-old-male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 diabetes mellitus; Hypertensive heart disease without heart failure; Unspecified convulsions; Hyperlipidemia; Nutritional anemia; Bipolar disorder; Anxiety disorder; Delusional disorders; Insomnia; and Chronic obstructive pulmonary disease.According to R4's MDS (Minimum Data Set) assessment dated [DATE] under section C, R4 has BIMS (Brief Interview of Mental Status) score of 11 indicating moderately impaired cognition. According to R4's face sheet, R1 is deemed not responsible for self and has assigned emergency contact/responsible party. According to facility census, R4's room was documented on 09/15/2025 at 9:13 AM. On 09/30/2025 at 12:45 PM V5 (Restorative Director) said, couple of weeks ago, I spoke to V2 (Assistant Administrator) and mentioned that R4 should be moved to another room. I didn't initiate the change of R4's room though.On 09/30/2025 at 1:15 PM V1 (Administrator/Abuse Prevention Coordinator) said, in case of a resident room change, either Director of Nursing or Social Service Director notifies residents' emergency contact of the change. On 09/30/2025 at 2:03 PM V10 (Social Service Staff) said, I worked on 09/15/2025 but I'm not aware of R4's change of room. If a resident has an emergency contact, we call the emergency contact and notify them of change of room. It is documented then in the resident's electronic health record.On 09/30/2025 at 2:22 PM V2 (Assistant Administrator) said, I changed R4's room in the system on 09/15/2025 at 9:13 AM as I was notified by V5 (Restorative Director) that R4 wanted to change the room. I was assisting with change of room. I spoke to R4, she indicated she wanted to be in a different room, I took her then to the new room, R4 liked it, and she stayed there. Normally, nurses or social service staff would notify the resident's emergency contact about the room change. I didn't notify R4's family that day.The facility Room Changes policy dated November 2026 reads in part, Policy: To make room changes when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. Policy specifications: 3. Prior to the room change, the resident, his or her roommate (if any), and the resident's representative will be provided with information concerning the decision to make the room change.

Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that 2 of 5 medication carts were locked while unattended while being reviewed for medication storage per policy and procedure. Findings include:The (7/28/25) facility census includes 158 residents.On 7/29/25 at 9:23am, V25 (Registered Nurse) left the (Unit B) medication cart (unlocked and unattended) while administering medications to R41 in the room (behind a curtain). When V25 returned to the medication cart surveyor inquired if it was locked V25 stated No. Surveyor inquired why the medication cart was left unlocked and unattended V25 responded I could see it from the door however V25 stood behind R41's curtain during medication administration and the medication cart was in the hallway. The (10/25/14) medication administration policy states during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. On 7/29/25 at 12:28pm, the (Unit C) medication cart was unlocked and unattended. Surveyor inquired if the (Unit C) medication cart (assigned to V11/Licensed Practical Nurse) was locked V33 (Certified Nursing Assistant) inspected the medication cart and responded, Oh my God. Surveyor inquired again if the (Unit C) medication cart was locked V33 proceeded to lock the cart and replied, It wasn't. On 7/29/25 at 12:32pm, (4 minutes later) surveyor inquired why V11's cart was left unlocked and unattended V11 stated That was an error that I made. The (10/25/14) storage of medications policy states medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer mediations.

Based on observation, interview and record review, the facility failed to ensure that dietary staff are properly certified for food handling. This failure has the potential to affect all 153 residents who receive food by mouth from the kitchen. Findings include:On 7/28/2025 at 9:35AM, during an initial tour of the kitchen, there were two staff members, V18 (Cook) and V17 (Cook/Dietary aide). Surveyor asked about the dietary manager and V18 said that she is not here today, she must have called off, it's only the two staff for the shift. 07/28/2025 11:25AM, during a second observation of the kitchen, V14 (Dietary Manager) was in the kitchen, stated that she just came in. There were two other staff members in the kitchen V19 and V20 (Dietary aides). V14 was asked why there was only two staff at the beginning of the shift, and she said that there was a call off and she called these two staff to come in. V14 added that she normally schedules 3 aides and one cook including herself on each shift.07/29/2025 9:05AM, during an observation in the kitchen, noted V18 (Dietary aide/cook) preparing garlic mashed potatoes, stated that she is helping the cook. V14 (Dietary manger said that she has 3 aides and 1 cook on schedule today, surveyor inquired about cook certification for V18 and V14 stated that V19 is cooking under her license. Surveyor requested the food handling certificates for all the dietary staff, V14 presented a list of 9 staff members including herself. V14 also presented an active food manager license for herself and 3 food handling certificates for three dietary aides. The cook and the dietary aide/cook who were the only staff in the kitchen when the survey team entered do not have food handling certificates. Out of the 9 dietary staff only 3 have a current food handling certificate. On 728/2025 V14 (dietary manager) presented some food handling certificates for the dietary staff. Two of the certificates for V21 and V22 (Dietary staff) does not have an expiration date, V14 later presented a new certificate for the two staff dated 7/28/2025, surveyor pointed out to V14 that there are still about 4 staff members with no certificate, including the two staff in the kitchen upon entrance. 7/29/2025 at3:00PM V14 brought 3 additional food handling certificates dated 7/29/2025 for V17 (Cook), V18 (Cook/dietary aide) and V42 (dietary aide). 7/30/2025 at 9:00AM, V14 brought one more dated 7/30/2025 for V20 (dietary aide).V14 was asked why the dietary staff does not have food handling certificates and she said that she does not know.Job description for the position of a cook and dietary aides (undated) states in part: the primary purpose of this position is to ensure that safe food handling procedures are being consistently maintained, maintain all federal, state, and local nutritional/dietary regulations.Under qualifications and essential requirements, the description states that the cook must possess a sanitation certificate.

Based on observation, interview and record review, the facility failed to prepare and handle food in a manner that prevents food borne illness by failing to ensure that garbage is properly disposed, failed to date opened cooking seasonings, failed to remove a scoop from a flour bin, failed to allow cooking equipment air dry before use, failed to ensure that the ice machine was kept clean and failed follow proper hand hygiene protocol during food preparation. These failures have the potential to cause food borne illness to 153 residents at the facility that receives oral diet from the kitchenFacilityFindings include:On 7/28/2025 at 9:35AM, during an initial tour of the kitchen, there were two staff members, V18 (Cook) and V17 (Cook/Dietary aide). Surveyor noted three bags of garbage that are full and in the middle of the floor close to where the V17 (Cook) was preparing some food. Surveyor noted one large container of paprika seasoning, onion powder, garlic powder and Italian seasoning on the shelf that were open with no open dates. Surveyor also observed one container of flour in the kitchen with lid but have a scoop left inside. This observation was presented to V17 and V18 (Dietary aide/cook). V17 said that she does not know who left the scoop inside, probably the previous shift, and V18 came and removed the scoop from the bin. The ice machine in the employee break room was noted with lots of dirt on top, and debris all over the machine.07/28/2025 11:25AM, during a second observation of the kitchen, V17 (Cook) was observed preparing pureed diet for residents. V17 finished with the sweet peas, washed the food processor, and did not let it air dry. V17 proceeded to use the same blender with water dripping from it to prepare the pureed meat. When presented with this observation, V17 said that she was supposed to let it dry but because the surveyor wanted to see the next pureed food that's why she did not let it dry.V14 (Dietary Manager) who is now present said to 18, Even if the president is standing here, you are supposed to let the food processor air dry before using it. Surveyor also presented the ice machine to V14 (Dietary manager), and she said that the housekeepers are supposed to clean the ice machine, she will let them know.The surveyor also observed V19 (Dietary aide) who was preparing sandwiches for residents. V19 touches the surfaces with her gloved hands and continues to grab the slices of bread and eat with same gloves without changing her gloves. V14 (Dietary manager) whispered something to V19 who proceeded to remove her gloves ad donned another pair of gloves without performing any type of hand hygiene, then continues to prepare the sandwiches. V19 switched her gloved three more times while preparing the sandwiches but did not wash her hands or use any hand sanitizer in between glove changes.07/29/2025 9:05AM, during an observation in the kitchen, noted V18 (Dietary aide/cook) preparing garlic mashed potatoes, stated that she is helping the cook. V14 (Dietary manger said that she has 3 aides and 1 cook on schedule today, surveyor inquired about cook certification for V18 and V14 stated that V19 is cooking under her license.07/29/2025 9:20AM, surveyor observed two staff V21 and V22 (Dietary aides) preparing desert, V21 was observed wiping the table with his gloved hand and used the same hand to divide and grab the pieces of cakes before putting them in a plastic bag. Surveyor asked V14 (Dietary manager) if they make use of spatula in the kitchen and she said yes, went and brought a spatula and handed it to V21. V21 used the spatula to divide the cakes and continued to grab them with the same gloved ands without changing his gloves or performing any type of hand hygiene.Hand washing/hand hygiene policy dated March 2024 states in part: it is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids.Under policy specifications #4 states: when hands are not visible soiled, employees may use an alcohol-based hand rub containing at least 60% alcohol in all the following situations:C. before donning gloves. H. before and after putting on and upon removal of PPE including gloves.6. The use of gloves does not replace compliance with hand washing/hand hygiene procedures.

Based on interview and record review, the facility failed to follow their water management policy by 1. Failed to implement the facility's water management program by failing to educate team members on the principles of an effective water management program, 2. failed to maintain documentation that describes the facility's water system, 3. failed to annually conduct a risk assessment and identify control points to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the water system, 4. failed to ensure control measures were applied to address potential hazards at each control point, 5. failed to evaluate the effectiveness of the water management program annually using infection control surveillance data, water quality data, and rounding data, 6. failed to report relevant information to the QAPI (Quality Assurance and Performance Improvement) committee, and 7. failed to document all activities related to the water management program and maintain the documentation for a minimum of three years. This failure affects all 158 residents residing in the facility.Findings include:On 07/30/2025 at 12:40 PM, V7 Maintenance Director was inquired of completing the water testing per the facility policy. V7 said, We don't test no water here. The city has come and checked the water before. The previous administrator has handled all the paperwork since I've been here three years. On 07/30/2025 at 2:30 PM, V36 Assistant Administrator was inquired of completing the water testing per the facility policy. V36 said, We don't have any documents for water testing.V7 provided a blank environmental assessment of water systems to this surveyor for review. V7 and V36 were unable to provide any documentation on implementation of the risk assessment.The 03/2023 Water Management Policy states in part: Policy: It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens (e.g., ASHRAE, CDC, EPA). Policy Explanation and Compliance Guidelines:1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing.a. Team members have been educated on the principles of an effective water management program, including how Legionella and other water-borne pathogens grow and spread. Education is consistent with each team member's role.b. The water management team has access to water treatment professionals, environmental health specialists, and state/local health officials.2. The maintenance director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder.3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic water-borne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements:a. Premise plumbing: This includes water system components as described in the documentation of the facility's water system.b. Clinical equipment: This includes medical devices and other equipment utilized in the facility that can spread Legionella through aerosols or aspiration.c. At-risk population: This facility's entire population is at risk. High risk areas shall be identified through the risk assessment process. Supporting documentation of any areas or resident population that exhibit greater risk than the general population shall be kept in the water management program binder.4. Data to be used for completing the risk assessment may include, but are not limited to:a. Water system schematic/descriptionb. Legionella environmental assessmentc. Resident infection control surveillance data (i.e. culture results)d. Environmental culture resultse. Rounding observation dataf. Water temperature logsg. Water quality reports from drinking water provider (i.e. municipality, water company)h. Community infection control surveillance data (i.e. health department data)5. Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder.6. Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical control points temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management program action plan.7. Testing protocols and control limits will be established for each control measure.a. Individuals responsible for testing or visual inspections will document findings.b. When control limits are not maintained, corrective actions will be taken and documented accordingly.c. Protocols and corrective actions will reflect current industry guidelines (i.e., ASHRAE, OSHA, CDC, EPA).8. The water management team shall regularly verify that the water management program is being implemented as designed. 9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate effectiveness.12. The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program, and as needed such as when any of the follow events occur: a. Data review shows control measures are persistently outside of control limits, b. A major maintenance or water service change occurs (including replacing tanks, pumps, heat exchangers, distribution piping, or water service disruption from the supplier to the building), c. One or more cases of disease are thought to be associated with the facility's systems, or d. Changes occur in applicable laws, regulations, standards, or guidelines.14. Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of three years.15. The water management team shall report relevant information to the QAPI committee.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that that prescribed medications were administered within regulatory requirements and failed to document medication administration timely for 14 of 68 residents (R3, R5, R7, R14, R23, R46, R51, R66, R76, R109, R114, R127, R140, R150) in the sample. Findings include:The (7/28/25) facility census includes 158 residents.On 7/29/25 at 8:52 am, V11's (LPN/Licensed Practical Nurse) stated that she's a new graduate (1 month ago) and assigned to 44 residents. Surveyor advised that the residents' 9am medication administration would be observed at this time V11 responded I (V11) have 4 residents left and affirmed she (V11) passed 9am medications to 40 of the assigned residents - since 8am (within 52 minutes). V11 dispensed R75's 9am medications and scheduled Amlodipine was not initially found V11 stated It's not on the cart I have to go get it from over there (referring to the facility emergency box) then continued to search the medication cart and located the medication. V11 subsequently attempted to obtain R75's blood pressure however resident requested to get dressed and go to the bathroom first. R75's blood pressure was then taken - prior to administration. A total of 22 minutes transpired during R75's medication administration observation. Considering reasonable person concept, assigned workload, and R75's medication administration observation V11 likely administered 9am medications (prior to 8am) therefore not within regulatory requirements. On 7/29/25 at 9:11am, V25 (RN/Registered Nurse) was assigned to 26 residents. Surveyor inquired about the 9am medication administration V25 stated I only have 1 left, 1 more person to give meds to. Surveyor inquired when V25 started medication administration V25 responded We (staff) start it when I (V25) came in, I got here at 7am so about 7:30 it was. Surveyor inquired about the regulatory requirements for 9am medication administration V25 replied You have to start between 8am and 10:00 for the morning shift. Surveyor inquired why seven (7) residents (R7, R14, R51, R109, R114, R127, R140) assigned to V25 were highlighted red and marked late on the EMAR (Electronic Medical Administration Record] V25 replied It needs to be completed, I (V25) just need to click it out and affirmed the highlighted residents received prescribed medications however they were not documented immediately after administration. On 7/29/25 at 9:28am, V26 (LPN) was assigned to 31 residents. Surveyor inquired about the 9am medication administration V26 affirmed that all but one (1) assigned resident (R112) who was currently receiving therapy received their medications. Surveyor inquired why five (5) additional residents (R5, R23, R46, R66, R76) assigned to V26 were highlighted green and marked due on the EMAR V26 stated I (V26) just gotta sign all of the stuff, the meds and stuff. Surveyor inquired about the regulatory requirement for medication administration V26 responded Chart it as you give. On 7/29/25 at 9:36am, V27 (RN) stated that the 9am medications were passed to all her (V27's) assigned residents. Surveyor inquired why R3 and R150 were highlighted green and marked due on the EMAR V27 responded These residents are assigned to the other Nurse and affirmed they were assigned to V26 (on the split assignment). The (10/25/14) medication administration policy states when medications are administered from a central location, such as the medication room, medications for the immediate administration time may be prepared no more than 60 minutes in advance for all residents, or per applicable state law or regulation. The individual who administers the medication dose records the administration on the resident's MAR record directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.

Based upon observation, interview, and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for 20 of 68 dependent residents (R2, R3, R5, R7, R8, R14, R23, R36, R46, R51, R66, R76, R109, R114, R127, R139, R140, R141, R150, R161) in the sample and failed to ensure a licensed nurse had the required training/coursework to manage the facility restorative program. These failures have the potential to affect 158 residents. Findings include: Review of facility assignment sheet for 7/20/2025 on third shift documents that V39 (Certified Nursing Assistant) was assigned to A/B unit and V40 (Certified Nursing Assistant) was assigned to the C/D unit. The sheet also documents that V39 and V40 were responsible for the following activities “Answer all call lights, ADLs, POC (point of care)”. On 7/29/2025 at 12:35 AM, V2 (Director of Nursing) affirmed that on 7/20/2025 only 2 certified nursing assistants were assigned to care for the residents in the facility. V2 explained that V2 was not notified of the staffing issues until the morning, when V3 (Infection Preventionist) arrived to the facility at around 4:00 AM. V2 affirmed that no other staff were called or arrived to assist the staffing shortage. V2 affirmed that the usually staffing for the unit for 3rd shift was around 5-6 CNAs. On 7/30/2025 at 10:14 AM, V34 (MDS Nurse, Licensed Practical Nurse) stated that V34 was working on 3rd shift on 7/20/2025. V34 stated that there were only 2 CNAs scheduled for the facility during that shift. V34 stated that management was notified but no other certified nursing assistants arrived prior to the end of the shift. V34 stated that the unit that V34 was assigned to was “mainly residents that were ambulatory and didn’t need as much assistance with ADLs so with the nurses performing the work of the aides, we were able to get by”. V34 was unsure if only having 2 certified nursing assistants was a safe ratio for the facility’s care needs. V34 affirmed that the aides had to care for around 75 residents per aide. On 7/30/2025 at 12:34 PM, V39 (Certified Nursing Assistant) affirmed that V39 worked on 7/20/2025 and was the only certified nursing assistant working on the C/D unit for 3rd shift. V39 explained that there was usually 3-4 nursing assistants working on the C/D unit at night. When asked if the residents needs were able to be met, V39 replied, “It wasn’t an ideal situation”. V39 stated that V39 reported that there was only 1 nursing assistant to the staff nurses who told the management of the facility. V39 affirmed that V39 did not go to the A/B unit. On 7/30/2025 at 1:03 PM, V40 (Certified Nursing Assistant) affirmed that V40 was the only certified nursing assistant assigned to the A/B unit on 7/20/2025 on 3rd shift. V40 explained that the majority of the residents on the A/B unit are in need of assistance with activities of daily living and are incontinent. V40 recalled the night and explained that the assignment was “not doable, but I had to make it doable. All I could do was try to check and change them as best I could. No one was called in to help, it was just me. Management was aware. I couldn’t go to the C/D unit to help, we couldn’t afford to leave and help each other”. V40 affirmed that the staffing ratio for that night was unsafe and inappropriate. On 7/31/2025 at 11:43 AM, V1 (Administrator) affirmed that the facility’s census on 7/20/2025 was 153 residents. This affirms that the ratio of certified nursing assistants to residents is 1:76.5. Facility provided list of incontinent residents documents in part that 57 residents in the facility are incontinent and 54 residents require assistance with activities of daily living. Facility assessment (4/4/2025) identifies that approximately 9 certified nursing assistants are needed on to meet the facility’s resident needs on night shift. Findings include: The (7/28/25) facility census includes 158 residents. On 7/28/25 at 9:44am, gnats were observed flying in R127’s room. Surveyor inquired about facility concerns R127 stated “There’s gnats all over the place. The bathroom is a s**t show with gnats in there. The showers are filthy and smell bad. The food here sucks, the food in prison is better than this place.” R127’s CPAP (Continuous Positive Airway Pressure) mask was uncontained. Surveyor inquired if staff keep the CPAP mask in a bag (to prevent infection) when not in use R127 stated “No.” On 7/28/25 at 9:56am, surveyor inquired about the gnats observed flying in the (Unit B) hallway V9 (Housekeeping) stated “I ain’t been here in a couple days so I don’t know about that.” Surveyor inquired what was hanging on the walls in R139’s room V9 responded “That’s a fly thing, I see gnats on there.” Surveyor inquired why so many gnats were flying around in R139’s room V9 replied “I see what you’re talking about. He (R139) always has food in his drawer or food in his room and I don’t know why.” V9 inspected R139’s room and dresser drawers (as requested) however there was no food present. A urinal was noted on R139’s dresser - with a tan crusty substance inside the container. Surveyor inquired about concerns with R139’s urinal V9 stated “They’re (staff) supposed to be pouring the urine out they’re (gnats) attracted to that pee. They (staff) need to get a new jug (urinal) and pour that stuff out.” On 7/28/25 at 10:01am, a pullup was observed on R140's bedroom floor and a thick clump of dirt was lying next to it. The pullup appeared to be stepped on (smeared dirt was noted on the outside). Trash was covering R140’s dresser and was also noted on the floor. Surveyor inquired what was on R140’s floor V10 (CNA/Certified Nursing Assistant) subsequently entered the room and responded, “There’s a brief right here, and a piece of paper” then picked up several items from the floor and stated “This looks like dirt ma am, he (R140) doesn’t let anybody come into his room” however nobody was in the room prior to observation. Surveyor inquired about the trash on R140’s dresser V10 replied “I see a lot of cups and pieces of paper.” Surveyor inquired about staffing concerns V10 stated “I (V10) usually work on the C/D side, they (facility) put me on B hall today because were short due to call ins I’m guessing. [The 7/28/25 schedule affirms V15 (CNA) scheduled for dayshift (7am-3:30pm) called off]. On 7/28/25 at 10:10am, R161 affirmed “I (R161) arrived Saturday (7/26/25), I need Physical Therapy. I had this leg (right leg) amputated so I need to be fitted for the prosthesis.” R161 was lying in bed however assistive devices to turn/reposition in bed were not in place. Surveyor inquired about facility concerns R61 stated “The biggest concern is that I (R161) don’t have side rails, this table is the only thing preventing me from falling from the bed. A rail would make a big difference because that’s the only way I can move.” A floor mat was adjacent R161’s bed (near the window) however the other floor mat present was leaning against the footboard. R161’s bed was not in low position and the floor was notably wet (under the bedside table). R161’s CPAP mask was lying on the bed and uncontained. On 7/28/25 at 10:19am, surveyor inquired about R161’s fall prevention interventions V11 (LPN/Licensed Practical Nurse) stated “Lower bed, the mat on the floor and the call light within reach.” Surveyor inquired about concerns with R161’s floor mats V11 responded “He (R161) doesn’t have a mat on this side because the tray is there” (referring to the bedside table). Surveyor inquired what was spilled on R161’s floor V11 responded “It’s wet but I can’t tell you what it is.” Surveyor inquired if R161’s bed was in the lowest position V11 replied “No, it’s not” and proceeded to lower the bed. Surveyor relayed concerns with R161’s bed (without side rails) V11 stated “That would be something I (V11) would have to communicate with someone, I would need to go to the DON (Director of Nursing) and I would ask her (DON).” Surveyor inquired if R161’s CPAP mask was dated and/or contained in a bag V11 inspected the mask and stated, “It’s not in a bag and there’s no date on there.” On 7/28/25 at 10:31am, R2 was up in a wheelchair however the back of R2’s shoes were folded downward, and both heels were on top of the shoes. Surveyor inquired if R2 can walk V11 (LPN) stated, “With assistance.” Surveyor inquired about concerns with R2’s shoes V11 refrained from responding and proceeded to pull the back R2’s upward then placed both feet in the shoes correctly. On 7/28/25 at 10:40am, ten (10) residents were noted to be unsupervised in the dining room (with soda/snack machines). V23 (Medical Records) subsequently entered the dining room, surveyor inquired who was supposed to be monitoring the dining room V23 (Medical Records) stated, “I’m not sure, they (facility) have a list on the front board.” Surveyor inquired if staff were present in the dining room V23 responded “No ma am.” On 7/28/25 at 12:20pm, the (Unit B) hallway floors were notably soiled with dirt and grime. V9 (Housekeeping) was observed mopping the floor however the dirt and grime remained on the floor. On 7/28/25 at 12:22pm, R161 stated “I have not gotten my morning eye drops, the Simbrinza for my glaucoma.” On 7/28/25 at 12:31pm, surveyor inquired why R161 did not receive prescribed eye drops V11 (LPN) reviewed the EMAR (Electronic Medication Administration Record) and stated “He (R161) gets them at 9pm” however was referring to Latanoprost on the screen. Surveyor inquired if R161 has another eye drop prescribed V11 affirmed “He does not.” [R161’s (7/26/25) physician orders include Simbrinza to the left eye three times a day - scheduled for 9am administration]. On 7/28/25 at 12:50pm, R161 affirmed that he received Simbrinza “A few minutes ago” (roughly 3 hours late). On 7/28/25 at 12:33pm, water was noted to be dripping from the main dining room ceiling onto the floor. Surveyor inquired why the water was leaking from the ceiling V7 (Maintenance Director) stated “It’s been coming from the HVAC (Heating Ventilation Air Conditioner) it’s fixed” and affirmed “I just repaired that.” On 7/29/25 at 8:52 am, V11’s (LPN) stated that she’s a new graduate (1 month ago) and assigned to “44” residents. Surveyor advised that the residents’ 9am medication administration would be observed at this time V11 responded “I (V11) have 4 residents left” and affirmed she (V11) passed 9am medications to 40 of the assigned residents - since 8am (within 52 minutes) however a total of 22 minutes transpired during R75’s medication administration observation. [Considering reasonable person concept, assigned workload, and R75’s medication administration observation V11 likely administered 9am medications prior to 8am - therefore not within regulatory requirements]. On 7/29/25 at 9:11am, V25 (RN/Registered Nurse) was assigned to “26” residents. Surveyor inquired about the 9am medication administration V25 stated “I only have 1 left, 1 more person to give meds to.” Surveyor inquired when V25 started medication administration V25 responded “We (staff) start it when I (V25) came in, I got here at 7am so about 7:30 it was.” Surveyor inquired about the regulatory requirements for 9am medication administration V25 replied “You have to start between 8am and 10:00 for the morning shift.” Surveyor inquired why seven (7) residents (R7, R14, R51, R109, R114, R127, R140) assigned to V25 were highlighted red and marked “late” on the EMAR (Electronic Medical Administration Record] V25 replied “It needs to be completed, I (V25) just need to click it out” and affirmed the highlighted residents received prescribed medications however they were not documented immediately after administration. On 7/29/25 at 9:23am, V25 (RN) left the (Unit B) medication cart (unlocked and unattended) while administering medications to R41 in the room (behind a curtain). When V25 returned to the medication cart surveyor inquired if it was locked V25 stated “No.” Surveyor inquired why the medication cart was left unlocked and unattended V25 responded “I could see it from the door” however V25 stood behind R41’s curtain during medication administration and the medication cart was in the hallway. On 7/29/25 at 9:25am, surveyor inquired about the appearance of the (Unit B) hallway floor V16 (Housekeeping) stated “It looks like dirt and paint. You gotta use the stripper, buff it, and wax.” V16 affirmed that the night shift staff is assigned to buff the floors (due to residents in the hallway during the day) however it was not getting done. On 7/29/25 at 9:28am, V26 (LPN) was assigned to “31” residents and affirmed that all but one (1) assigned resident (R112) who was currently receiving therapy received their medications. Surveyor inquired why five (5) additional residents (R5, R23, R46, R66, R76) assigned to V26 were highlighted green and marked “due” on the EMAR V26 stated “I (V26) just gotta sign all of the stuff, the meds and stuff.” Surveyor inquired about the regulatory requirement for medication administration V26 responded “Chart it as you give.” On 7/29/25 at 9:36am, V27 (Registered Nurse) stated that the 9am medications were passed to all her (V27’s) assigned residents. Surveyor inquired why R3 and R150 were highlighted green and marked “due” on the EMAR V27 responded “These residents are assigned to the other Nurse” and affirmed they were assigned to V26 (on the split assignment). On 7/29/25 at 9:38am, a large puddle of water was observed on the main dining room floor with a bath blanket present. Water was noted to be dripping from the ceiling and a wet floor sign was near the puddle however collection containers were not in use - to prevent hazards. On 7/29/25 at 12:28pm, the (Unit C) medication cart was unlocked and unattended. Surveyor inquired if the (Unit C) medication cart (assigned to V11/Licensed Practical Nurse) was locked V33 (Certified Nursing Assistant) inspected the medication cart and responded, “Oh my God.” Surveyor inquired again if the (Unit C) medication cart was locked V33 proceeded to lock the cart and replied, “It wasn’t.” On 7/29/25 at 12:32pm, (4 minutes later) surveyor inquired why V11’s cart was left unlocked and unattended V11 stated “That was an error that I made.” On 7/29/25 at 12:34pm, surveyor inquired about R36’s (left lower leg) lidocaine patch which was dated 7/24 (5 days prior). V11 (LPN) reviewed R36’s EMAR and stated, “He (R36) gets that at 6am, so that’s before I get here.” R36’s physician orders state – apply Lidocaine patch to right hip - not the leg. On 7/29/25 at 1:00pm, R141 was in the dining room wearing a shoe on the left foot and a sock (with holes) on the right foot. V11 (LPN) directed R141 to go to his room for medication administration and failed to address the footwear. Surveyor inquired why R141 was not wearing both shoes V11 stated “He (R141) refuses to put the other one on” and failed to offer any assistance with ambulation and/or footwear. On 7/29/25 at 1:26pm, R139 was observed seated in a wheelchair (in the hallway) with his pants pulled down (a pullup and both thighs were exposed). R139 was wearing a sock on the right foot however the left foot was exposed, and both feet were on the floor. V26 (LPN) was in the hallway (standing next to surveyor) during observation however failed to address concerns with R139’s privacy and/or safety until surveyor inquired about the resident. On 7/30/25 at 10:05am, surveyor inquired about R161’s functional status and fall prevention interventions V35 (Restorative Nurse) stated “He (R161) requires some max assist and dependent on staff as far as moving, sitting up. He requires staff assistance with transfers, he’s missing limbs on the lower extremity. He’s missing the right leg and left ankle, foot. I have him for fall mats, bed in lowest position, call light within reach, toileting needs addressed.” Surveyor inquired if R161 was offered side rails V35 responded “He was not because we (facility) do not do side rails here. He asked when I saw him and it was the weekend, I said I would speak to administration about side rails.” Surveyor inquired if V35 spoke to administration about R161’s siderails V35 replied “ No, we (staff) were busy doing other things. I could probably do a overhead trapeze if he (R161) wants to use it.” Surveyor inquired if it was appropriate to use only 1 floor mat when R161 was lying in bed V35 stated “ They should have both been put down while he was in bed.” On 7/30/25 at 10:11, surveyor inquired if R2 requires assistance with placing shoes on V35 responded “Yes, properly” making sure they’re on all the way, laced.” On 7/30/25 at 10:17am, surveyor inquired if R139 can dress himself V35 responded “Yes, he (R139) can put his clothes on with cueing.” Surveyor relayed concerns regarding R139 observed in a wheelchair without shoes and/or non-slip socks on V35 replied “Everyone should have on shoes unless he has on slippers.” On 7/30/25 at 10:21am, surveyor inquired why R141 wears only 1 shoe V35 responded “His (R141) foot is actually swole, he just doesn’t want to, he’s very difficult to manage.” Surveyor inquired if R141 was offered different shoes (due to identified swelling) V35 replied “I’m not sure.” On 7/30/25 at 11:00am, surveyor inquired if V35 was certified in restorative V35 stated “No, I’m working on getting enrolled today” however failed to provide (requested) documentation to affirm she was enrolled in a restorative nursing program. R8's (7/14/25) MRR (Medication Record Review) states Please take the following action described below however actions and/or instructions were excluded from the document. On 7/30/25 at 2:34pm, surveyor inquired about R8's (7/14/25) pharmacist recommendations which were excluded from the MRR V2 (Director of Nursing) stated He (pharmacist) checked off a recommendation for her (R8) but didn't send us (facility) a recommendation and presented (7/30/25) email (sent to consultant pharmacist) which states for (R8’s name) in the chart you (pharmacist) documented a pharmacy recommendation for med (medication) change but there is not recommendation attached. Can you email me (V2) this information [16 days after the recommendation was made]. The (11/2017) staffing policy states our facility provides adequate staffing to meet the needed care and services for our resident population. In addition, staffing will meet all operational activities as required. Our facility maintains adequate staffing on each shift to ensure that our resident’s needs are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services and provide supervision to CNAS and other support staff in the absence of the Administrator and/or department heads. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the residents’ comprehensive care plan. Other operational support staff are adequately staffed to ensure that resident needs are met, and that the operation of this facility is conducted. The facility periodically reviews its staffing needs using census, resident assessments, skill level required, and the Facility Assessment process to determine adequate and minimal staffing levels. When the facility drops below minimal staffing levels the facility will follow this course of action: call all line staff to augment staff shortage. Call contracted agency / temp placements to fill staff shortage with administrator approval.

Based on interview and record review, the facility failed to ensure that advance directives were accurately completed and consistently maintained for 5 residents (R17, R55, R69, R92, and R145) reviewed for Advance Directives in a sample of 68 residents, resulting in discrepancies between documented wishes and care provided. R17 is [AGE] years old and have resided at the facility since [DATE], past medical history includes, but not limited to type 2 diabetes, hyperlipidemia, unspecified bipolar disorder, essential primary hypertension, iron deficiency anemia, etc. [DATE] 11:42 AM, per record review, R17 had an advance directive in the system that was signed [DATE], but there was no selection for the type of treatment indicated in the form. [DATE] 11:40 AM, Surveyor presented this observation to V2(DON) and she said that there should be an indication for the type of treatment required for the resident to help the staff in determining what to do in an emergency. Resident's completed advance directives should be uploaded in their medical record. Findings include: R55's undated Physician Order For Life-Sustaining Treatment (POLST) Form, records a selection for Attempt Resuscitation/CPR (Selecting CPR mean Full Treatment in Section B). However, Section B of the same undated form incorrectly indicates a choice for Selective Treatment: Primary goal of treating medical conditions with selected medical measures. R69's undated Order For Life-Sustaining Treatment (POLST) Form does not contain any selections in Sections A, B, C, or D. However, the form is signed by both R69 and the physician. R92's Order For Life-Sustaining Treatment (POLST) Form, dated [DATE], does not contain any selections in Sections A, B, C, or D. However, the form is signed by both R92 and the physician. R145's undated Order For Life-Sustaining Treatment (POLST) Form does not contain any selections in Sections A, B, C, or D. However, the form is signed by both R145 and the physician. On [DATE] at 12:25pm, V4 (Social Services Director) said, Yes, R55's POLST is not documented right. I'll (V4) have that fixed. Of course, the forms should be filled out completely. I'm (V4) not sure what happened with these (R69, R92 and R145 POLST forms). If the POLST forms are not completed and completed correctly the hospital and our facility won't know what to do. Facility policy titled, Advance Directives, undated, documents, in part, . Policy: It is the policy of this facility to allow the resident, authorized legal representative or next of kin to make decisions regarding health care, per Indiana law. Advanced Directives shall not be required as a provision of service or admission. To acknowledge and honor the resident's decision to the extent permissible under state law. To enhance a resident's quality of life by supporting resident's decisions and choices about their planned course of care, to the extent possible by facility policy and state laws. 2. At the time of admission, the Social Service Director shall provide each resident or their legal representative, educational information regarding state and federal laws. Information shall include copies of the following: a. The state developed written description of the law concerning Advance Directives is Your Right to Decide b. Copy of the facility's Advance Directives Policy. 3. Facility staff will refer residents, families or legal representatives to the resident's personal physician and/or attorney for discussion and assistance regarding Advance Directives and decisions regarding life-sustaining measures. In no event shall staff give legal advice on the need for preparation of health care directives. 4. The adult competent resident, their legal representative or individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, recognized under state law, has been executed. Documentation concerning this inquiry and the individual's response shall include the date the inquiry was made and the individual making the inquiry. This information shall then be documented in the resident's medical record in the Social Service Progress Notes. The resident's Advance Directives shall be copied and maintained in the resident's medical record. An acknowledgment of receipt of information concerning Advance Directives and related state laws will also be maintained in the resident's medical record. 17. Advance Directive(s) shall be reviewed by the interdisciplinary team when completing the comprehensive assessment and addressed on the resident's plan of care, physician progress notes, physician's orders and in Social Service progress notes. 23. A copy of the original order and related physician progress notes regarding Advance Directives shall be maintained in the medical record with advance directive documents. 25. Each medical record binder will be labeled in such a manner to quickly identify Advance Directive(s). 27. Social Service and Medical Record Departments shall conduct Quality Assurance activities and report to Quality Assurance Committee.

Based on interview and record review, the facility failed to implement its policies and procedures related to the Identified Offenders Program (IOP) for 10 out of 10 residents (R37, R43, R90, R162, R163, R164, R165, R166, R167 and R168), failed to perform criminal background checks for new residents within 24 hours of admission for 4 residents (R37, R164, R166, and R168), and failed to obtain fingerprint orders within 72 hours of a hit on the preliminary criminal history for 10 out of 10 residents (R37, R43, R90, R162, R163, R164, R165, R166, R167 and R168). These failures affected 10 residents (R37, R43, R90, R162, R163, R164, R165, R166, R167 and R168) in the sample of 68 residents reviewed for abuse policies and procedures.Findings include: Facility census, dated 7/28/25, documents 158 residents residing at the facility.On 7/29/2025 at 11:08am, surveyor requested the required documentation for IOP for 5 residents (R43, R165, R166, R167, and R168). On 7/29/25 at 12:25pm, V4 (Social Services Director) and this surveyor reviewed the requested criminal background checks for R43, R165, R166, R167, and R168 as follows: R43: V4 affirmed that R43 was admitted on [DATE] and R43's CHIRP (Criminal History Information Response Process), dated 8/09/2024, has multiple hits and arrest charges of: criminal trespass to land; retail theft; burglary; armed robbery; and aggravated arson. V4 affirmed that R43 required fingerprints and R43's fingerprints were done on 9/03/2024 (almost a month after R43 was admitted to the facility. V4 stated, We (staff) are unable to find when the fingerprints were ordered. R165: V4 affirmed that R165 was admitted on [DATE] and R165's CHIRP (Criminal History Information Response Process), dated 1/08/25, has multiple hits and arrest charges of: theft; violate order of protection; knowingly damage property; retail theft; criminal trespass to land; and driving under the influence/drugs. V4 affirmed that R165 required fingerprints. V4 stated that they (staff) were unable to locate documentation confirming whether R165 was fingerprinted. R166: V4 affirmed that R166 was admitted on [DATE] and R166's CHIRP (Criminal History Information Response Process), dated 12/27/24, has multiple hits and arrest charges of: theft; retail theft; home invasion/armed/force; residential burglary; unlawful possession of weapon by felon; possession of controlled substance; domestic battery/bodily harm; violate order of protection; criminal trespass to land; criminal damage to property; and unlawful use of a weapon. V4 affirmed that R166's CHIRP was not completed within 24 hours of admission. V4 affirmed that R166 required fingerprints. V4 stated that they (staff) were unable to locate documentation confirming whether R166 was fingerprinted. R167: V4 affirmed that R167 was admitted on [DATE] and R167's CHIRP (Criminal History Information Response Process), dated 8/28/24, has multiple hits and arrest charges of: disorderly contact; battery; battery makes physical contact; domestic battery/bodily harm; telephone harassment; and assault. V4 affirmed that R167 required fingerprints. V4 stated that they (staff) were unable to locate documentation confirming whether R167 was fingerprinted. R168: V4 affirmed that R168 was admitted on [DATE] and R168's CHIRP (Criminal History Information Response Process), dated 8/26/24, has multiple hits and arrest charges of: residential burglary and burglary. V4 affirmed that R168's CHIRP was not completed within 24 hours of admission. V4 affirmed that R168 required fingerprints. V4 said, We (staff) are unable to find when the fingerprints were ordered. R168 was fingerprinted on 9/03/2025 (over a year after admission).On 7/29/25 at 12:25pm, V4 (Social Services Director) said, The IOP for the residents was being completed by the old Social Services Director who no longer works here. I'm (V4) not sure why all the IOP stuff was not done. CHIRPs are done on new admissions either before they (new admission residents) are admitted or immediately once admitted . If there is a hit on the CHIRP, fingerprints are ordered immediately. Fingerprints are done to make sure they (residents) aren't pedophiles especially since there is a school right by us (facility). Background checks are done on the residents to keep the other resident's safe. Certain things might have to be put in place so keep everyone safe. On 7/29/25 at 1:20pm, surveyor requested the required documentation for IOP for an additional 5 residents (R37, R90, R162, R163, and R164).On 7/30/25, V4 (Social Services Director) and this surveyor reviewed the requested criminal background checks for R37, R90, R162, R163, and R164 as follows: R37: V4 affirmed that R37 was admitted on [DATE] and R37's CHIRP (Criminal History Information Response Process), dated 2/01/23, has a hit of knowingly damaging property. V4 affirmed that R37's CHIRP was not completed within 24 hours of admission. V4 affirmed that R37 required fingerprints. V4 said, We (staff) are unable to find when the fingerprints were ordered. R37 was fingerprinted on 2/08/23 (over a month after admission). R90: V4 affirmed that R90 was admitted on [DATE] and R90's CHIRP (Criminal History Information Response Process), dated 8/8/24, has multiple hits of burglary; residential burglary; theft; deviate sexual assault and rape. V4 affirmed that R90 required fingerprints. V4 said, We (staff) are unable to find when the fingerprints were ordered. R90 was fingerprinted on 9/03/24 (almost a month after admission). R162: V4 affirmed that R162 was admitted on [DATE] and R162s CHIRP (Criminal History Information Response Process), dated 12/14/22, has multiple hits and arrest charges of: domestic battery; domestic battery/physical contact; and unlawful use of a weapon. V4 affirmed that R162 required fingerprints. V4 stated that they (staff) were unable to locate documentation confirming whether R162 was fingerprinted. R163: V4 affirmed that R163 was admitted on [DATE] and R163s CHIRP (Criminal History Information Response Process), dated 12/07/22, has multiple hits and arrest charges of: domestic battery/bodily harm. V4 affirmed that R163 required fingerprints. V4 stated that they (staff) were unable to locate documentation confirming whether R163 was fingerprinted. R164: V4 affirmed that R164 was admitted on [DATE] and R164's CHIRP (Criminal History Information Response Process), dated 10/31/22, has multiple hits and arrest charges of: retail theft; resist peace office; and possession of controlled substance. V4 affirmed that R164's CHIRP was not completed within 24 hours of admission. V4 affirmed that R164 required fingerprints. V4 stated that they (staff) were unable to locate documentation confirming whether R164 was fingerprinted. Facility policy titled, Abuse Prevention Policy, undated, documents, in part, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. I. Pre-admission Screening of Potential Residents: This facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. This facility will: Request a Criminal History Background Check within 24 hours after admission of a new resident, Check for the resident's name on the Illinois Sex Offender Registration Web site: www.isp.state.il.us, Check for the resident's name on the Illinois Department of Corrections sex registrant search page. www.idoc.state.il.us. While the background or fingerprint checks, and/or Identified Offender Report and Recommendations are pending, the facility shall take all steps necessary to ensure the safety of residents. Facility policy titled, Resident Rights Guideline, dated 10/2023, documents, in part, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times. Safe Environment: The right to a safe, clean, comfortable, and home-like environment that allows independence as possible. Freedom from Abuse, Neglect, Misappropriation of Property and Exploitation: The right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation, and misappropriation of your property by anyone.

Based upon observation, interview, and record review the facility failed to provide supervision, failed to implement fall prevention interventions, and/or failed to address safety hazards for five of 68 residents (R2, R139, R141, R144, R161) in the sample. Findings include: R144 is [AGE] years old and have resided at the facility since 2014, past medical history includes, but not limited to chronic obstructive pulmonary disease, unspecified dementia, type 2 diabetes, Parkinson’s disease, delusional disorder, etc. 07/28/2025 3:32 PM R144 was observed in his room at the end of the hall, awake, alert and oriented with confusion, stated he just came back from the hospital but does not know why. R144 was naked with his dirty diaper on the bed, G-tube plunger noted at the bedside table, resident's bed was unplugged from the wall, another cord not attached to anything was lying close to resident's bed. There was no call light close to resident or any floor mats noted. 07/28/2025 3:36 PM 11 (LPN) said that she is the assigned nurse for the resident, R144 has a lot of behavior and must have unplugged the bed from the wall and now V11 cannot get it back to the wall, she will get maintenance to fix it. V11 said that resident went to the hospital for altered mental status, he had a fall recently but did not go out the same day. V11 added that resident do not have a G-tube, the g-tube plunger is not supposed to be in his room, resident has a habit of picking stuff from another room and bringing it back to his room, he is currently the only resident in the room. Fall risk evaluation dated 4/3/2025 scored R144 as 11, high risk for fall. Minimum Data Set (MDS) assessment dated [DATE] indicate a BIMs score of 10 for residents’ cognitive pattern, section GG (functional status) indicated that resident requires supervision/ staff assistance for all Activities of Daily Living (ADLS). Per record review, R144 has had 3 falls this year, on 3/17/2025, resident had an unwitnessed fall in the hallway in the B wing. On 5/17/2025 resident was observed in his room on the floor at 11:30PM in a sitting position with clothes on the floor. At 0100, resident was noted in the hallway and was redirected to his room, then at 0300 the nurse aide reported that resident was bleeding, and the nurse documented a laceration to left lateral eyebrow and bruising to the left elbow. Resident was sent to the hospital for further observation. On7/20/2025 resident had a witnessed fall while ambulating in the hallway without assistive device and sustained a skin tear on the left side of forehead. R144 was again sent out to the hospital for aggressive behavior. 07/29/2025 9:35 AM, Resident was not in his room, room noted to be deserted, one pair of shoes and 3 tubs of deodorant on the dresser, there was a garbage can and an isolation bin at the entrance of the room. At 9:40AM surveyor asked staff about the resident, and she said that he was moved to another rom this morning. Resident was observed in his new room at the end of another hall. Care plan dated 7/28/2025 stated that resident is a high risk for fall related to shuffled gait, dementia, use of psychotropic medication, Parkinson, etc. Interventions include keep call light in reach, keep bed in lowest position, assure floor is free of glare, liquids, foreign objects, keep personal items within reach, floor mats x2, etc. On 07/30/2025 10:00 AM, surveyor asked V35 (Restorative Nurse) if R144 have a fall care plan prior to 7/28/2025 and what type of interventions were in place. V35 said that R144 has an initial fall care plan but it was updated on 7/28/2025 with additional interventions. Resident did not have a floor mat prior to the last fall, they included toileting as needed, educated resident watching the pathway, report when there is a fall, etc. V35 was unable to identify the interventions in place for R144 prior to 7/28/2025. Fall policy revised August 2008 stated in that as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. Under monitoring and follow up, #2 The staff and physician will monitor and document the individual’s response to interventions intended to reduce falling or the consequences of falling. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident falling (besides those that have already been identified). Findings include: The (7/28/25) facility census includes 158 residents. R161’s (7/26/25) care plan states resident is high risk for falls due to limited mobility, weakness, and missing limbs, interventions: bed to the lowest position, floor mats in place x2. On 7/28/25 at 10:10am, R161 affirmed “I (R161) arrived Saturday (7/26/25), I need Physical Therapy. I had this leg (right leg) amputated so I need to be fitted for the prosthesis.” R161 was lying in bed however assistive devices to turn/reposition in bed were not in place. Surveyor inquired about facility concerns R161 stated “The biggest concern is that I (R161) don’t have side rails, this table is the only thing preventing me from falling from the bed. A rail would make a big difference because that’s the only way I can move.” A floor mat was adjacent R161’s bed (near the window) however the other floor mat present was leaning against the footboard. R161’s bed was not in low position and the floor was notably wet (under the bedside table). On 7/28/25 at 10:19am, surveyor inquired about R161’s fall prevention interventions V11 (LPN/Licensed Practical Nurse) stated “Lower bed, the mat on the floor and the call light within reach.” Surveyor inquired about concerns with R161’s floor mats V11 responded “He (R161) doesn’t have a mat on this side because the tray is there” (referring to the bedside table). Surveyor inquired what was spilled on R161’s floor V11 responded “It’s wet but I can’t tell you what it is.” Surveyor inquired if R161’s bed was in the lowest position V11 replied “No, it’s not” and proceeded to lower the bed. Surveyor relayed concerns with R161’s bed (without side rails) V11 stated “That would be something I (V11) would have to communicate with someone, I would need to go to the DON (Director of Nursing) and I would ask her (DON).” On 7/30/25 at 10:05am, surveyor inquired about R161’s functional status and fall prevention interventions V35 (Restorative Nurse) stated “He (R161) requires some max assist and dependent on staff as far as moving, sitting up. He requires staff assistance with transfers, he’s missing limbs on the lower extremity. He’s missing the right leg and left ankle, foot. I have him for fall mats, bed in lowest position, call light within reach, toileting needs addressed.” Surveyor inquired if R161 was offered side rails V35 responded “He was not because we (facility) do not do side rails here. He asked when I saw him and it was the weekend, I said I would speak to administration about side rails.” Surveyor inquired if V35 spoke to administration about R161’s siderails V35 replied “No, we (staff) were busy doing other things. I could probably do a overhead trapeze if he (R161) wants to use it” (R161 was admitted 4 days prior). Surveyor inquired if it was appropriate to use only 1 floor mat when R161 was lying in bed V35 stated “They should have both been put down while he was in bed.” R2’s (7/1/25) functional assessment affirms partial/moderate assistance is required for putting on footwear. R2’s (4/5/25) care plan states resident is at risk for falls due to lower extremity weakness and unsteady balance, intervention: encourage resident not to attempt self-transfer or self-ambulation. ADL (Activities of Daily Living) care includes the following intervention: ensure proper fitting shoes are being worn. On 7/28/25 at 10:31am, R2 was observed in the dining room seated in a wheelchair. The back of R2’s shoes were folded downward, and both heels were on top of the shoes. Surveyor inquired if R2 can walk V11 (LPN) stated, “With assistance.” Surveyor inquired about concerns with R2’s shoes V11 refrained from responding and proceeded to pull the back R2’s upward then placed both feet in the shoes correctly. On 7/30/25 at 10:11am, surveyor inquired about R2’s functional status and fall prevention interventions V35 stated “He (R2) requires assistance, contact while he’s walking. He’s currently in a wheelchair now because he’s weak. He’s encouraged not to self-transfer.” Surveyor inquired if R2 requires assistance with placing shoes on V35 responded “Yes, properly making sure they’re on all the way, laced.” On 7/28/25 at 10:40am, ten (10) residents were noted to be unsupervised in the dining room (with soda/snack machines). V23 (Medical Records) subsequently entered the dining room, surveyor inquired who was supposed to be monitoring the dining room V23 (Medical Records) stated, “I’m not sure, they (facility) have a list on the front board.” Surveyor inquired if staff were present in the dining room V23 responded “No ma am.” On 7/28/25 at 12:33pm, water was noted to be dripping from the main dining room ceiling onto the floor. Surveyor inquired why the water was leaking from the ceiling V7 (Maintenance Director) stated “It’s been coming from the HVAC (Heating Ventilation Air Conditioner) it’s fixed” and affirmed “I just repaired that.” On 7/29/25 at 9:38am (the following day), a large puddle of water was observed on the main dining room floor with a bath blanket present. Water was noted to be dripping from the ceiling and a wet floor sign was near the puddle however collection containers were not in use – to prevent hazards. R141’s (11/25/24) care plan states resident is limited in his functional abilities due to left sided weakness without full range of motion to left shoulder, intervention: provide required level of assistance and support. On 7/29/25 at 1:00pm, R141 was in the dining room wearing a shoe on the left foot and a sock (with holes) on the right foot. V11 (LPN) directed R141 to go to his room for medication administration and failed to address the footwear. Surveyor inquired why R141 was not wearing both shoes V11 stated “He (R141) refuses to put the other one on” and failed to offer any assistance with ambulation and/or footwear. On 7/30/25 at 10:21am, surveyor inquired about R141’s functional status and fall prevention interventions V35 stated “He’s (R141) able to provide his own dressing assistance and uses a roller walker for ambulation but he doesn’t like to wear shoes on one of his feet but he does put on non-skid footwear.” Surveyor inquired why R141 wears only 1 shoe V35 responded “His foot is actually swollen, he just doesn’t want to, he’s very difficult to manage.” Surveyor inquired if R141 was offered different shoes (due to identified swelling) V35 replied “I’m not sure.” R139’s (5/1/25) BIMS (Brief Interview Mental Status) determined a score of 7 (severe cognitive impairment). R139’s (2/3/25) care plan states resident receives limited to extensive assist with dressing, intervention: allow extra time to complete ADLS (Activities of Daily Living). On 7/29/25 at 1:26pm, R139 was observed seated in a wheelchair (in the hallway) with his pants pulled down (a pullup and both thighs were exposed). R139 was wearing a sock on the right foot however the left foot was exposed, and both feet were on the floor. V26 (LPN) was in the hallway (standing next to surveyor) during observation however failed to address concerns with R139’s privacy and/or safety until surveyor inquired about the resident. On 7/30/25 at 10:17am, surveyor inquired about R139’s functional status and fall prevention interventions V35 stated “He (R139) uses a wheelchair, he can walk with an assistive device with staff. Keep areas free of obstacles, ensure positioning, items within reach, provide toileting assistance as needed.” Surveyor inquired if R139 can dress himself V35 responded “Yes, he can put his clothes on with cueing.” Surveyor relayed concerns regarding R139 observed in a wheelchair without shoes and/or non-slip socks on V35 replied “Everyone should have on shoes unless he has on slippers.” The falls clinical protocol (revised 8/08) states as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risk of serious consequences of falling.

Based upon observation, interview, and record review the facility failed to maintain an effective pest control program and failed to ensure the facility remained free from flying insects. This affected two residents (R127, R139). These failures have the potential to affect 158 residents.Findings include:The (7/28/25) facility census includes 158 residents.On 7/28/25 at 9:40am, gnats were observed flying in the (Unit B) hallway. On 7/28/25 at 9:44am, gnats were observed flying in R127's room and a can of insect repellent was lying on the bed. Surveyor inquired about facility concerns R127 stated There's gnats all over the place. The bathroom is a s**t show with gnats in there and affirmed the door is kept shut to prevent gnats from entering the room. Surveyor inspected R127's room however food and/or trash were not present. On 7/28/25 at 9:54am, a total of nine (9) fly traps were observed hanging on the walls in R139's room, multiple flies and/or gnats were noted on each fly trap. On 7/28/25 at 9:56am, surveyor inquired about the gnats observed flying in the (Unit B) hallway V9 (Housekeeping) stated I ain't been here in a couple days so I don't know about that. Surveyor inquired what was hanging on the walls in R139's room V9 responded That's a fly thing, I see gnats on there. Surveyor inquired why so many gnats were flying around in R139's room V9 replied I see what you're talking about. He (R139) always has food in his drawer or food in his room and I don't know why. V9 inspected R139's room and dresser drawers (as requested) however there was no food present. A urinal was noted on R139's dresser - with a tan crusty substance inside the container. Surveyor inquired about concerns with R139's urinal V9 stated They're (staff) supposed to be pouring the urine out they're (gnats) attracted to that pee. They (staff) need to get a new jug (urinal) and pour that stuff out. On 7/28/25, surveyor requested the facility pest control binder however only one (1) pest control service inspection report dated 3/17/25 was received.On 7/30/25 a10:49am, surveyor inquired about pest control services provided by the facility V7 (Maintenance Director) stated, A company comes when we (facility) call them (pest control company) if there's an issue, and they (pest control company) come out frequently as well. Surveyor inquired how frequent the pest control company comes to the facility V7 responded Every 3 months. Surveyor inquired if pest control came to the facility to inspect and/or apply treatments since 3/17/25 (4.5 months ago). V7 replied No however subsequently provided a pest control service inspection report dated 7/26/25. The (1/1/23) pest control policy states the facility maintains an effective pest control program to remain free of pests. Facility wide pest control strategies are developed emphasizing kitchens, dining rooms, laundries, central supply, garbage storage areas, resident areas, and other areas prone to pest infestations. A contract with a pest control company may be elected to assure regular inspection and application of chemical pesticides.

Based on observation, interview, and record review, the facility failed to ensure 1 resident's (R92) personal and medical information was kept confidential. This failure affects 1 resident (R92) out of a sample of 68 residents reviewed for personal privacy and confidentiality of records.Findings include:On 7/28/25 at 10:11am, during a tour of R92's room, surveyor observed a paper posted directly above R92's bed. The paper documents, in part, (Name of Company that performs PASARRs/ Preadmission Screening and Annual Resident Review); R9's full name; Full name and address of the facility R9 resides at; and stated that R92 is a [NAME] Class Member and R92 requested to not proceed to assessment. R92's room is semi-private, and the information was clearly visible to visitors, staff, and the other resident in the room.On 7/28/25 at 10:11am, R92 said, I (R92) don't know what that paper is. The nurse put it up there.R92's face sheet documents diagnoses that include, but are not limited to major depressive disorder, borderline personality disorder, and mild intellectual disabilities. R92's BIMS (Brief Interview for Mental Status) score, dated 5/16/25, documents a score of 5, which indicates that R92's cognition is severely impaired.On 7/29/25 at 9:23am, during a tour of R92's room, surveyor again observed the paper with R92's personal and medical information posted directly above R92's bed.On 7/30/25 at 2:17pm, V2 (Director of Nursing/DON) stated that we (staff) don't usually put information like this above residents' beds for privacy and his (R92) is a shared room.Upon review of R92's EMR (electronic medical record), there was no documentation indicating R92 had consented to having personal medical information posted in view of others.Facility policy titled, HIPAA (Health Insurance Portability and Accountability Act), undated, documents, in part, HIPAA law ensures medical records remain confidential by requiring covered entities to implement safeguards to protect PHI. Such covered entities include healthcare providers, health plans, and healthcare clearinghouses, among others. Further, HIPAA law outlines specific requirements these entities must follow to ensure the confidentiality, integrity, and availability of PHI. Some of these requirements include: 1. Privacy Rule: This rule establishes national standards for protecting the privacy of PHI. It outlines how PHI can be used, disclosed, and accessed by covered entities and their business associates. Criminal penalties can result in fines and imprisonment. Criminal penalties are enforced by the Department of Justice (DOJ), and can be imposed on individuals who knowingly obtain or disclose PHI without authorization.Facility policy titled, Resident Rights Guideline, dated 10/2023, documents, in part, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times. Privacy and Confidentiality.

Based on observation interview and record review, the facility failed to ensure a resident's urinary drainage bag was covered in a manner that promotes dignity. This failure affects 1 resident (R150) in a sample of 68.Findings include:R150's Minimum Data Set (7/21/25) documents in part that R150 has a brief interview of mental status summary score of 11, indicating that R150 has cognitive impairment and that R150 utilizes an indwelling catheter. On 7/28/2025 at 9:59 AM, R150 was observed lying in bed with an uncovered urinary drainage bag hanging from the frame of the bed. Approximately 500 mL of straw-colored urine was observed in the bag. R150 stated that the facility staff have not kept the drainage bag in a privacy bag while in bed.On 7/28/2025 at 10:01 AM, V2 (Director of Nursing) observed the uncovered urinary drainage bag and affirmed that the drainage bag was not stored in a manner that promotes resident dignity. V2 stated that the facility standard is that all resident's urinary drainage bags are kept in privacy bag to promote privacy.Facility policy titled, Resident Rights Guideline (revised 10/2023) documents in part (residents have) the right to be treated with dignity and respect .

Based on interviews and record reviews the facility failed to follow their policy and procedures for behavior and substance abuse management by not adequately monitoring and communicating suspected or observed substance use in the facility; not conducting room searches per the facility's protocol of reported suspicion of substance abuse; not referring suspected substance abuse to law enforcement; and not identifying or implementing personalized care plan interventions for prevention of suicidal/self-harming behavior and substance use. This failure applied to two of two (R1, R4) residents reviewed for supervision and resulted in R1 and R4 testing positive for drug use while in the facility and R1 engaging in self-harming behavior. Findings include: 1. R1 is a [AGE] year-old male with a diagnosis history of Severe Bipolar Disorder with Psychotic Features, Generalized Anxiety Disorder, Hypertensive Heart Disease Without Heart Failure, Cannabis Use, and Nicotine Dependence who was admitted to the facility 04/11/2025. R1's admission Hospital Records dated 04/08/2025 document he was admitted for psychiatric evaluation 04/01/2025 due to suicidal ideations with plan to walk into traffic, burning himself with a lighter and was noted with a history of severe mental illness, previous suicide attempts and hospitalizations and cannabis use; he had 5 prior hospitalizations with the last one being at a Behavioral Health Facility in 2024; he shared that he began burning himself on Sunday because it provided relief of his symptoms; he has a history of three prior suicide attempts via overdosing and walking into traffic with the most recent attempt within the last year, a history of self-harm including burning and cutting; reported using cannabis daily and last cocaine use of 15 years ago; noted with poor insight, judgment, and impulse control; he has a substance abuse history of cannabis and reported last using cocaine 15 years ago. R1's PASRR I (Preadmission Screening and Resident Review) dated 04/08/2025 documents his current Mental Health Diagnoses include Recurrent Severe Major Depressive Disorder, Anxiety Disorder, Schizophrenia, and Cannabis Use; he exhibited self-injurious behavior within the past 30 days and reports depressive symptoms including hopelessness, helplessness, worthlessness, guilt, anhedonia (lack of pleasure or interest in doing things that used to be pleasurable), apathy, lack of motivation, lack of energy, concentration difficulties, anxiety symptoms within the past 30 days. R1's PASRR II (Preadmission Screening and Resident Review) dated 04/10/2025 documents he was admitted to the hospital on [DATE] for thoughts of ending his own life; his long term goal is placement where he is able to receive mental health support; a wellbeing assessment indicated he may have depressive symptoms; he has a history of psychiatric hospitalizations; he enjoys anything that has to do with nature and the outdoors, hiking and going for long walks and a good day is when the sun is shining; he may benefit from a plan to keep himself and others safe and he may benefit from psychotherapy to decrease mental health symptoms. R1's admission Hospital Records dated 04/11/2025 document a diagnoses history of Depressive Type Schizoaffective Disorder, Cannabis Use Disorder, Non-Suicidal Self Harm, and Thoughts of Self Harm. R1's admission Progress Notes dated 04/11/2025 documents he is a [AGE] year-old male with a history of Marijuana and cigarette use. R1's admission progress note dated 04/22/2025 he has a history and current diagnosis of drug/alcohol abuse, and has a history of Suicidal Ideations with intent, as well as mental health diagnosis. He also has a history of non-suicidal self-harm. Staff will continue to monitor and encourage him to comply with recommended and prescribed treatments across all disciplines. R1's Community Access assessment dated [DATE] documents he does not desire independent access to the community. R1's Substance Use History assessment dated [DATE] documents he has no history of using Cocaine. R1's Suicidal Risk assessment dated [DATE] documents he has no history of suicide attempts. R1's Current Care Plan (initiated 04/16/2025) documents he has chronic health conditions, challenges, and bipolar disorder with current episode severe and depressed with psychotic features and factors that will require monitoring; social services will provide support and case management services and referral will be made to psychotherapeutic service providers with interventions of conducting appropriate assessments to promote knowledge and interventions to address identified areas of interest and follow person-centered care models that afford him as much initiative, control, and self-determination as possible. R1's Current Care Plan (initiated 04/24/2025) documents he is at moderate risk for suicidal ideation due to the last suicidal ideation hospitalization being prior to admission to this facility with interventions including social services to provide one to one counseling as needed and will continue to assess his risk level quarterly. R1's current care plan does not include personalized interventions for suicidal ideations or attempts or self-harm; does not include a history of substance abuse or interventions for substance abuse; does not include activities or personalized interventions based on past interests and preferences; and does not include a daily routine. R1's progress note dated 05/04/2025 at 4:52 PM documents the PRSC (Psychosocial Rehabilitation Services Coordinator) found him with 4 other residents huddled in a room violating facility rules. Resident was counseled and placed on monitoring. No documentation of attempt to conduct a room search, notification to the physician of suspicious behavior, request for specimen collection, referral to law enforcement, nor his response to interventions were noted. R1's progress note dated 05/05/2025 at 6:22 PM documents he eloped from facility and ran down the road. Staff attempted to get him to return to facility, resident refused; at 06:27 PM Writer was notified by staff that he had aggressive behavior and verbalized he had thoughts of harming himself. Assistant Director of Nursing was notified, resident to be transferred the hospital for evaluation. R1's Hospital Record dated 05/05/2025 documents he attempted to run away from the nursing home today because he did not feel he was getting the help he needed there; he stated he was able to get a lighter into the facility and continue burning himself, and watched as other patients were able to smoke crack; he states he began smoking marijuana again while there; Urine drug screen was positive for both cannabinoids and cocaine; he did not admit to using cocaine but stated that others at the nursing home were smoking it; R1 expressed suicidal ideations and exhibited self-harming behavior; he has a history of marijuana use disorder; R1 reported he wanted to leave the facility this evening stating I was there for help and I do not get help.; R1 also reports persistent drugs in the facility, and he acknowledges that he smoked marijuana at the facility; R1 stated he is not receiving the help he needs. R1's progress notes and medical records from admission [DATE] until he transferred to the hospital 05/05/2025 do not include any documented counseling or conversations regarding substance use. Psychiatric Progress Notes for R1 requested by surveyor 05/13/2025 were not provided during the survey. 2. R4 is a [AGE] year-old male with a diagnosis history of Hypertensive Heart Disease, Psychoactive Substance Use, Suicidal Ideations, Bipolar Disorder, and Unspecified Convulsions who was admitted to the facility 09/11/2024. R4's admission Hospital Records dated 09/05/2024 documents he tested positive for Cocaine and has a Past Psychiatric History of Depression, Bipolar Disorder and Polysubstance Use Disorder including a history of using Cocaine and Alcohol; urinary drug screening results were positive for Cocaine; he was brought in for psychiatric evaluation due to complaints of depression and suicidal ideation with a plan to jump from a bridge with a chief complaint of nobody to talk to, they just throw the pills,; Severity of Illness Criteria includes severe/incapacitating substance abuse. R4's Current Care Plan Initiated 09/18/2025 documents he is an adult living with chronic health conditions, challenges, and psychoactive substance abuse and bipolar disorder that require monitoring with interventions including Staff to conduct appropriate assessments to promote knowledge and understanding of my past and to be able to formulate person-centered treatment interventions to address identified areas of interest; Identify if there are behaviors or factors from my past that should be considered in formulating my treatment plan. R4's current care plan does not include personalized interventions to address identified behaviors or factors from his past including triggers of substance abuse; does not include diversions from substance use or goals to achieve sobriety; and does not include an established routine. R4's Community Access Observation assessment dated [DATE] documents he may not access the community independently related to safety factor. R4's Behavioral progress note dated 01/14/2025 at 05:59 PM documents during a random room check, it was observed that he had cigarettes in an opened pack and more cigarettes with rolling paraphernalia on his bed. He had denied having these items upon initial questioning and remained in his room while the room search was completed. R4's progress note dated 01/25/2025 at 10:57 AM documents: Purpose of visit: Psychiatry follow up and medication management HPI: Patient report overall he has been doing well and describes current mood as good however reports disturbed sleep but not related to depressive mood, psychosis or anxiety and was demanding Seroquel to help me sleep R4 was educated there is no indication for Seroquel to be prescribed and was re-educated on sleep hygiene, he verbalized understanding and agreed; at 01:20 PM notes document R4 was sleep during the entire shift. Writer went to the room several times to encourage resident to allow them to take his blood pressure, but resident continued to sleep. No notification to the physician of suspicious behavior, nor implementation of interventions or his response to interventions were noted. R4's Behavioral progress note dated 01/28/2025 07:00 PM documents social services entered his room to initially speak with his roommate but smelled smoke among entry. Social Services will continue to monitor the resident's behaviors. No response to interventions were noted. R4's Behavioral progress note dated 01/31/2025 10:41 PM documents residents were observed in the main hall acting a bit strange and unusual prompting a wing room search. R4 was not in his room or on his wing; found in another resident's room on another wing and he appeared to have contraband cuffed in his hand. PRSC (Psychosocial Rehabilitation Services Coordinator) asked him to relinquish items and he refused only giving up the lighter that he had in his hand. The other items remained. PRSC asked resident to go to the nurses station to get his vitals checks as his pupils appeared dilated; at 12:09 AM [Recorded as Late Entry on 02/01/2025 at 01:01 AM] R4 was petitioned to the hospital per physician's orders for a Psychiatric evaluation. R4's Hospital Record dated 02/02/2025 documents he was admitted [DATE] and he was involuntarily petitioned to the emergency department from the local nursing home for psychiatric evaluation; per the nursing home report he was suspected of bringing in contraband to the nursing home and his toxicology screen was positive for cocaine. R4's Behavioral progress note 05/04/2025 at 04:51 PM [Recorded as Late Entry on 05/06/2025 at 03:49 PM] Documents PRSC (Psychosocial Rehabilitation Services Coordinator) found resident with 4 other residents huddled in a room violating facility rules. Resident was counseled and placed on monitoring. No documentation of attempt to conduct a room search, notification to the physician of suspicious behavior, request for specimen collection, referral to law enforcement, nor his response to interventions were noted. Behavior Report Form dated 05/04/2025 documents R1, R5, R6, and R7 were observed huddled in a room together smoking and exhibiting behaviors of violating rules; they will continue to be monitored for behavior. No documentation of attempt to conduct a room search, notification to the physician of suspicious behavior, referral to law enforcement, nor their response to interventions noted. R4's progress notes and medical records from 01/14/2025 until 05/13/2025 when the survey was concluded, did not include any documented counseling or conversations regarding substance use, nor participation in substance abuse groups. Handwritten social services progress notes for R4 requested by surveyor 05/12/2025 were not provided during the survey. On 05/06/2025 at 1:52 PM R1 stated his main issue with the facility is all the partying. On 05/06/2025 at 2:10 PM V9 (Psychosocial Rehabilitation Services Coordinator) stated on 05/04/2025 she observed R1, R4, R5, R6 and R7, and in a room smoking and she forgot to add R4's name on the behavioral report form. V9 stated she notified V4 (Clinical Director). V9 stated when doing room searches, they found marijuana gummies in a female resident's room approximately 6-7 months ago, however that resident is no longer in the facility, they have received reports of marijuana smoking a few months ago and those residents are no longer in the facility. On 05/06/2025 between 9AM - 4PM in separate interviews V12 (Anonymous staff) reported on 05/04/2025 they observed R1, R4, R5, R6, and R7 smoking and the smell was not of cigarettes or marijuana; V14 (Anonymous Staff) reported they occasionally smell marijuana when monitoring residents rooms. On 05/07/2025 at 9:27 AM R1 stated he saw so much partying going on at the facility the night of 05/04/2025 he had to get out of the facility. On 05/07/2025 at 12:05 PM R4 stated he had been in the facility since September, and he sees residents high in the facility. R4 stated it's easy to get drugs or alcohol through the room windows. R4 stated he does not use outside pass privileges. R4 stated he feels the facility does not monitor residents behaviors adequately. On 05/07/2025 between 9AM - 4PM in separate interviews V13 (Anonymous Staff) reported that they have seen Marijuana paraphernalia on multiple units including where R4, R5, and R6's rooms are located and has smelled pipes burning, they have seen behaviors that indicate residents might be under the influence of substances such as red partially closed eyes, on Sunday 05/04/2025 they smelled a burning pipe in the facility, and multiple residents have used drugs in the facility; V15 (Anonymous Staff) reported they have smelled Marijuana in the halls; V16 (Anonymous Staff) reported they have smelled Marijuana in the halls and it's difficult to determine the source; V17 (Anonymous Staff) reported they have smelled marijuana in the facility and nurses have also reported smelling it, residents have also reported other residents drug use in the facility; V18 (Anonymous Staff) reported that they have observed a marijuana smell in the halls near residents rooms and in residents rooms and sometimes they report this to the nurse or social worker and sometimes they don't because when they do report it no one does anything about it. On 05/12/2025 at 2:26 PM V4 (Clinical Director) stated R1 had not met the outside pass criteria because he hadn't attended any programming. V4 stated if residents show signs suspicious of substance use, they will want to alert the physician, might do a specimen draw and follow whatever the physician recommends. V4 stated signs of drug use include unusual odors, glassy eyes, unsteady gait, flight of speech, a lot of anxiety, and sometimes delusions. V4 stated odors of marijuana or other illegal substances would be cause for alarm and rooms should be searched. V4 stated if residents have not been outside and test positive for illegal substances that does indicate they got it somehow while in the facility. V4 stated the facility monitors residents behaviors through clinical rounds in the building looking out for safety issues which includes room searches. V4 stated social services documents soft notes when there are observations of potential substance use or room searches due to protection of the residents rights. On 05/13/2025 at 11:23 AM V4 (Clinical Director) agreed it is the facility's responsibility to monitor drug use while in the facility even if visitors are bringing in drugs or paraphernalia. V4 stated if they do find contraband or signs of substance use, they inform the physician or follow any recommendations the physician may have. V4 stated behaviors are documented once they're observed. V4 stated on 05/03/2025 when R1 received snacks from his friend staff were present, they received the snacks for him because there were too many for his room and there were no concerning items found. V4 stated yes when asked by surveyor if residents showing signs of substance use should receive increased monitoring which he stated would include performing room checks with these individuals more regularly. V4 stated the response to this behavior includes trying not to look at them as being targeted. V4 stated the approach is always to be positive and try to get the resident to look at the times in which they're sober and try to express we're concerned about their safety and wellbeing and encourage sobriety. V4 stated if residents are found with contraband or show signs of drug use searches are commenced. V4 stated increased monitoring would consist of routine room checks likely on a daily basis which they encourage residents to be present for. V4 stated he wouldn't say it is normal for R4 to be found with contraband. V4 stated the rolling paper R4 was found with on 01/14/2025 was cigarette rolling paper. V4 stated R4 doesn't usually exhibit any unusual behaviors. V4 stated R4 doesn't go outside the facility, he has back spasms and doesn't normally like to venture out. V4 stated R4 had not had any visitors that he is aware of. V4 stated the concern with the cigarette rolling paper R4 was found with would be it is contraband and smoking material. V4 stated none of the residents are permitted to use Marijuana, that the facility is a drug and alcohol-free facility, and use of marijuana is illegal in the facility. V4 stated yes when asked by surveyor if a resident has a history of self-harm do they require specialized services. V4 stated specialized services would include involving the resident in psychosocial groups, they would also receive one to one social services counseling, would see the psychiatrist on a regular basis, as well as receive required medications. V4 stated care planned interventions for residents with a history of self-harm would include monitoring for any mood changes, encouraging them to take advantage of any open-door policies they have, clinical rounds from social services staff to assess residents mood and behavior which is ongoing. V4 stated these interventions would also include talking to the residents, monitoring them, interacting, asking them about their state of mind and reminding them staff do care and are available to talk. V4 stated there may not be documentation of these interactions and attempts unless there's an intense episode because some interactions only require minor conversation and interaction. V4 stated to his knowledge R1 did not have a history of refusing psychosocial services. V4 stated we do complete psychosocial progress notes that are not necessarily documented in the electronic health record system. The facility did not provide documentation of law enforcement notification of potential drug use in the facility at any time during the course of the survey. The facility's Managing Behavior Policy dated 10/01/2023 and received 05/12/2025 states: This policy is designed to provide guidance for managing challenging behaviors in residents while ensuring their safety, and well-being. The facility is committed to providing a safe and therapeutic environment for all residents. Behavioral interventions will be individualized, evidence based, and focused on identifying and addressing the underlying causes of behaviors. Behavioral Care Plan Development: if a resident exhibits challenging behaviors, an individualized behavioral care plan will be developed. This plan will be based on the resident's history, preferences, and identified triggers and will include specific interventions aimed at reducing the behavior. Personalized Activities: The resident will be offered therapeutic activities tailored to their preferences. Routine and Familiarity: Establishing consistent daily routines and using familiar caregivers can help reduce behaviors triggered by anxiety or confusion. Documentation and Reporting: Behavioral Incidents: All behavioral incidents, interventions used, and the resident's response will be documented in the residents medical record. The facility's Substance Use History Policy dated 04/08/2024 and received 05/12/2025 states: The purpose of the policy is To create an environment as free of accidents and hazards as possible for residents with history of substance abuse. When substance use is suspected, (in the facility) which could lead to overdose, facility staff should implement care plan interventions, which includes notification of the resident's physician or provider. If the facility determines through observation that a resident may have access to illegal substances that they have brought into the facility or secured from an outside source, these cases may warrant a referral to local law enforcement. Care Planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety. Residents with SUD (Substance Use Disorder) may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to: Odors; Changes in residents behaviors including Unexplained Drowsiness. The facility's Residents Possession and Use of Illegal Substance Policy dated 04/08/2024 and received 05/12/2025 states: The possession and use of illegal substances by residents will not be tolerated. Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use, which includes but is not limited to: Changes in resident behavior; Increased, unexplained drowsiness. If the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source, the facility will not act as an arm of law enforcement. In accordance with state laws, a referral will be made to local law enforcement. To protect the health and safety of residents the facility will provide additional monitoring and supervision. The facility's Policy on Contraband Materials, Inspection of Rooms and Use of Recording Devices Policy received 05/12/2025 states: This organization reserves the right to conduct inspections if there is reason to suspect/believe that a resident has contraband items/materials in his/her possession. These items include, but are not limited to illicit (street or over the counter) drugs. In situations where illegal activity appears to have taken place appropriate authorities will be notified. Again, safety and security are of the utmost concern. The facility may choose, at its discretion, to involve drug sniffing dogs if residents are suspected to be trafficking drugs inside the facility.

Based on observation, interview, and record review, the facility failed to monitor a high fall risk resident (R2) while in bed, failed to put in additional interventions to address R2's behavior of moving/wiggling around the bed, and failed to keep the call light within reach. This affected one of three residents (R2) reviewed for fall prevetion interventions. This failure resulted in R2 suffering a brain bleed in two areas of the brain after the fall. Findings Include: R2 is a [AGE] year old with the following diagnoses: chronic obstructive pulmonary disease, and nontraumatic intracranial hemorrhage. The Admission Hospital Records, dated 2/17/24, documents R2 was sent to the hospital for altered mental status. R2 was noted with elevated blood pressure, has poor attention, span, and has severe encephalopathy. A CT (Computed Tomography) scan of the brain was completed on 2/13/24 and no brain bleeds are documented on this scan. A Nursing note, dated 2/23/24, documents R2 is a new admission. R2 often yells out but when staff approaches, R2 is not able to verbalize what R2 needs. R2 educated on the use of the call light but continues to yell out. The Fall Risk Observation, dated 2/23/24, documents a score of 17, indicating R2 is a high fall risk. R2 is a high fall risk due to having intermittent confusion, being confined to a chair, needing assistance with elimination, being newly admitted to the facility, and has had a recent decline and functional status. The Full Clinical/Body Observation, dated 2/23/24, indicates R2 was admitted on this day from the hospital and is easily distractible, has impaired memory, and disorganized thinking. A Nursing note, dated 2/24/24, documents R2 is alert to self only. R2 ' s behavior remains anxious at intervals. R2 is not able to make needs known and is dependent and all areas of ADL care. A Nursing note, dated 2/25/24, documents R2 is not ambulatory. R2 ' s behavior of yelling out and asking for help from staff, but when staff responds, R2 cannot say what is needed. R2 ' s behavior remains anxious at intervals. R2 is not able to make needs known clearly. R2 is dependent in all areas of ADLs. A Nursing note, dated 2/27/24, documents R2 is noted on the left side of the bed lying on the floor by the wall. The bed was in the lowest position and the call was attached to the bed, which R2 did not pull for assistance. A small amount of blood was noted from the left forehead. The physician ordered to send R2 to the hospital for a medical evaluation. R2 was placed in a wheelchair to the nurse's station for observation. The Fall Event, dated 2/27/24, documents the form was not completed post fall and to see progress note for fall information. The Fall Risk Observation, dated 2/27/24, documents a score of 15 indicating R2 is still a high fall risk. The Care Plan, dated 2/27/24, documents R2 has a history of falls due to altered mental status and lower extremity weakness. Documented interventions on this day include observe R2 frequently and place in supervised areas when out of bed, keep call light within reach at all times, and place R2 in a fall prevention program. The intervention for fall mats was not placed until 3/5/24. The Minimum Data Set, dated dated [DATE], documents Section GG, R2 is a substantial/maximal assist for rolling in the bed, dependent for all transfers, and cannot ambulate. The Hospital Records, dated 2/28/24, documents R2 presented to the emergency department status post fall. The nursing home reported R2 fell and hit R2's head. R2's baseline is alert and oriented times one and is currently acting normal. Upon assessment, a 2 cm superficial, lateral abrasion was noted to the left lateral brow. No exposed subcutaneous tissue was noted. The CT of the head documents there is a combination of a subdural and intraparenchymal hemorrhage in the bilateral, parasagittal parieto - occipital lobes with adjacent edema. Neurosurgery was consulted and R2 was admitted to the intensive care unit for observation. The Facility Reported Incident, dated 2/28/24, documents R2 admitted to the facility on [DATE] after a recent hospitalization . At the hospital, R2 was treated for altered mental state and hypertensive encephalopathy. R2 was also diagnosed with polysubstance abuse, drug induced seizures, and generalized weakness. On 2/27/24, R2 had an unwitnessed fall in R2 ' s room. Upon entering the room, R2 was noted lying on the left side of the bed. The nurse performed to a head to toe assessment and noted a laceration above the left eyebrow with minimal bleeding. R2 was asked what happened and how did R2 fall, R2 responded, I don't know. The nurse received orders to send R2 the hospital for medical evaluation. The facility was notified R2 was being admitted with a diagnosis of brain bleed. The IDT (Interdisciplinary Team) met and believed the fall may be related to acute medical change. R2 returned to the facility on [DATE] with a diagnosis of UTI (urinary tract infection), sepsis, and bilateral intracranial bleeds. A Nursing note, dated 2/28/24, documents the hospital called the facility to notify R2 had brain bleed and is being transferred to the intensive care unit. A Nursing note, dated 2/28/24, documents the IDT (Interdisciplinary Team) met to discuss the fall that was not witnessed and occurred yesterday. R2 was found in R2's room lying on the floor on the left side of the bed. When asked why did R2 fall, R2 was not aware. A laceration was noted to the left eyebrow. The physician ordered to send R2 to the hospital for acute medical evaluation. A Nursing note, dated 3/4/24, documents the IDT met today after R2 returned from the hospital. R2 had a room closer to the nurse's station, frequent monitoring, bed in the lowest position in mats placed on both sides of the bed for interventions related to the root cause of the previous fall. The Minimum Data Set, date 3/5/24, documents a Brief Interview for Mental Status score as 12 (moderate cognitive impairment). On 5/2/24 at 12:55PM, R2 was lying in bed awake. R2's bed was low to the floor and had one side of the bed pushed against the wall completely, so R2 is only able to exit the bed from one side. There is one fall mat in place that is the length of the bed. The call light was clipped to the comforter of the bed that was at R2 ' s feet. When asked to sit up and reach the call light to see if R2 was able to reach, R2 only stared at the surveyor and did not move. R2 is alert and oriented times one at the time of this interview. R2 was only able to state R2's full name. R2 was not able to state date, R2's birthdate, where R2 was, or who the president is. R2 did not remember any having any falls or being injured in any falls. At 1:04PM, V6 (Assistant Director of Nursing/ADON) was called into the room and showed the position of the call light. V6 stated the call lights are normally clipped up on residents' pillows but R2 had the call light placed by R2 ' s feet because the position of the bed needed to be up against the wall for R2's safety. V6 reported R2 needed to be facing the doorway so staff could check on R2 as they passed R2 ' s room. On 5/2/24 at 1:30PM, V4 (Restorative Nurse) stated interventions are put into place based on resident behaviors. V4 reported R2 is part of the fall program in the facility due to having recent falls and being a high fall risk. V4 stated all the interventions that are in place should be charted in the care plan the day they were initiated. V4 reported R2 can move a little bit in bed but cannot ambulate. V4 reported the call light should be clipped where R2 can reach it and not the the feet. On 5/2/24 at 2:05PM, V6 stated when R2 was interviewed about the fall, R2 did not remember falling and was not able to verbalize what R2 was doing to cause the fall. V6 reported R2 was agitated and moving a lot when R2 first arrived to the facility. V6 stated restorative will do an assessment and put in interventions for a resident based on the assessment. V6 reported all interventions are documented in the care plan. V6 stated, It would have made sense to put the bed low and falls mats in place, due R2 moving around a lot. V6 reported R2 is alert and oriented times one. On 5/3/24 at 8:07AM, V9 (CNA) stated when R2 first arrived to the facility, R2 had a behavior of yelling out and wiggling around the bed or wheelchair. V9 reported R2 was always trying to get out of bed. V9 stated R2 was not able to move around in bed a lot, but the moving R2 was able to do would change R2's position in bed. V9 was not able to remember if the fall mat was put in place before or after the fall. V9 reported R2 is now safe because R2 has R2's bed placed against the wall. On 5/3/24 at 8:18AM, V10 (Nurse) stated R2 was admitted back from the hospital after a fall and R2 had a brain bleed. V10 described R2 as a restless person in bed but was never able to ambulate. V10 reported R2 did a lot of crying and yelling out and could not keep still. V10 stated R2's bed was low and a mat was in front of the bed when R2 returned from the hospital, but V10 was not able to remember what interventions were in place at the time of the fall. V10 reported R2 was a high fall risk before and after the fall. V10 stated R2 is alert and oriented times one. V10 reported intervention should be in place when it is noticed a resident is having a behavior to try and stop the fall. V10 reported the call light should always be within reach of a resident even if they cannot use it to help to keep the resident safe. On 5/3/24 at 12:19PM, V12 (Nurse) stated when R2 was first admitted , R2 was not very active, but became more active on the next day and yelled more. V12 reported R2 was moving around more in the bed. V12 stated the fall happened in the evening and V13 (CNA) told V12 about the fall. V12 was not able to remember time frames but stated the last time R2 was checked R2 was awake but not moving around. V12 reported R2 fell off the side of the bed and was between the bed and the air conditioning unit. V12 stated R2 had a small laceration and was sent to the hospital for an evaluation because R2 hit R2's head. V12 was unaware of why R2 is a high fall risk. V12 stated a resident is a high fall risk if they have previous falls, and unsteady gait, or keep trying to get up on their own. V12 reported R2's room at the time of the fall was in the middle of the hallway and staff tried to check on R2 as they walked on the hall. V12 denied being aware of any increased monitoring on R2 on the day of the fall. V12 stated a fall mat was down in front of the bed at the time of the fall, but was not on the other side of the bed where R2 fell . V12 reported fall mats were placed on both sides of the bed when our to return from the hospital. V12 denied being aware of why fall mats were not on both sides of the bed. On 5/3/24 at 1:23PM, V13 (Certified Nursing Assistant/CNA) stated R2 was fed around 5:30 PM and was taken back to bed on the day of the fall. V13 reported R2 was found around 6-7 PM. V13 stated R2 was acting like normal and was all over the place. V13 reported R2 is able to roll all around the bed. V13 stated R2 was found in between the bed and the radiator on the floor after yelling out for help. V13 reported a fall mat was down on the opposite side of the bed from where R2 fell . V13 stated R2 is a smaller, thinner person and can fit into small places, like the space between the bed and the radiator. V13 reported R2 was a high fall risk and staff just kept checking on R2 when they walked on the hall. V13 was not aware why the fall mats were on both sides of the bed at the time of the fall. On 5/6/24 at 2:40PM, V14 (Primary Physician) stated a brain bleed can occur from a lot of things, especially if someone is on blood thinners. V14 reported a brain bleed can happen spontaneously, with a slight bump to the head, or something more severe. V14 stated interventions are put in place based off the residents risk of fall. V14 reported if all the proper interventions were place then this incident could not have been prevented. V14 stated if interventions are needed, they should be put in place for the safety needs of the resident. V14 reported R2 had a behavior of getting on a bed and yelling. The policy titled, Falls - Clinical Protocol, dated 08/2008 documents, . Treatment/Management: 1. Based on the proceeding assessment, the staff and physician will identify permanent interventions to try to prevent subsequent falls into address risks of serious consequences of falling . 2. If underline causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature of category of falling, until falling, reduces or stops, or until the reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance).

Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy and to prevent incidents of staff to resident verbal and physical abuse. This failure affected two residents (R1 and R7) reviewed for abuse. V4 yelled, pulled R1's hair, and hit R1's arms, and V4 grabbed R7 by the left wrist resulting in bruising. Findings include: R1's BIMS (brief interview of mental status) score, dated 4/17/23, notes R1's score is 13 out of 15. R1 is able to make needs known. R1's behavior assessment summary, dated 4/17/23, notes R1 does not exhibit any behaviors. R1's quarterly assessment, dated 4/17/23, by V11, PRSC (Psychiatric Rehabilitation Services Coordinator), noted R1 is an active speaker that communicates her concerns and desires when the need arises. For the most part, R1 gets along well with staff and her peers. R1 demonstrated she is alert and oriented as evidenced by a score of 13out of 15 on the BIMS, and a mood score of 11 out of 27, indicating moderate depression. R1 has a medical and psychiatric diagnosis that impacts mood and stability. 1:1 psychosocial programming addresses R1's need for increasing life management skills, symptom awareness, behavior management to maintain compliance and stability, and also improving communication skills. R1's behaviors care plan, initiated 2/27/2023, notes R1 likes having people pay attention to her. This includes spending time in the hallway, even when there may not be anyone else there. When what R1 says does not get immediate attention, R1 tries harder to get attention by yelling, crying, or cursing demanding to be heard and taken more seriously. R1's psychosocial well-being care plan, initiated 1/27/2022, notes R1 may be at risk for abuse related to attention seeking behaviors, interfering in peers' affairs, anxiety, agitation, or restlessness. R1's mood state care plan, initiated 2/16/2021, notes R1 exhibits signs/symptoms of mood distress related to diagnosis. R1's mood score is 11 out of 27, indicating severe moderate depression. R1 expresses feeling down, depressed, or hopeless and trouble falling or staying asleep most days of the week. R7's BIMS score, dated 4/4/23, notes R7's score is 14 out of 15. R7 is able to make needs known. R7's annual assessment, dated 4/4/23, by V11, PRSC, noted V11 met with R7 to conduct an annual assessment and discuss the goals of her care plan. R7 is alert and oriented to places, persons, and time. R7 was diagnosed with unspecified schizoaffective disorder, a single episode of major depressive disorder, alcohol abuse with alcohol abuse hallucinations, and other medical conditions. At the interview session, R7 presented with a receptive affect and congruent mood. R7's speech is clear and her hearing appears to be with in normal range. R7's thought process is goal oriented and logical. R7's mood score is 13 out of 27 indicating moderate depression. R7 is encouraged to ventilate feelings with staff whenever R7 is experiencing an increase in agitation or sadness. R7 has a history of becoming verbally aggressive when she experiences increased agitation when provoked. R7 has not expressed aggressive behavior during the last review. R7's behaviors care plan, initiated 1/3/23, notes R7 exhibits signs/symptoms of depression. Before admission, R7 experienced hallucinations. R7's mood score is 10 out of 27, indicating moderate depression. R7's psychosocial well-being care plan, initiated 1/3/2023, notes R7 may be at risk for abuse related to diagnosis of schizoaffective disorder. On 5/8/23 at 10:00am, R1 stated R1 wanted to take a bubble bath on 4/23/23. R1 stated R1 went to the nurses' station to get towels. R1 stated V4, RN (Registered Nurse), instructed R1 to go back to R1's room. R1 stated V4 was yelling at R1. R1 stated V4 came from behind the nurses' station and stood behind R1's wheelchair. R1 stated V4 pulled R1's hairm and hit R1 in the arms before staff came and took R1 to R1's room. On 5/9/23 at 3:30pm, R1 was re-interviewed regarding the incident. R1's story remained unchanged from previous day. On 5/9/23 at 1:45pm, R7 stated staff is mean to R7. R7 stated three weeks ago, R7 threw her medications on the floor because R7 did not want to take them. R7 stated V4, RN, grabbed R7's left wrist, causing R7 to sustain bruising to that area. R7 stated R7 did not report this incident to any staff. On 5/10/23 at 10:00am, R2 stated R1 will leave R1's room [ROOM NUMBER]-4 times, starting about 10:00pm sometimes. R2 stated R2 can hear V4, RN, yelling at R1 to get back in R1's room, and V4 is tired of (R1). R2 stated the facility makes residents sign a form that residents can be restrained if out of control. R2 stated the restraint is an injection that will make you sleep all day or night. R2 stated R1 was given an injection, and R1 went to sleep. On 5/8/23 at 6:30am, V4, RN, stated on 4/23/23, R1 returned to facility early from being out on pass with family. V4 stated R1 was supposed to be out on pass with R1's family for a couple of days. V4 stated R1's family informed her that they could not control R1 at home, and brought R1 back to the facility. V4 stated R1 was in wheelchair at nurses' station between 9:30pm and 10:00pm, requesting a can opener to open can of soup. V4 stated she informed R1 they didn't have a can opener; R1 became agitated. V4 stated she attempted to move R1's wheelchair, R1 pushed her wheelchair backwards and locked the brakes on it. V4 stated R1 hit her in left leg with the wheelchair when R1 pushed wheelchair backwards. V4 stated she leaned over the right side of wheelchair to unlock brake. V4 stated R1 was positioned at the front of the nurses' station with wheelchair facing C wing, she was standing behind wheelchair facing C wing with back to main lobby. V4 stated V8, CNA, was sitting in nurses' station at the time of this incident, and came to assist V4. V4 stated there were no other residents in hallway at the time of the incident. On 5/8/23 at 9:10am, V5, DON (Director of Nursing) stated when R1 goes out on pass with R1's family, R1 will exhibit behaviors upon returning because R1 wants to stay at home with family. V5 stated R1 was supposed to be with family for 3 days; family brought R1 back on day 2 due to R1's behaviors at home. V5 stated R1's family was unable to control R1 at home. On 5/8/23 at 10:00am, R1 was sitting in her wheelchair with her hair neatly pulled back in a ponytail. When questioned, R1 was observed to be fearful to discuss incident that occurred on 4/23/23. R1 was observed to frequently remove her hairband and comb her hair with fingers and then reapply hairband. On 5/9/23 at 1:45pm, R7 was observed lying in bed in R7's room with covers pulled over cheeks. When questioned, R7 was observed to be fearful to discuss incident and the staff involved. Review of R1's medical record notes on 4/22/23, R1 is going home for overnight pass today 04/22/23 at 10:00am will be back tomorrow 04/23/2023 by 5:00pm. On 5/8/23 at 9:20am, V6, ASSD (Assistant Social Services Director) stated V6 was present in the facility until 8:00pm on 4/23/23. V6 stated the incident occurred after V6 left the facility. V6 stated R1 was fine and not exhibiting any behaviors. On 5/8/23 at 10:00am, V9, CNA (Certified Nurse Aide) stated V9 was in the front lobby at time of incident. V9 stated V9 heard R1 and V4, RN, yelling at each other. V9 stated R1 was self-propelling in wheelchair in hallway prior to the incident. V9 stated R1's hair looked tousled after the incident. V9 stated R1 cares about her appearance and fixes her hair frequently throughout the day, about every 2 hours. V9 stated her hair appeared to have been pulled. V9 stated V9 brought R1 back to R1's room and fixed R1's hair. On 5/8/23 at 10:30am, V8, CNA, stated R1 was coming down the hall, complaining she wanted towels to take a bubble bath. V8 stated R1 was informed R1 would have to wait a minute because there were no towels available at that time. V8 stated then R1 wanted a can of soup opened. V8 stated R1 became upset and started yelling when R1 was informed the kitchen was closed, and V8 could not get a can opener for R1. V8 stated she was at nurses' station charting with her back to R1. V8 stated V4, RN, asked R1 to leave the nurses' station and go to R1's room. V8 stated when V8 turned around, V8 observed V4's hands on R1's wheelchair armrest, and V4 was attempting to re-direct R1. V8 stated when V4 touched her wheelchair, R1 became more upset. V8 stated 2 staff members came and escorted R1 back to her room. V8 stated R1's hair was not tousled prior to the incident. On 5/8/23 at 10:50am, V7 (security) stated on the evening shift on 4/23/23, she was working at the front desk. V7 stated V13, LPN (Licensed Practical Nurse), was standing at the double doors separating main lobby from nursing units. V7 stated V13 was holding the door open while speaking with V7. V7 stated there was music playing, and V7 observed R1 self-propel past the double doors. V7 stated V7 heard V4 and R1 yelling. V7 stated V7 could hear V4, RN, stating, If I count to 5 and have to get up, then she heard V4 counting. V7 stated when V7 heard V4 say '5', V7 got up immediately and ran towards C-D nurses' station. V7 stated she observed V4 with her hand wrapped in R1's hair, R1 was screaming and crying. V7 stated she yelled out R1's name. V7 stated V4 turned around, and saw V7 coming down the hallway to assist R1. V7 stated V8, CNA, was standing at nurses' station with hands in her pockets, not providing assistance during incident. V7 stated R1 had a clip in her hair, and V7 observed the clip dented/broken in R1's hair. V7 stated V9, CNA, was also in the front lobby at the time of incident, and followed V7 to the C-D wing. V7 stated V9, CNA, took R1 to R1's room to fix R1's hair. V7 stated V7 reported this incident to V3 (Assistant Administrator) immediately. On 5/9/23 at 12:20pm, V10, PRSC (Psychiatric Rehabilitation Services Coordinator), stated R1 exhibits behavior such as attention seeking. V10 stated sometimes R1 just wants to talk to someone. V10 stated R1 goes out on pass with R1's family for overnight visits. V10 denied R1 going on longer visits with family. V10 stated R1 goes with R1's family on Saturdays at 10:00am, and returns the following day between 4:00pm and 5:00pm. V10 stated R1 usually gets upset when R1 returns because R1 wants to stay at home with family. On 5/9/23 at 12:40pm, V11 PRSC stated that R1 reported incident to him on 4/24/23. V11 stated that R1 was trying to get some of R1's clothes to laundry and V4 RN was trying to prevent R1 from doing that due to time of day. V11 stated that R1 informed him that V4 stood up came to R1 trying to make sure R1 went to her room. V11 stated that R1 showed V11 some redness on R1's right arm that resulted from the incident the previous evening. V11 stated that R1 informed him that V4 grabbed the back of R1's neck and hit her arms. On 5/9/23 at 12:50pm, V12, CNA, stated R1 informed V12 on 4/24/23 that R1 had an incident the night before. V12 stated R1 mentioned R1 was scolded and yelled at. V12 stated R1 would not tell V12 the name of the staff member involved or any further details of the incident. On 5/9/23 at 1:20pm, V13, LPN, stated V13 is not sure exactly what happened on 4/23/23 between V4 and R1. V13 stated V13 was on a break at the time of the incident. V13 stated V13 did a wellness check on R1; R1 would not tell V13 what happened. V13 stated R1 looked upset. V13 stated R1 does get agitated on Sundays after being with R1's family because R1 does not want to come back. V13 stated R1 returned to facility at 4:30pm on 4/23/23. V13 stated R1 was calm and cooperative by 7:00pm. On 4/23, V13, LPN, noted: (recorded as late entry on 04/24/2023 10:24pm). V13 was away from the unit and when V13 returned, V13 was made aware of an allegation of abuse between R1 and V4. V13 immediately went to R1's room to assess R1. R1 was in room sitting in wheelchair. R1 was calm and safety was maintained. Review of this facility's investigation into an allegation of abuse involving R1 and V4 notes this event occurred on 4/23/23 at 10:00pm. Review of V4's timecard, dated 4/23/23, notes V4 did not clock out and exit this facility until 11:45pm. Review of this facility's abuse prevention policy, dated 02/2017, notes this facility affirms the right of its residents to be free from abuse. This will be done by immediately protecting residents involved in identified reports of possible abuse and implementing systems to promptly and aggressively investigate all reports and allegations of abuse. Verbal abuse includes, but is not limited to, threats of harm, saying things to frighten a resident.

Based on interview and record review, the facility failed to have effective interventions in place to prevent or reduce the risk of falling for a high risk fall resident for one 1 of 3 residents (R1) reviewed for fall prevention in a total sample of 3. This failure resulted in R1 falling and getting a laceration to the back of the head requiring 17 staples. Findings Include: R1 is a [AGE] year old with the following diagnoses: dementia with behavioral disturbance, weakness, history of falling, hypertensive heart failure, and transient ischemic attacks. R1 admitted to the facility on [DATE]. The Hospital Admission Records, dated 11/21/22, document R1 was brought to the emergency room by a family member for progressive worsening of altered mental status and gait instability over the last four weeks. R1 has had one episode of falling down where stitching was required at the hospital. R1 has been having falls that are mostly backwards. The physical therapy assessment during this hospitalization shows R1 continues to demonstrate decreased safety awareness and impaired functional mobility due to cognitive deficits. R1 is retropulsive and needs frequent queuing to perform activity. The Care Plan, dated 11/29/22, documents R1 is a high risk for falls related to a diagnosis of difficulty in walking, unsteadiness on feet, history of falling and weakness and poor safety awareness. On 12/8/22, the following interventions were documented: R1 was placed on the Falling Star program, the bed is kept in the lowest position, encourage R1 to use call light and ask for assistance, and staff to anticipate R1's needs. On 12/17/22, the only intervention documented is to send R1 out for an acute evaluation due to a fall. There are no other interventions documented after the fall on this day. On 1/20/23, the following interventions were documented: move R1 closer to the nursing station, increased, staff, supervision, and skilled therapy services to evaluate. The Physical Therapy Evaluation, dated 12/5/22, documents R1 requires physical therapy for gait training, safety awareness, and transfer skills. Due to the documents physical impairments and associated functional deficits, R1 is at risk for falls, decline in function, and increased dependency on caregivers. The Fall Risk Assessment, dated 12/7/22, documents R1 scored a 9, which indicates R1 is it a low risk for falls. R1 is documented to be alert and oriented at all times, up ad lib, and has not had any falls in the last three months. This assessment is incorrectly documented based on other facility charting and interviews. The Fall Event ,dated 12/17/22, documents R1 was noted standing up out of the wheelchair and fell to the side landing on R1's side and bumping the head against the wall. R1 is unable to state why the fall occurred. R1 was sitting in a high visual area and stood up before R1 could be reached by staff. R1 when was sent to the hospital for R1 was sent to the hospital for an evaluation but return with no injuries. R1 is ambulatory but does not have a steady gait and is noted with impulsivity. Nursing note, dated 12/17/22, documents R1 was observed sitting in the wheelchair at the nurse's station. R1 stood up out of the wheelchair and fell over onto the left side. R1 did bump the back of the head on the wall. R1 was alert and responsive. R1 was sent to the hospital for further evaluation. R1 was sent back to the facility later in the day with no findings. Nursing note, dated 12/26/22, documents R1 is sitting at the nurse's station due to requiring frequent redirection. R1 makes attempts to ambulate with an unsteady gait. Nursing note, dated 12/28/22, documents R1 requires constant redirection due to walking with an unsteady gait without assistive devices. R1 is often noncompliant with redirection. The Fall Event, dated 1/20/23, documents R1 was sitting in the bathroom on the floor. R1 was assisted to the bed and a body assessment was completed. Blood was noted at the base of the head. R1 was unable to state how the laceration occurred. On the day of the occurrence, R1 was initially observed, sitting on the toilet. R1 was sent to the emergency room and returned with 17 staples at the head and negative imaging. R1 is ambulatory but unsteady. R1 will work with therapy and gait training. Staff have been encouraged to check frequently to provide necessary assistance and meet all needs. Nursing note, dated 1/20/23 at 6:52AM, documents R1 had an unwitnessed fall in the room. The body assessment revealed a laceration to the back of R1's head. R1 was transferred to the hospital for medical evaluation. R1 was on 1:1 monitoring while awaiting hospital transfer. Nursing note, dated 1/20/23 at 11:19AM, documents the hospital called the facility to notify that imaging was being completed on R one. R1 will be receiving 17 staples to the back of the scalp. Nursing note, dated 1/20/23 at 12:33PM, documents R1 received back from the hospital status post fall. R1 had a bandage wrapped around the head. Upon assessment, 17 staples were noted to the back of the scalp in the shape of U. The Final Facility Incident Report, dated 1/26/23, documents R1 was observed sitting on the toilet in assisted back to bed. Upon assessment, the nurse observed blood on the back of R1's head. R1 is alert but confused at times and was unable to articulate what had occurred. However, R1 stated that R1 did not fall. R1 was transferred to the emergency department for an evaluation and returned with a negative CT scan and 17 staples to the posterior head. Upon investigation, blood was noted on the back of the toilet bowl tank. Staff believed R1 pushed back and hit head on the tank. R1 is noncompliant with seeking staff assistance for toileting and transfers. R1's room has been moved closer to the nurse's station to provide increased supervision. R1's plan of care has been updated, including wound and pain regimen. The Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score as 12 (moderate cognitive impairment). Section G of this MDS documents R1 is an extensive two person physical assist with transfers. R1 needs supervision of a one person physical assist with walking in the room and in the corridor. R1 is an extensive one person physical assist for toilet use. On 2/21/23 at 3:14PM, R1 and V3 (Family member) showed this surveyor the healed laceration to the back of R1's head. The healed laceration is pink/red in color and is open to air. It is located directly in the middle of the back of the head in a V shape. It is approximately 3 inches long. R1 reported remembering falling, but was unable to say how many times R1 fell , and was not able to give any details about the falls. R1 was able to state R1's name. R1 stated the date was September 23, 2022, and the president was (previous president). When asked where R1 was, R1 responded in (another city in a casino). R1 stood up to readjust in the bed, and when R1 stood up, R1 kept swaying back and forth until V3 held onto R1. On 2/21/23 at 3:14PM, V3 stated, (R1's) always trying to get up out of the bed, and (R1's) equilibrium is off. (R1) will fall down almost as soon as (R1) gets up. (R1) is not steady and has not been for a while, which is why I brought (R1) to live here. (R10 is confused. Sometimes yes means yes and no means no, but other times, (R1) has no clue what is going on. The last time (R1) fell , (R1) cut the back of (R1's) head and needed staples. They told me that they can't do 1:1 with (R1) here, but they haven't told me anything else that they are doing for (R1).I just want to make sure (R1) doesn't have any more falls where (R1's) hurting herself. On 2/21/23 at 3:43PM, V4 (Restorative Nurse) stated, We put a new interventions anytime there's a new fall or certain interventions are working. We assess interventions quarterly or the time of a new fall. (R1) has poor safety awareness, and it takes a while for certain age things to come together for (R1) to understand. Either myself or the QA (Quality Assurance) nurse is responsible for putting in interventions. An intervention should always be put in after a fall. There's never a reason an intervention should not be put in. The intervention put in depends on the situation. (R1's) a high fall risk because of the lack of safety awareness, unsteady gait and balance, some medications, and the score on (R1) fall risk assessment indicates (R1's) a high fall risk. When a resident is admitted , we will go through the hospital paperwork and put interventions then depending on what they are admitted for . I don't know if (R1) was a high fall risk when (R1) first came in. V4 was asked why R1 scored as not a fall risk on the admission fall risk assessment, and V4 was not able to to answer the quesion. When a resident has a fall, the nurse will also put in interventions that are not as specific. After we meet, then we will update the care plan as needed. Like I said, I was on vacation for that fall (12/17 fall). If no other intervention was put in after she went to the hospital then I can't speak on that. There should always be another intervention put in after they come back. We put in interventions to help prevent falls so they are less likely to occur. On 2/21/23 at 4:03PM, V5 (Physical Therapist) stated, We found out that (R1) can walk, but has poor safety awareness with an unsteady gait. (R1) had some in proper techniques with sequencing issues. (R1) also had poor cognition. It would fluctuate, but usually (R1) was alert and oriented to self, but sometimes it would be times two. With (R1's) cognition, (R1) can't learn anything new, but (R1) can be retrained on what (R1's) body was already able to do. We focus on always having someone with you when getting up or transferring. Sometimes (R1) would respond and do what we asked immediately, but other times you would have to initiate through verbal or tactile cues for (R1) to follow through. During the time we worked with (R1), (R1) had no changes to (R1's) safety awareness. It still remained poor, and that's why we couldn't keep (R1) in therapy. On 2/21/23 at 4:16PM, V6 (MDS (Minimum Data Set)/Care Plan Nurse) stated, Every department head is responsible for updating the care plans individually. I then do an audit once a month to make sure everything in the care plan is up to date. If I find something is missing, then I would go to that department manager and let them know what is missing. If a resident has a fall and they are missing an intervention, then I would let restorative know. When a resident first comes back from the hospital, they need a new intervention as soon as they come back. I would tell them verbally or write note and leave it for them that they need to update the care plan. If there isn't a new care plan then they forgot or thought someone else put it in. It should always be put in. On 2/21/23 at 5:26PM, V7 (Nurse) stated, We had (R1) sitting in the chair at the nurse's station with us, and (R1) stood up and fell over to the left side out of the chair. (R1) didn't stand all the way up, but (R1) had (R1's) butt off the back of the chair, and just fell over to the side. (R1) thinks (R1's) more independent than (R1) is, and that (R1) can walk, but (R1) can't. A couple of us were sitting there, but we yelled for (R1) to sit down, but (R1) didn't listen, and we couldn't get to her in time. (R1) has an unsteady gait and is just very wobbly. Yes, (R1) is a high fall risk. (R1) is a high fall risk because of the unsteady gait, and being confused. I would say (R1) is alert and oriented to her name. (R1) can follow directions for a while, and then (R1) forgets what you said. I don't know who puts in interventions. I am only there PRN (as needed) every other weekend. I'm not sure how to find what gets put into place for residents. I don't know what was put into place after this fall. No, I did not enter in any interventions after the fall that night. On 2/21/23 at 8:53PM, V8 (Nurse) stated, I went to (R1's) room just after around 5 in the morning to start passing medications. I noticed (R1) was not in the bed. I went into the bathroom and I saw (R1) sitting on the toilet pulling on the brief. I went to bring (R1) back to bed, and saw blood around (R1's) neck. I asked (R1) if (R1) fell , and (R1) told me no, that (R1) picked a scab on (R1's) face. I told (R1) there would not be that much blood from a scab like that. I started looking through (R1's) hair, but (R1's) hair was very dense, and I did see blood on the back of (R1's) head. I told (R1's) CNA (Certified Nursing Assistant); we got (R1) dressed and brought (R1) out to the nurse's station, and I assessed (R1) again; in the light and I saw the laceration. (R1) likes to keep trying to walk around alone. (R1) has dementia, so (R1) will repeat the directions that you give her, but (R1) will still do what (R1) wants. I know management will have full meetings to put in interventions. We just know who is a high fall risk for the residents that have been here a while. The managers put in the intervention after the fall. We just let them know that the resident had a fall. I know she had to get 17 staples to the back of (R1's) head. We are updated on new interventions from what we get in report. I know (R1) had a fall before, but I don't know what new interventions were put in place. On 2/22/23 at 11:13AM, V9 (Quality Assurance/ QA Nurse) stated, We have a meeting with the IDT (Interdisciplary Team) after every fall. If the fall happens over the weekend or when we aren't here, we will have it the morning the next day, or first thing that Monday. I do put in interventions along with the other department heads. We all try to communicate with each other on when and what interventions are being put in so we know as a team. We agree as a team on what interventions are being put in for people. I do know that (R1) has had a couple falls. The first intervention we normally put in is sending people to the emergency room for an evaluation. After they come back, that is when we will add an intervention that is specific to the fall. The intervention we come up with depends on who the resident is and what caused the fall. We are trying to make sure that we prevent another fall from happening, so we make sure the intervention matches what caused the fall. Per the progress note, (R1) had a fall on 12/17. On 12/19, an intervention was put in place by me that (R1) was sent out to the hospital for an evaluation. Interventions are usually put into place that same day or the next day by the IDT. Usually the nurse will put in a general intervention, and then we will assess what they put in and add anything else that is needed. We are usually pretty good about it, and normally only takes us two or three days before we get an intervention in the care plan. An intervention should be added after every new fall. There is no reason an intervention should not be added after a fall. The only intervention after that fall was what I put in the 19th of her being sent out to the hospital for an evaluation. I don't see anything in (R1's) care plan added after that until the second fall happened. I'm gonna be honest with you. I was out sick a couple days after that fall, so it's probably something that was just missed on our end. There was no new interventions put in place after (R1) came back from the hospital. Normally, we would've put an intervention that was related to the reason (R1) fell . We put in interventions to try to help from the same fall occurring twice. (R1) did have a fall again after this. I don't know what happened with that fall, but (R1) was sent to the hospital again and I believe had some injury. I can't remember what the injury was. On 2/22/23 at 11:30AM, V10 (CNA/Certified Nursing Assistant) stated, I know the nurse came to tell me that (R1) fell , and (R1) had a cut on the back of (R1's) head, so I sat and watched (R1) while the nurse got everything ready for (R1) to go out. I do know that (R1) is always trying to get up on (R1's) own and never really listens to what we are telling (R1). (R1) can't walk very good either. (R1) is always falling down when (R1's) trying to stand back up and just is not steady. I don't know what (R1's) interventions were added after the first fall. We just know who is a higher fall risk because we've been working with them. On 2/22/23 at 2:15PM, V2 (Assistant Director of Nursing/ADON) stated, I just make sure that there is documentation in place after a fall. I make sure that the calls were made to who they were supposed to go to. I make sure the assessments are done after the fall, and I make sure that the interventions are documented after we decide what to put in place. As a team we meet each morning Monday through Friday to discuss anything that has happened with the resident. Interventions are put in usually immediately after the fall. A nurse on the floor who is taking care of the resident at that time of the fall will put in an intervention. They always call to notify us about the fall, so I will always follow up to make sure they put an intervention. After we meet with the team, we then put in another intervention if we feel we need one. The only reason we wouldn't put in an intervention is if they're at the hospital and not in the facility. We always make sure we do some thing when they come back. I don't remember what we put into place for (R1) after each fall. The expectation is that an intervention is put in after the fall either by the team or the nurse.(R1) is not safe to ambulate alone due to (R1's) overall status. That is how (R1) came to us. (R1) came to us from the hospital because (R1's) family could not take care of (R1) anymore at home. (R1) kept falling at home. (R1) was a high fall risk on admission because of this. I would say (R1) is normally alert one to two, but no more than that. We have a care plan team of different nurses, and it would be their responsibility to put in the intervention in the care plan. They discuss amongst themselves who put in the intervention for each specific resident and fall. If no intervention was put in after the first fall, then I don't know what each staff member was doing to monitor (R1). It's better when we have then in place on the care plan so everyone can follow the same interventions. On 2/22/23 at 2:58PM, V11 (Primary Physician) stated, I remember (R1), but I cannot remember this situation. I am not responsible for putting in interventions. That would be whoever they want in the facility to do that. They should be following their policies the best they can. I don't remember how this resident walks. I believe she uses a wheelchair or some other assistive device. Falls aren't something that can be prevented, but we try to make sure that they are as safe as possible to prevent any serious injuries. The policy titled, Falls and Fall Risk Managing, dated 08/2008, documents, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Prioritizing approaches to managing falls and fall risk: 1. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident fall risk identify several possible interventions, the staff may choose to prioritize interventions . 6. Staff will identify an implement relevant (e.g., hit padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring, subsequent falls and fall risk: 1. The staff will monitor and document each resident response to interventions intended to reduce falling or the risks of falling. The policy titled, Falls- Clinical Protocol, dated 08/2008, documents, . Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls into address risks of serious consequences of falling . 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops, or until a reason is identified for its continuation (for example, if the individual continue to try to get up and walk without waiting for assistance) . monitoring, and follow up: . 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized, even if falls cannot be prevented.

Based on observation, interview, and record review, the facility failed to provide residents with supervision while in the dining room at breakfast time, and failed to monitor residents while in the smoking area, in accordance with facility protocols for resident supervision. These failures applied to four of four residents (R1, R2, R3, and R4) reviewed for supervision, and resulted in R2 getting hit in the face and sustaining an injury to the right eye, and R3 being transferred to local hospital for evaluation after being hit in the face. Findings include: 1. R1 is a [AGE] year-old male, originally admitted to the facility 7/8/2005, with diagnoses including: [CONDITION(S)], major depressive disorder, [CONDITION(S)], and [CONDITION(S)] disorder. During his stay at the facility, R1 has been assessed to have aggressive behaviors toward staff and residents. Care plan for R1, dated 8/16/2022, indicated R1 has a history of aggressive behavior, as he may experience an increase in agitation related to delusional thoughts. R2 is a [AGE] year-old female, originally admitted to the facility for 4/18/16, with diagnoses including [CONDITION(S)] and [CONDITION(S)]. R2 does not have a history of being physically aggressive per EMR (electronic medical record) documentation. Review of facility records documents on 7/19/2022 at approximately 7:00 AM, R1 and R2 were in the dining room preparing for breakfast. R2 was speaking with another resident at the table, when R1 approached her, and initiated a verbal altercation. The verbal altercation escalated when R1 picked up a chair and used it to hit R2 across the face. R2 sustained a scratch under her right eye that resulted in bleeding, swelling, and bruising. There was no staff present who witnessed this altercation or intervened at any time. R1 was sent for a psychiatric evaluation, and R2 refused to seek medical treatment outside of the facility. R1 was readmitted to the facility 8/31/22, with newly initiated care plans addressing aggressive behaviors. No care plans for behaviors prior to this incident were given, despite R1 having a history of aggression. On 9/9/22 at 1:30PM, R2 was observed in room, ambulating with walker, alert and oriented. A dark colored bruise was noted under the right eye. R2 said, (R1) took a chair and hit me in the head. I didn't do anything to provoke him; he said I was talking too much crap. Some people (residents) saw it, but some didn't. We were waiting for breakfast, and I was talking to my friend. (R1) came over and got mad and threw a chair on my head. The whole eye was bleeding, and I was so angry I wanted to throw a chair at him too. I went to the nurse and I told them I didn't want to go to the hospital; they sent him instead. There was no staff to break us up. After he hit me I went to the nurse. On 9/09/22 at 2:25 PM, V5, Clinical Director, said, (R1) displays behaviors of agitation sometimes. I believe at the time of this incident, staff were on their way to the dining room, and the altercation was unwitnessed. On 9/09/22 at 2:38PM, V1, Administrator, said, Staff should be always supervising the dining room when it is open. If we only have one staff available to monitor, all the residents are moved to one side. On 9/09/22 at 2:57PM, V6, Certified Nursing Assistant/CNA said, I was in the small dining room, either picking up trays, passing trays, or supervising. I remember (R2) yelling and cursing. I didn't witness a physical altercation. I didn't go to see what was going on because I thought someone else was on that side of the dining room. EMRs reviewed for R1 and R2. Both R1 and R2 were assessed for being at risk for sustaining abuse. 2. R3 is a [AGE] year old male, originally admitted to the facility 11/30/2009, with diagnoses including [CONDITION(S)] and [CONDITION(S)] following cerebral vascular disease affecting left non-dominant side, dementia, and [CONDITION(S)] disorder. R3 is alert and oriented, and able to follow simple commands upon request. On 9/9/22 at 1:59PM, R3 was observed in bed, alert, dressed, and unable to answer questions appropriately. At 2:05 PM, V3, Licensed Practical Nurse/LPN said, I am the nurse for (R3). He might not be able to reply, but he uses gestures in order to express himself. That could make him more vulnerable to abuse. Facility Abuse Risk Review (dated 5/16/22) stated R3 is is at-risk for all kinds of abuse related to severity of mental illness symptoms, cognitive functioning, and medical co-morbidity. No interventions were indicated. R4 is a [AGE] year old male, who was admitted to the facility 8/10/18, with diagnoses including [CONDITION(S)]. R4 was originally admitted to the facility from a local hospital, where he was primarily treated for aggressive behaviors. During his stay at the facility, R4 was identified as a criminal offender with a history of violent behavior, and exhibited aggressive behaviors towards staff and residents. Facility records show on 7/01/22, R4 approached R3 in the smoking area and physically attacked him. R3 sustained knots on his head, and was hospitalized for further evaluation. A staff member on duty at the time indicated R3 and R4 were not in their field of view when this incident occurred because they were in the doorway of the smoking area with another staff member who was also responsible for monitoring. R4 was sent to the hospital for psychiatric evaluation and did not return. On 9/9/22 at 4:14PM V7, Certified Nursing Assistant/CNA, said, During smoke time, (R4) came outside, started yelling and hitting on (R3). Me and the Activity Aide were at the door passing out the cigarettes. (R3) can't do much; he's not very strong, so he was just sitting there getting hit. (R3) was sitting by the gate, not right in front of the door where he could be easily seen. Me and the Activity Aide broke it up after (R4) hit (R3) in the face. This incident could have been prevented if someone was outside and keeping a closer eye on the patio. On 9/10/22 at 1:38 PM, V8, Activity Aide, was observed during smoking activity. V8 said, I am the only person out here physically at the moment, but there should be three staff members assigned to monitor the smoking area when its open. This does not include the person at the door who passes out the cigarettes. The staff who are monitoring are supervising to make sure that the smoking rules are being enforced and to prevent altercations. Whenever residents are in a room together, they need to be supervised. On 9/10/22 at 2:38PM, V1, Administrator, said, There should be three people monitoring the smoking area at all times. Facility Abuse Policy reviewed which states in part; Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Facility was asked for any policy related to supervision during dining or smoking upon; none were provided during the course of this survey.

Based on observation, interview, and record review, the facility failed to keep residents free from physical abuse from another resident. These failures applied to four of four residents (R1, R2, R3, and R4) reviewed for abuse, and resulted in R2 getting hit in the face and sustaining an injury to the right eye, and R3 being transferred to local hospital for evaluation after being hit in the face. Findings include: 1. R1 is a [AGE] year-old male who was originally admitted to the facility 7/8/2005, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During his stay at the facility, R1 has been assessed to have aggressive behaviors toward staff and residents. Care plan for R1, dated 08/16/2022, indicated R1 has a history of aggressive behavior, as he may experience an increase in agitation related to delusional thoughts. R2 is a [AGE] year-old female, originally admitted to the facility for 4/18/16, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 does not have a history of being physically aggressive per EMR (electronic medical record) documentation. Review of facility records documents on 7/19/2022 at approximately 7:00 AM, R1 and R2 were in the dining room preparing for breakfast. R2 was speaking with another resident at the table, when R1 approached her, and initiated a verbal altercation. The verbal altercation escalated when R1 picked up a chair and used it to hit R2 across the face. R2 sustained a scratch under her right eye that resulted in bleeding, swelling, and bruising. There was no staff present who witnessed this altercation or intervened at any time. R1 was sent for a psychiatric evaluation, and R2 refused to seek medical treatment outside of the facility. R1 was readmitted to the facility 8/31/22, with newly initiated care plans addressing aggressive behaviors. No care plans for behaviors prior to this incident were given, despite R1 having a history of aggression. On 9/9/22 at 1:30PM, R2 was observed in room, ambulating with walker, alert and oriented. A dark colored bruise was noted under the right eye. R2 said, (R1) took a chair and hit me in the head. I didn't do anything to provoke him, he said I was talking too much crap. Some people (residents) saw it, but some didn't. We were waiting for breakfast, and I was talking to my friend. (R1) came over and got mad and threw a chair on my head. The whole eye was bleeding, and I was so angry I wanted to throw a chair at him too. I went to the nurse and I told them I didn't want to go to the hospital; they sent him instead. There was no staff to break us up. After he hit me I went to the nurse. On 9/09/22 at 2:25 PM, V5, Clinical Director, said, (R1) displays behaviors of agitation sometimes. I believe at the time of this incident, staff were on their way to the dining room, and the altercation was unwitnessed. On 9/09/22 at 2:38PM, V1, Administrator, said, Staff should be always supervising the dining room when it is open. If we only have one staff available to monitor, all the residents are moved to one side. On 9/09/22 at 2:57PM, V6, Certified Nursing Assistant/CNA, said, I was in the small dining room, either picking up trays, passing trays, or supervising. I remember (R2) yelling and cursing. I didn't witness a physical altercation. I didn't go to see what was going on because I thought someone else was on that side of the dining room. EMRs reviewed for R1 and R2. Both R1 and R2 were assessed for being at risk for sustaining abuse. 2. R3 is a [AGE] year old male, originally admitted to the facility 11/30/2009, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility Abuse Risk Review (dated 5/16/22) stated R3 is is at-risk for all kinds of abuse related to severity of mental illness symptoms, cognitive functioning, and medical co-morbidity. No interventions were indicated. R3 is alert and oriented, and able to follow simple commands upon request. On 9/9/22 at 1:59PM, R3 was observed in bed, alert, dressed, and unable to answer questions appropriately. At 2:05 PM, V3, Licensed Practical Nurse/LPN said, I am the nurse for (R3). He might not be able to reply, but he uses gestures in order to express himself. That could make him more vulnerable to abuse. R4 is a [AGE] year old male, who was admitted to the facility 8/10/18, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was originally admitted to the facility from a local hospital, where he was primarily treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility records show on 7/01/22, R4 approached R3 in the smoking area, and physically attacked him. R3 sustained knots on his head and was hospitalized for further evaluation. A staff member on duty at the time, indicated R3 and R4 were not in their field of view when this incident occurred ,because they were in the doorway of the smoking area with another staff member, who was also responsible for monitoring. R4 was sent to the hospital for psychiatric evaluation and did not return. On 9/9/22 at 4:14PM, V7, CNA, said, During smoke time, (R4) came outside, started yelling and hitting on (R3). Me and the Activity Aide were at the door passing out the cigarettes. (R3) can't do much; he's not very strong, so he was just sitting there getting hit. (R3) was sitting by the gate, not right in front of the door where he could be easily seen. Me and the Activity Aide broke it up after (R4) hit (R3) in the face. This incident could have been prevented if someone was outside and keeping a closer eye on the patio. On 9/10/22 at 1:38 PM, V8, Activity Aide, was observed during smoking activity. V8 said, I am the only person out here physically at the moment, but there should be three staff members assigned to monitor the smoking area when its open. This does not include the person at the door who passes out the cigarettes. The staff who are monitoring are supervising to make sure that the smoking rules are being enforced and to prevent altercations. Whenever residents are in a room together, they need to be supervised. On 9/10/22 at 2:38PM, V1, Administrator, said, There should be three people monitoring the smoking area at all times. Facility Abuse Policy reviewed which states in part; Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Facility was asked for any policy related to supervision during dining or smoking upon; none were provided during the course of this survey.

Based on observation, interview and record review, the facility failed to effectively monitor and supervise a legally blind resident, failed to evaluate and update care plan interventions following each fall and failed to implement individualized care plan interventions for fall prevention as per their policy for one of three residents (R3) in the sample reviewed for falls. These failures resulted in R3 experiencing multiple falls with injuries that required hospital treatment. Findings include: R3's diagnoses (per face sheet) include but not limited to [CONDITION(S)], Malignant Neoplasm of Larynx, [CONDITION(S)] with Seizures and Syphilis Unspecified. On 7/12/21 at 10:26 am, observed R3 in his room asleep on a low bed pushed all the way against the wall and fall mat was observed on one side of the bed. On 7/13/21 from 9:03am until 12:45pm, R3 was intermittently awake or asleep in a low bed with fall mat on one side, with bed pushed back against the wall. On 7/14/21 at 10:14am, with V4, ADON (Assistant Director of Nursing) visited R3. R3 was awake. Observed R3 unable to see, able to pull call light when in his hand, and able to stand up and walk. Observed V4 and a staff assist R3 to walk in room. On 7/14/21 at 1:13pm, observed R3 asleep in low bed with no fall mat. V10 was asked if R3 has fall mat on the floor, V10 said no, and to ask Restorative. R3 had a history of falls according to the following information: 1. R3's progress notes dated 5/1/21 at 11:31pm documented, R1 was found on the floor lying face down noted with a cut to the left side of fore head at the end of his left eyebrow. R3 was sent to emergency room for treatment. Local Hospital emergency room documents dated 5/2/21, R3 had a 2.5 centimeter laceration on the left eyebrow region, requiring sutures. CT (Computed Tomography/computerized x-ray imaging) of the Head done with results: Impression: New 7.4mm well defined focus of high density within the posterior aspect of the left insula compatible with small focus of subarachnoid hemorrhage (Brain bleed). R3 was transferred to a local Trauma Hospital for further evaluation (per 5/2/21 facility progress notes). R3 returned to the facility on [DATE] (per progress notes), with diagnosis of Subarachnoid hemorrhage, head injury, nasal bone fracture, left orbital fracture and left eyebrow sutures. 2. R3's progress notes dated 5/4/21 4:24am documented, R3 was found sitting on the floor with a small amount of blood near the top of his head. A small laceration was found near the top of the forehead. R3 was sent to a local hospital for treatment. 3. R3's Progress notes dated 6/10/21 2:10pm documented, Resident is placed on floor per his care plan to prevent fall. Resident hit his head trying to roll from side to side on his floor bed. Skin cut on his forehead. R3 was sent to emergency room . R3's emergency room documents dated 6/10/21 stated in part; The patient states that he attempted to get out of his bed and fell on to the ground hitting the left side of his head. CT of the Facial bones result showed Mild preseptal soft tissue swelling of left orbit and CT of the brain result showed Mild soft tissue swelling with laceration over the left frontal calvarium (part of the skull). A three centimeter laceration of the frontal scalp was sutured. 4. R3's progress notes dated 6/16/21 8:15am stated in part; Staff made aware resident was observed on the floor in his room. Resident noted lying on left side in room with floor mat in place Noted with open area above left eyebrow. R3's local hospital document dated 6/16/21 stated in part, Patient presented from the nursing home after he fell and hit his head. Patient was found to have a laceration of the forehead for which he received stitches. He was discharged back to the nursing facility. Following discharge chest x-ray reported left sided pneumothorax and therefore the patient was called back to the hospital. 6/16/21 History and Physical Examination Assessment and Plan indicated, Pneumothorax: likely traumatic. Treatment for the forehead laceration included Wound closure Derma bond Advanced. A 6/16/21 Chest X-ray result moderate to large left sided pneumothorax persists, slightly increased in size compared to the previous exam. The following interviews were conducted regarding R3's falls: On 7/13/21 at 9:53am, V10 (Licensed Practical Nurse), on duty at the time R3 alleged fall on June 16, 2021, said R3 was in bed at that time, behavior was agitated, redirected couple of times, we have been there a couple of times to redirect him. I gave him [MEDICATION(S)] to calm him down he is visually impaired. We check on him at least every hour. Injury, he had a laceration on the left eye brow and was sent to the hospital. The bed was on low position and floor mat was in place. V10 was asked how R3 sustained injury with the low bed and fall mat. It was an unwitnessed fall but he probably stand up and attempted walking. On 7/14/21 at 9:54am, V10 was asked what other interventions can be done for R3 to prevent falls. V10 said, At this point it would be one on one supervision, or put him on the Broda chair here in the nursing station. On 7/13/21 at 2:10pm V4, ADON, who was the facility Fall Coordinator said, R3 attempts to ambulate which cause him to fall. V4 also indicated R3's gait was impaired, and judgement poor. The fall interventions in place for R3 were frequent monitoring, fall mat, low bed, call lights, toileting and inclusion in Falling star program and bringing R3 to the nursing station where multiple staff can watch him. V4 also said Restorative evaluate R3 for other fall interventions such as alarms which he had in the past but discontinued because it was not effective. V4 also said that the other option was for R3 to be on one to one, but we cannot always provide one to one. On 7/14/21at 10:47am, V12 (Restorative Nurse) said The IDT (Interdisciplinary Team) makes the decision what intervention to put in place for a resident who keeps on falling. Fall mat is not indicated for R3 because when he tries to ambulate he can trip over the fall mat. If he fall from the bed then low bed will break the fall. R3's nursing care plan addressed care issues including falls on the following dates: 8/21/20: Continue to assist with dressing and grooming. Therapy to evaluate. Therapy to evaluate on return. 5/3/21 upon return will be added to falling star program. Will encourage to engage in scheduled activities and be placed on location monitoring and offered toileting. Educated to use call light and ask for assistance for transfer. Kept in high visual places. Continue with dressing and grooming. 6/17/21 upon return, will be evaluated for appropriate safety devise. He will continue with low bed and continue to keep in common area when possible. Educated on call light and ask for assistance for transfer. Kept in high visual area. Continue to assist in grooming. Upon return will be added to star program. A fall mat was not included in any of the care plan reviewed. Policy and Procedure titled Falls and Fall Risk Managing 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on interview and record review, the facility failed to provide a safe environment by placing a resident with a history of aggressive behaviors in a room with a resident who was at risk for being abused. This failure resulted in R2's emergent transfer to a hospital with the following injuries of :a fracture of bilateral nasal bones with soft tissue swelling and a left frontal scalp hematoma after an incident with roomate (R1). Findings include: R1 is [AGE] years old with [DIAGNOSES REDACTED]. R1 has documented history of physically aggressive behaviors, dating back from 2017, including: 7/17/19 hit peer in the eye; 1/19/20 pulled peers hair; 2/19/20 verbally aggressive. R1's aggressive documented as at risk; may become physically aggressive towards others due to impulsivity . R2 was [AGE] years old, with [DIAGNOSES REDACTED]. R2 was put on Hospice Care starting from 11/19/2020 up to time of passing on 6/3/2020. R2 was assessed as at risk for Abuse. Aggressive Risk review indicated that R2 has history of verbal aggression but has not exhibited such behavior recently. Progress notes dated 4/16/2020 documented that R1 struck R2 three times in the face. R2 was sent to the hospital and came back to the facility with documented injuries of [MEDICAL CONDITION] nasal bones with perinasal soft tissue swelling, Left frontal hematoma. At the time of this incident, R1 and R2 were roommates. On 8/19/2020 at 2:09PM, V1 (Administrator) said that the BIMS (Brief Interview for Mental Status) is the basis of roommate selection. The facility also takes in consideration the history of aggressive behavior. R1's BIMS' score at the time she was transferred to R2's room was 15, intact cognition, and R2 was 11 moderately impaired. R1's care plan approaches for R1's Behavior were: Anticipate needs in order to decrease behavioral symptoms. Social services to assess R1's aggression. Staff will separate resident from others as needed. R1 will be monitored by staff. R1 will be reminded and redirected to lower risk of harm by staff. R1 will be reminded that staff is available 24/7 to assist at all times to provide emotional support and whatever support she needs. Redirect R1 during periods of increased agitation. R1 to refer to psychologist/psychiatrist for behavior management as needed. On 8/20/2020 at 10:38 AM, V11 (Social Services Director) said that R1's treatment plan should have been more individualized. Not just a cookie cutter type. The approaches should have been more specific and the facility is working on training staff. V11 also said that R1 has unpredictable behavior, with incongruent affect, and does not show signs and symptoms leading to aggressive behavior and knowing these facts, does not think it was safe for R1 and R2 to be in the same room. Abuse Prevention Policy and Prevention state in part; The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriations of property and mistreatments by anyone including, but not limited to facility staff . or any other individuals. Care Plans Policy dated 4/2015 state in part; An individualized Comprehensive Care Plan that includes measurable objectives and timetable to meet the resident's medical, nursing mental and/ or psychological needs is developed for each resident. 6. Care plans are revised as changes in the resident's condition dictates.

Based on observation, interview, and record review, the facility failed to follow their policy titled, Falls-Clinical Protocol, by not implementing any new interventions after a fall for a resident with episodes of [MEDICAL CONDITION] and failed to monitor the effectiveness of current fall interventions for one (R1) of three residents reviewed for falls in a total sample of five. This failure resulted in R1 having a second episode of [MEDICAL CONDITION] , falling and being transported to the local hospital to be treated for [REDACTED]. Findings Include: Per the Face-sheet, R1 is a [AGE] year old with the following Diagnosis: [REDACTED]. A Nursing note dated 6/3/19 documents R1 stood up to get R1's weight taken and fell backwards hitting R1's head. Injury noted to the back of R1's head and a dry pressure dressing applied to control the bleeding. R1 sent to the hospital and was admitted for [MEDICAL CONDITION]. The Hospital Records dated 6/4/19 document R1 passed out and reports feeling lightheaded before falling. R1 developed a laceration which was sutured in the emergency room . A Nursing note dated 6/4/19 documents R1 returned to the facility with a dry dressing to the right side of R1's head and seven staples to the head. The Facility Incident Report dated 6/5/19 documents R1 fell due to an episode of [MEDICAL CONDITION] and returned to the facility with seven staples to the head. A Nursing note dated 7/3/19 documents R1 became faint and the nurse caught R1. R1 assisted back to bed and the doctor was notified. A Nursing note dated 12/18/19 documents R1 was ambulating to the nurse station when R1 fell backwards. An assessment was performed on R1 and blood noted coming from the back of R1's head. R1 sent to the hospital per the doctor's order. The Facility Incident Report dated 12/18/19 documents R1 collapsed to the floor, striking the back of R1's head. R1 received three stitches to the back of the head and the fall is believed to be related to R1's [MEDICAL CONDITION]. Care Plan to be updated upon R1's readmission. A Nursing note dated 12/19/19 documents R1 admitted to the hospital for [MEDICAL CONDITION], receiving two stitches to the back of the head. A Nursing note dated 12/20/19, R1 readmitted to the facility from the hospital with three staples to the right side of the head. R1 reported getting dizzy at the nurse's station and passed out, causing the cut to R1's head. R1 instructed to sit on the side of the bed three to five minutes before getting up to help blood pressure from dropping. The Hospital Records dated 12/20/19 document R1 found with profound orthostasis and was admitted for the same. R1 started on a blood pressure support medication. On 1/2/2020 at 1:13PM, no interventions noted in R1's room for falls. R1 ambulating the halls freely. On 1/2/2020 at 1:42PM, R1 ambulating with no assistive devices or supervision. R1 with three sutures to the back of the right side of the head that are healing. R1 stated, I fainted twice actually going to get my medication, so I think I am scared to get up to get it or something. I was walking to the nurse's station both times and right before I was lying down in my bed. I got up and went to go get my medicine and I fell on the floor. No, I didn't sit on the side of the bed for a couple minutes before I got up first. I think I just forgot I had to do that and got up. Sometimes I get dizzy and things go black, but sometimes it happens so fast I can't even tell it is coming. Both times I busted my head open and had to go to the hospital to get staples. The first time I got seven staples and this time I got three, I think. No one told me anything or did anything after either fall. I still walk around when I want and stuff like that. In the hospital, they told me I need to sit at the side of my bed before I stand up for five minutes, so I don't pass out. When I came back the only person to tell me to do that was the nurse {V4, LPN} I didn't have any meetings or anything with someone telling me what they are going to do now that I fell twice. Yes, I was started on another medication but I don't remember what it was or what it is for. No, I don't get my blood pressure checked every day. I don't remember how often I get it done but it's less than once a week. I don't know what they are doing to keep me from falling again. Sometimes I don't remember to sit on the side of my bed and I get dizzy when I start walking but I haven't fell yet again. On 1/2/2020 at 2:14PM, V3 (CNA) stated, No high fall risks on the D wing. I guess we find out who is high fall risk through hearsay. I haven't seen anybody with any fall interventions in place that I know of. On D wing, everybody can walk. No one needs supervision when they walk on D wing. I never heard about R1's fall from anybody. This is my first time hearing about it. There is a look back on the computer system we use and it will tell you there if the person is a high fall risk or not. I have never looked in R1's chart. I think because of HIPAA policy. On 1/2/2020 at 2:46PM, V4 (LPN) stated, The management will let us know if something happened that makes them a high fall risk. I went to get R1 before lunch time and R1 was coming up to the nurse's station. I was getting the accu-check machine ready to test R1's blood sugar and I had my back turned. I heard a boom and turned around and R1 was on the floor. No, I don't know what fall interventions R1 has in place. I know they changed some of R1's insulin when R1 came back from the hospital. R1 has some stitches to the back of the head. I think R1's admitting [DIAGNOSES REDACTED]. I don't know who is in charge of falls here. We have a stand up meeting every morning and they let us know when new interventions are put in place. I know R1 was just admitted from the hospital with [MEDICAL CONDITION] and R1 has some insulin changes but that is all I know. On 1/3/2020 at 11:25AM, V5 (LPN) stated, R1 was walking up to the nurse's station to come get R1's blood sugar checked I think. R1 was in the doorway and R1 just fell back. We weren't able to catch R1 before R1 hit the floor. R1 hit her head and we sent R1 out to the hospital. She came back with some stitches or staples. This was the first time R1 fell like this for me. We just tell R1 to dangle first, before R1 starts walking. I can't tell you if R1 does it or not. R1 is independent, so we don't really need to monitor if R1 is doing that. We take her blood pressure every day and every shift to monitor it. No, we don't do a meeting or anything here after a fall. We do 72 hour charting once they come back from the hospital to see how they are adjusting to post fall. It would probably be a doctor's order that is an intervention. If they come back from the hospital with new orders, then we follow those. We just watched R1 more closely for 72 hours. On 1/3/2020 at 12:45PM, V6 (DON) stated, We put an immediate intervention in immediately so they don't fall again. We send them out to the hospital if they hit their head. The Fall Committee meeting happens the next day and we discuss the fall and we come up with an intervention. We then talk about the fall after they come back from the hospital and follow up with the recommendation from the hospital and use those in our interventions. We also do the reportable, if it results in any injury. This was [MEDICATION NAME] because we can't control it. R1's fall was due to a medical reason. The hospital started [MEDICATION NAME] for R1 when R1 came back and that has been the only intervention that was put in place. We are also monitoring her blood pressures and blood sugars every day. With [MEDICATION NAME], a blood pressure should be taken before giving it every time. On 1/3/2020 at 1:05PM, V6 stated, Yes, the vital signs should have been being taken every shift. [MEDICATION NAME] is a medication where you need to do that and it wasn't being done. The ADON and myself just went and changed the order so it will start being taken once a shift now. I understand your concern with R1's falls. [MEDICAL CONDITION] are a medical condition that can cause falls as well and we have to put interventions in place for those residents, so I see what you mean. The Physician order [REDACTED]. The Care Plan dated 6/5/19 documents R1 is at risk for falling related to diabetes mellitus, acute kidney failure, and [MEDICAL CONDITION] and collapse. No interventions put into place after the fall on 12/18/19. The Medication Administration Record [REDACTED]. The blood pressures for R1 reviewed from 06/2019 to 12/2019. Blood pressures only being taken on the 7th of every month. The policy titled, Falls- Clinical Protocol, dated 08/2008 documents, The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Risk factors for subsequent falling include lightheadedness or dizziness, . Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent fall and to address risks of serious consequences of falling. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

Based on interview and record review, the facility failed to ensure that staff protected a resident that was assessed as a high risk for physical abuse, failed to notify a physician regarding an increase in aggressive/delusional behaviors, failed to notify the psychiatrist after a resident to resident physical assault, failed to ensure that a resident was closely monitored after a [MEDICAL CONDITION] medication was discontinued and failed to ensure that staff provided supervision per facility policy for two residents (R3, R4) of five residents reviewed for abuse. These failures resulted in R3's physical assault on R4 which required an emergent transfer to a hospital with the following injuries: facial trauma, one centimeter (cm) laceration to right cheek that required two sutures, a two centimeter laceration to right index finger which required four sutures, a [MEDICATION NAME] fracture of right fourth finger and a fractured left wrist. Findings include: R3's Resident Face Sheet documents a medical [DIAGNOSES REDACTED]. R3's medical record documents a history of three incidents of resident to resident physical altercations in which R3 was the aggressor. Two of the incidents involved R3's former room mates: 4/21/19: R3 hit roommate. 5/2/19: R3 involved in a physical altercation in lunch room and hit peer with a lunch tray and 5/6/19: R3 physically assaulted roommate. It is documented on a reportable abuse form that on 5/6/19, R3's roommate was standing on R3's side of the room. R3 physically assaulted her roommate and caused multiple bruises/scratches. R3's Minimum Data Set ((MDS) dated [DATE] documented that R3 was Cognitively Intact. R3's Care Plan dated 5/1/19 documents: (R3) is at risk for adverse consequences related to receiving antipsychotic medication for treatment of [REDACTED]. Intervene as needed. Monitor (R3's) behavior and response to medication. R3's Care Plan dated 4/24/19 documents: (R3) has verbal and physical behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing and striking at others). Approach: Assess whether (R3's) behavior endangers herself and/or others. Intervene if necessary. R4 is R3's roommate. R4's Resident Face Sheet documents a medical [DIAGNOSES REDACTED]. R4 is [AGE] years old. R4's MDS dated [DATE] documents in the Cognitive Patterns section that R4 is rarely/never understood. R4's Abuse Risk Review dated 7/19/19 documents that R4 is at risk for Physical abuse due to Serious Mental Illness and Confusion/disorientation. R4's Care Plan dated 7/10/19 documents: R4 is a suitable for risk of abuse and neglect due to her [DIAGNOSES REDACTED]. (R4) will be reminded and redirected to lower risk of harm. On 9/11/19 at 1:44pm, V6 (Social Services Supervisor) stated, The reason (R3) got into it with prior roommates was because they were loud and had a lot of visitors. That's why we paired her with (R4) who has no visitors and is quiet. I didn't think (R3) would be a threat to (R4). On 9/11/19 at 10:45am, V5 (LPN-Licensed Practical Nurse) indicated that R3 was moved into R4's room after the physical altercation with a room mate on 5/6/19. R3's Resident Census sheet documents that she was moved into R4's room on 5/8/19. R4's medical record documents that on 9/8/19, R4 was physically assaulted by R3 and that it was unwitnessed. R4's progress note authored by V5 and dated 9/8/19 at 9:42pm documents: Nurse was called by CNA (Certified Nurse Assistant) stating that (R4) was on the floor. Writer immediately went to room and notice(d) resident lying on left side by (R3's) bed. Resident was examined and observed with blood and multiple purple/reddish discoloration on left side on back, buttock, right shoulder, left arm to forearm, left hand swollen. Laceration on right cheek, right index finger and by right side of eye. Resident was placed back in bed in a comfortable position, (R3) was asked to leave room so that (R4) can be properly assessed and cared for. Upon (R3) getting out of bed, staff noted a belt with blood stains on it. R3's progress note authored by V5 and dated 9/8/19 at 10:20pm documents, in part: Writer noticed that (R4) had bruises and red marks on her body, writer asked (R3) what happened. Writer suspected that (R3) have something to do with it. R4's hospital record dated 9/9/19 documents that the following treatments were performed as a result of the injuries: Laceration repair to right cheek. One centimeter (cm) in length and required two sutures. Laceration repair to right index finger. Two cm in length and required four sutures. Computerized Radiography of both hands revealed: IMPRESSION: [MEDICATION NAME] fourth metatarsal diaphysis (finger). Avulsion fracture of left ulnar styloid (wrist). This hospital record documents: [AGE] year old female presents to the ED (Emergency Department) from nursing home for assault. Patient has clear evidence of head trauma, laceration to face and laceration to finger as well as (bruising) of (both) hands and shoulders as well as ankles and several other places of the upper and lower extremities. R3's MDS dated [DATE] documents that R3 was Cognitively Intact at the time of the physical assault on R4. R3's progress notes document the following: 8/13/19: 3. [MEDICAL CONDITION]-Advised to see the psychiatrist for advise. 8/27/19: (R3) can be paranoid at times and says that she is German speaking what she perceives to be the German language derived from [DIAGNOSES REDACTED]. 9/3/19: Resident was met due to her presenting with delusional statements that she was born in Germany and that she was married to the prince of Germany. 9/3/19: (R3) also exhibits symptoms of mood distress as evidenced by scoring a 6 of 27 on the PHQ-9 (Patient Health Questionnaire for Depression), indicating mild depression. (R3) has exhibited increased agitation and verbal aggression towards staff when redirected or when she doesn't understand. Clinical services will continue to monitor for changes in behavior. 9/7/19 12:45pm: Resident exhibited verbally aggressive behavior towards staff once she was observed placing an outgoing call to facility from smokehouse phone. 9/7/19: 1:33pm: Resident was engaged in a verbal altercation in dining room following lunch with peer. On 9/8/19, the physical assault incident with R4 occurred. The facility's surveillance video was reviewed with V1 (Administrator) on 9/12/19 at 12:40pm. It was noted that V4 (CNA) brought R4 into her room at 6:24pm. From 6:24pm to 8:52pm, no staff members entered R3 and R4's room to monitor them. At 8:52pm, V4 entered the room and found R4 on the floor. According to the facility assignment dated 9/8/19 evening shift, V4 (CNA) and V5 (LPN) were assigned as primary nurses for R3 and R4. Their time cards denote that V4 and V5 both clocked out for lunch at 8:26pm and 8:27pm. V9 (LPN), V11 (LPN), V17 (CNA) and V18 (CNA) were the other staff members scheduled on that shift and on that wing. All staff stated that V4 and V5 did not let them know that they were going on break and as a result, R3 and R4 were not monitored. R4's Care Plan dated 7/10/19 documents: R4 is a suitable for risk of abuse and neglect due to her [DIAGNOSES REDACTED]. (R4) will be reminded and redirected to lower risk of harm. On 9/12/19 at 1:23pm, V2 (DON-Director of Nursing) stated, The assignment should be covered if both nurse/CNA of the assignment take break together. They should be letting all the other team members know that they are taking a break so that there is no break in resident supervision. Rounding on residents should be every one hour, if they need close monitoring, like the hospital. It is documented that on 8/13/19, R3's physician recommended to be seen by psychiatrist. On 8/27/19, a Psychotherapy Progress Note documented that R3 refused to begin individual therapy and refused to participate in evaluation for individual therapy. On 9/11/19 at 10:45am, V5 (LPN) stated, (R3) was having outbursts leading up to this incident (9/8/19). But she usually had those every day. On 9/11/19 at 2:28pm, V23 (Social Services) stated, I noticed that in the last couple of weeks that (R3's) delusions and verbal aggressions were increasing. There was definitely a change in her demeanor the last couple of weeks. There was a change in her verbal aggression from what her norm was. I know she was having delusions. On 9/11/19 at 1:44pm, V6 (Social Services Supervisor) stated, Just last week, (R3) started to spark again with verbal aggressions towards staff and peers. On 9/11/19 at 2:27pm, V6 indicated that if R3 felt like something was going on, then she may have requested to see the psychologist. V6 stated, Psychotherapy is referred for increased behaviors, after an incident or if deep depression. V6 stated that R3 was care planned to go to anger management therapy and symptom management groups due to the conflicts with peers. V6 was only able to provide one anger management session sign in sheet that had R3's signature for attendance dated 7/27/19. V6 indicated that when R3 refused psychotherapy sessions and anger management groups, there was no alternative plan for her to learn how to deal with her anger. With R3's increasing verbal aggressions, increasing delusions and refusal to have a psychotherapy evaluation, there is no documentation of consistent behavior monitoring/tracking or physician notification regarding the behaviors. R3's Medication Administration Record [REDACTED]. On 9/6/19, R3's Quetiapine dosage was increased to 50 mg twice a day for a total of 100 mg for [MEDICAL CONDITION]. On 9/6/19, it is also documented that R3's [MEDICATION NAME] 0.5 mg (for [MEDICAL CONDITION]) twice a day was discontinued on 9/6/19. R3's MAR indicated [REDACTED]. R3's MAR indicated [REDACTED]. There is no documentation in R3's medical record that the physician or psychiatrist were notified regarding the missed doses. On 9/12/19 at 1:44pm, V22 (Psychiatrist) stated, We saw her on Friday 9/6/19. She was refusing [MEDICATION NAME] order and I ordered for there to be an increase in the [MEDICATION NAME] medication. She was increased from 25 mg three times day to [MEDICATION NAME] 50 mg twice a day. On Sunday, she beat someone up and no one from the facility called me. I did not get any phone call on Saturday or Sunday. If her aggressive behavior was increasing, I should have been notified. I was not called until Monday 9/9/19 by (V21-Quality Assurance Nurse) and I sent (R3) to the hospital right away. She should have been sent on Sunday after the incident. If agitation, I would have ordered a PRN (as needed). I would do something. If there was adequate monitoring and supervision, then this could have been avoided. Because I changed her medications, she should have been closely monitored. She refused the [MEDICATION NAME] for 1-2 days. She was already on the long [MEDICATION NAME] stays In the system for 2 weeks. Really, if someone called me about her increasing aggression on Saturday, I would have given PRN medication, placed her on 1:1 monitoring or sent her to the hospital. Then, this won't happen. V22 confirmed that she was not notified regarding R3's missed doses or refusal to take medications. R3's medical record does not document that V22 was notified of the physical assault on R4. R3's progress notes document that R3 was allowed to remain in the facility until 9/9/19 at 1:34pm at which time she was transferred for a psychiatric evaluation. On 9/12/19 at 10:33am, V21 (QA-Quality Assurance Nurse) indicated that ideally she talks to the psychiatric team about resident behaviors and if medications should be increased, decreased or changed. V21 stated that it is not done on a consistent basis. V21 stated, The nurses will chart behaviors in the progress notes. There is no behavior tracking log. I see that the nurses are putting behavior notes in but not every shift and not consistently. I agree that we do not track [MEDICAL CONDITION] medications and behaviors consistently. A facility policy dated (MONTH) 2008 and titled, Routine Resident Checks documents: Routine resident checks shall be made to assure that the resident's safety and well being are maintained. 1.) To ensure the safety and well being of our residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel. A facility policy dated (MONTH) 2014 and titled, [MEDICAL CONDITION] Medication Policy documents: Policy: To establish the process for monitoring the use of and the reduction of doses of [MEDICAL CONDITION] medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. Procedural Specifications: 5. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication. A facility policy dated November, (YEAR) and titled, Notification of Resident Change in Condition Policy documents: Policy: It is the policy of this facility to promptly notify the resident, their legal representative(s) and attending physicians of changes in the resident's health condition. Standards: 1b. A significant change in the resident's physical, mental or psychosocial status i.e. deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complication. c. A need to alter treatment significantly i.e. a need to discontinue an existing form of treatment due to adverse consequences or to begin a new form of treatment. A facility policy dated (MONTH) 2008 and titled, Behavior Assessment and Monitoring documents: Monitoring: 1. If the resident is being treated for [REDACTED]. 2. The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) information about specific problem behaviors. A facility policy dated (MONTH) (YEAR) and titled, Abuse Prevention Policy documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility.

Based on interview and record review, the facility failed to prevent a cognitively impaired resident (R3) from being coerced to have sex by another resident (R5). This applied to one of 3 residents (R3) reviewed for sexual abuse. This resulted in non-consensual sex for a cognitively impaired resident. Findings include: According to the face sheet,R3's [DIAGNOSES REDACTED]. R3's Care Plan started 1/11/19 and revised 4/10/19 notes R3 may be a high risk for abuse related to her [DIAGNOSES REDACTED]. Staff provide redirection when R3 is observed wandering into unsafe areas or situations. On 5/13/19 at 2:14pm,V1(Administrator) stated that on 4/18/19 at 3:00pm, V10 (Care plan coordinator) saw R3 walking down the hallway with a sheet around her bottom half and asked her what happened and where she got her money in her hand. V1 stated; I interviewed R3 right away. At first, R3 could not say his name, but we asked more questions. We were able to discern she was speaking of R5. We had R5 in the social service office and asked R5 to come in the room with R3. She stated yes, that is the man who raped me. R3 was sent out to the hospital. R5 stated that they had been friendly and that he didn't know she had any deficits. He told R3 that he would give her a cupcake or money if they had sex. He said they went into the room, they had sex and her he gave her the money, which was $2. V6 and V7 (R5's roommates) stated there was a female in the room and they heard her moaning and making sexual noises. When the emergency room asked her what she was doing there, R3 stated she was at the hospital for pneumonia. She has dementia. R3 is alert to name and sometimes place. R3 will go into other rooms and staff monitor her location due to this. V1's final abuse investigation reads that R3 reports having non-consensual sex with R5. R5 was interviewed and states R3 asked him for a cupcake and a pop. He told her if she had sex with him, that he would buy it for her. He states she agreed and they went to his room, had sex and he gave her the $2. R3 is alert and oriented 1-2. R3 was noted with $2 in her hand, and when interviewed stated she did have sex with R5, but he raped her. V6 and V7 (R5's roommates) were interviewed and stated they were aware that R5 had a women in the room having sex, but they ignored it and she never screamed or said no. On 5/13/19 at 4:05pm, V11 (Psychiatric Rehabilitation Services Coordinator, PRSC) stated that R3 wanders into peers rooms. R3 is provided redirection as she is the type of person someone can easily take advantage of as she is confused. She has been like that for 6-7 months. The care plan edited today (5/13/2019) states to provide redirection when wandering into unsafe areas or situations. This redirection is for the other wings she does not reside in. R5 was a resident on other wing. On 5/14/17 at 2:47pm, V4 (PRSC) stated that on 4/18/19, R5 was alert and oriented to person, place and time. R5 stated that he asked R3 what she is doing down by his room and R3 stated she wanted to buy a pop. R5 stated he told her he could get it for her if they had sex. It sounded like a transaction. R5 stated he used protection. R5 stated he believed it was consensual. V4's progress note on 4/18/19 at 4:36pm notes R3 has been monitored 1:1 in social service office due to alleged non-consensual sexual encounter with a resident. R5 reported it was consensual, that he gave her $2.00 that she asked for to buy snacks. R5's cognition is scored 15/15 (no impairment) on 4/11/19 according to MDS assessment. emergency room (ER) records note on 4/18/19 at 4:42pm, R3 was brought to ER from nursing home for possible sexual assault as R3 came out of the room without her pants on. She had money in her hand. R3 stated the man who raped me gave me the money. R3 has dementia and at this time cannot recall the incident. R3 is disoriented to place and time. On 5/15/19 at 10:00am, V12 (Detective) stated that R3 was not able to remember or state what happened when interviewed due to her mental state. V6's witness statement signed and dated on 4/18/19 notes that V6 had seen his roommate (R5) bring an older lady in their room. After about 3-5 minutes later, he heard them having sex for about 10-15 minutes. V6's cognition is scored 15/15 on 4/15/19 MDS assessment. V7's witness statement on 4/18/19 notes that he seen roommate, R5 bring a lady in the room. After he heard them having sex but he didn't know how long because he turned his Television up. V7's cognition is scored 12/15 on 4/22/19 according to MDS assessment. Facility Abuse Prevention Program Facility Procedures notes that The facility prohibits abuse of its residents. Sexual Abuse includes but is not limited to sexual coercion.

Based on observation, interview and record review, the facility failed to demonstrate how they provide enough supervision and monitoring for an ambulating dementia resident who wanders into other resident's room and failed to have a care plan in place which specifies how staff should monitor and supervise a wandering dementia resident throughout the day. This applies to one of three residents (R1) reviewed for abuse in a sample of 10. This failure resulted in R1 being physically assaulted by a male resident (R2) on 9/07/2016 Findings include: According to a face sheet, R1 is a [AGE] year old female with dementia. R1's clinical notes contained the following information: 1/6/16: R1 was noted going to another resident's room with pants down and unable to redirect. 2/13/16: R1 was going into other resident's room, unable to redirect. 3/9/16: R1 needs constant redirection from being in other resident's room. 3/10/16: R1 frequently wanders. 5/30/16: R1 went into another resident's room. That resident asked her to get out. R1 did not and the other resident pushed her to the floor. 6/15/16: R1 wandering the halls of the facility, going in and out resident's rooms. R1 unable to be redirected. Continue to monitor frequently. 7/9/16: R1 is wandering in the corridor waiting for her mother. 8/9/16: R1 needs constant supervision and redirection due to R1 wandering throughout the facility and in peers' rooms. 8/13/16: R1 went into another resident room. The other resident grabbed R1, where R1 became agitated and physically aggressive, hitting other resident in mouth. MD notified with orders to monitor. 8/19/16: R1 needs constant supervision due to wandering and going in other residents' rooms. 8/20/16: R1 required constant supervision due to wandering and going room to room. 8/24/16: R1 observed walking throughout the unit from room to room due to wandering. 9/07/16: Report received of R1 wandering into R2's room. In an attempt to keep R1 in R2's room, R1 sustained a 0.2cm scratch to upper middle chest. On the morning of 9/14/2016 the surveyor attempted to locate R1. On 9/14/16 at 9am, E15 (Licensed Practical Nurse) stated she did not know where R1 was at. E15 stated R1 wanders throughout the facility. The surveyor observed R1 wandering in the hallway at 9:05am. On 9/14/16 at 9:30am, E12 (Clinical director, social services) stated R1 wanders into resident rooms. E12 stated R1 would leave her wing and go to other resident rooms. Staff saw R1 come out of R2's room on 9/07/16. E12 stated the plan currently in place is to supervise where R1 was; If we see R1, people will engage her in activity. On 9/15/16 at 12 noon, E1 (Administrator) stated the plan that is in place for R1 was constant supervision. This means the staff is to redirect R1 when they see her. An initial incident report that was faxed to Illinois Department of Public Health (IDPH) on 9/7/16 reads: R2 became aggressive toward R1 after R1 wandered into R2's room. The facility's final report sent to IDPH on 9/9/16 reads: R2 was discharged to the hospital for psychiatric evaluation. R2's care plan was updated for aggressive behavior. R1 sustained a scratch to her chest. First aid was applied. R1 will continue to be monitored for safety and wandering behavior. The following facility staff members were interviewed regarding this incident: On 9/14/16 at 10:35am E6 (Certified Nursing Assistant/CNA) stated, I was the first person to see R1 after she came out of R2's (male resident's) room on 9/7/16. I saw R1 without pants and R1 did not have any underwear on either. R2 told me that R1's pants were in his room. E6 reported, R1 does not take her own pants off. We take them off. E6 stated I heard R2 say, 'I raped R1.' Also, one of the nurses (E14) said to take R1 to the shower and give her a shower and have R2 take a shower right away. E6 stated, I thought something needed to be done; maybe they shouldn't have a shower. R1 had a shower the day before. I didn't understand it. This could have been my grandmother. On 9/14/16 at 10:50am, E11 (Certified Nursing Assistant) stated, I was sitting on the wing where R2's room is located on 9/7/16 at approximately 3pm. I saw R1 coming down the hall with no pants or pull ups on. At the same time, R2 threw her pants in hallway. R2 was laughing and smiling. R2 stated that he had sex with R1. R2 just kept saying it. R2 knows what he is doing. On 9/14/16 at 10:55am, E7 (Certified Nursing Assistant) stated that she was informed on 9/7/16 to give R1 a bath. E7 stated that she gave R1 a bath. E7 stated, I noticed scratches on back, neck and fresh red marks on R1's breast and red marks like hand prints on R1's neck. On 9/14/16 at 11am, E13 (Clinical supervisor/Social service) stated he interviewed R2 after the incident on 9/7/16. E13 stated R2 told him after the incident on 9/7/16 that he wanted to have sex with R1. R2 told E13 R1 left his room. E13 stated that there was an altercation when R2 was trying to keep R1 from leaving his room. E13 stated that he saw redness on R1's neck. On 9/15/16 at 12 pm, E14 (Licensed Practical Nurse) stated she did not tell any staff member to give R1 a shower. E14 stated that she assessed R1 and observed a scratch mark on her chest. E14 stated she then gave that information to E3 (Director of Nursing). R1's care plan dated 5/30/16 reads under Psychosocial Well-Being - R1 is an abuse risk manifested by her wandering. R1's care plan edit date 8/25/16 reads Psychosocial well- being - Resident may be at risk for abuse characterized by being touched inappropriately by a peer and wandering into other peer room. R1's care plan dated 5/30/16 reads under Behavior symptoms - R1 experiences wandering. The interventions listed for wandering were Maintain a calm environment and approach to R1. When R1 begins to wander, provide comfort measures for basic needs. Based on the care plan, the facility does not have a plan in place to address the supervision and monitoring for R1 due to wandering into other resident rooms to prevent possible abuse by other residents. There were no revision of the care after the incident involving R1 and R2 on 9/07/16.

Based on observations. interview and record review, the facility failed to provide appropriate supervision and ensure safety measures were in place and failed to do a thorough investigation into the falls/injuries and failed to determine the root cause of the falls/injuries for 3 (R1, R2, R3) of 3 residents reviewed for falls/injuries in the sample of 3 residents. This failure resulted in all 3 residents requiring sutures/staples to the head. R1 received 10 staples to the head, R2 received 3 sutures to the eyebrow and R3 received 2 staples to the head. The findings include: On 3/27/14 at 2:16 PM, R1 was seated in his wheel-chair outside his room in hallway. The vinyl covering on the bilateral armrests of the wheel-chair were extensively ripped exposing the padding. R1's legs were stretched outward, he had long dirty finger nails and kept saying "what am I doing?". R1 had 12 metal staples on the top of head toward his left side. R1 was very confused, disoriented and stated not to be in pain. R1 stated not to remember anything. The facility's incident report dated 3/20/14 at 12:12 PM documents R1 was being transported via an outside agency van escorted by facility staff member, E4 (certified nurse aide). As the van exited the road onto a ramp, R1 and R1's wheel-chair fell to the left. R1 sustained a laceration to the left side of his head. R1 was immediately taken to the hospital where he received 10 staples to the head. The report included 2 statements, one from Z1 (van driver) and other from E4. Z1's statement dated 3/20/14 documents as the van exited the road onto a ramp, the wheel-chair released R1 who fell and hit his head on a object in the vehicle. Z1 documents that E4 was sitting up front with Z1. Z1 documents R1 was bleeding and taken to the hospital. E4's written statement date 3/20/14 documents Z1 secures R1 in the van and E4 rode up front with driver, Z1. Z1 makes another stop to pick up 2 other individuals in which he needs to move R1 so he can fit the other 2 individual in the van. Z1 first drops off the other 2 individuals. As the van exited the road onto a ramp, the van comes to stop due to a stop sign. Z1 hits the gas as the van is turning left causing R1's wheel-chair to flip over to the side. The van stopped and E4 got out of the front seat and assisted R1. R1 was bleeding so he was taken to the hospital. Both Z1 and E4 assisted R1 into the hospital. R1's hospital report dated 3/20/14 documents R1 received 2 sutures used to repair galea and 10 staples used to the scalp. The hospital cat scan on the head dated 3/20/14 documents a right temporal parietal craniotomy with surgical clips seen in the region of the right posterior frontal temporal junction in the mid to low convexity but no hemorrhage or extra-axial fluid collection. R1's care plan does address R1 having had a craniotomy procedure but unsure of the time-frame. There was no other documentation provided nor did the facility do a thorough investigation to determine if R1 and his wheel-chair were secured in the van. The facility's work description labeled Transportation Aid documents the primary purpose of this position is to assist residents as needed with transportation to and from outside appointments and provide nonprofessional nursing care, monitoring and simple technical nursing services during these trips. The duties also include to ensure resident are safely secured in vehicle and to ensure the vehicles is clean, safe and in good working condition, such as, safety belts. Monitor and supervise residents in transport to assure safe travel. Follow all rules of the road and drive in a prudent and safe manner. Ensure all equipment used by resident, such as, wheel-chair is in good working condition. R1's care plan dated 1/20/14 documents potential for trauma, falls and injury as a problem. The approaches are to maintain safety and anticipate resident's needs. The care plan is updated on 3/20/14 but the approaches remain the same. The care plan also addresses R1's prone to uncontrolled bleeding as a problem due to R1's use of heparin and the potential for neglect. The approaches under neglect document to check positions when transferring or repositioning. R1's current (March 2014) physician order [REDACTED]. In addition, there is an order dated 3/20/14 to remove R1's 10 staples in 10 days. R1's quarterly Minimum Data Set ((MDS) dated [DATE] document R1 to have BIMS (brief interview mental status) of "1" which indicates he is severely confused and disoriented. R1 required total to extensive assistance of one person for ambulation and transfers. On 3/27/14 at 2:05 PM in the hallway outside of the large dining room, R2 was standing but slightly wobbly so we both moved closer to the wall so she could use the hand rail if needed. R2 pointed to her right eye brow. There was a little bump on the upper portion of the right eye socket and a half inch indentation on the right eye brow. R2 stated it hurts still. R2 stated she was standing in her room and all of sudden she falls hard and started bleeding from the head. R2 stated she then went to the nurse and told her what had happened. R2 stated she was sewn up but the area still bothers her. R2's nurses notes dated 2/21/14 documents R2 had a physical altercation with another peer and hit him because she thought he was talking about her. R2 was sent out to the hospital for an evaluation and did not return until 3/4/14. Nurses' notes and the facility's occurrence report dated 3/5/14 documents R2 coming to the nurses' station at 7:30 PM and saying she fell this morning and hit her head and arm. R2 was found to have a scabbed area and a purplish, deep red area on the right side of forehead and purplish deep red area to the right outer eye. The recommendation for R2 was to use a wheel-chair for unsteady gait and to report incident as soon as possible and send to physical therapy for evaluation. There was no other documentation presented such as possible witnesses and why the assigned nurse's aide did not notice the bruising. Nurses' notes and facility's occurrence report dated 3/6/14 document at 11 AM R2 stood up from wheel-chair to get coat and lost her balance and fell . The fall was witnessed by R4, R2's room-mate but there was no written statement provided by R4 nor does the report document whether R2 is orient times three. The recommendations are to give R2 a seat belt for the wheel-chair, encourage her to ask for help and to dangle her feet at the side of the bed prior to standing up. The facility's incident report and the occurrence report dated 3/9/14 at 2 PM document R2 was ambulating without staff assistance which resulted in a fall. R2 sustained a laceration to the right eye brow area. The incident report was lacking statement from staff as to the last time R2 was seen prior to the fall, what may have caused her to sustain the injury, and where did R2 fall, where was the supervision for R2, what interventions, if any, were in place. Nurse' note dated 3/9/14 documents R2 was found with 1/4 inch laceration to right eyebrow with small amount of bleeding. R2 was sent out to the hospital. Nurses' note 3/10/14 documents R2 returned with 3 sutures to the right eyebrow. The recommendation/resolution for the occurrence on the facility's incident report documents to remind resident on the importance of using the call light, bed in lowest position and floor mats in place. R2's care plan dated 1/16/14 and 3/10/14 document potential for falls as a problem. The approaches are observe gait, evaluate foot wear, provide increased assistance and maintain safety. The wheel-chair with a safety belt was added as approach after the 3/9/14 fall. On 3/27/14 at 2:30 PM, R2's bed was low but there were no alarms or floor mats present in the room. R2's nurses' notes 3/13/14 documents R2's refusal to use wheel-chair due to her unsteady gait. Nurses' note 3/16/14 documents R2's has altered mental status and is sent out to the hospital. R2's hospital report on bilateral carotid imaging done on 3/17/14 to rule out syncope documents normal carotid imaging and Doppler spectral blood flow analysis. The facility failed to determine the root cause of the falls and failed to provide adequate supervision. On 3/27/14 at 2:10 PM, R3 was seated in a wheel-chair outside his room. R3 was very confused, disoriented and lethargic. R3 was wearing a soft helmet. E3 (director of nursing) was present and stated the helmet is for spastic movement. E3 instructed E5 and E6, both nurses' aides to put R3 back to bed due to him being lethargic. On 3/27/14 at 2:20 PM, R3 is in bed. The bed is low to the floor and the length of the bed is parallel and against the wall. There are mats secured to the wall and a floor mat on the other side of the bed. R3 is sleeping and the soft helmet has been removed and put on the bed above R3's head. The head and foot boards are made of mesh-like material. The facility's incident report and the occurrence report dated 1/29/14 at 5:30 AM document that R3 was placed on a mattress which was on the floor due to abnormal and spastic movements associated with his disease process. R3 raised head and hit it on the bed frame. R3 was sent out to the hospital and returned with 2 staples to the top left side of the head. The incident report does not go into detail as to how the staff ensured R3's safety and how R3 was able to hit his head on bed frame. There are no written statements from staff and it is not clear if it was witnessed by anyone. R3's quarterly MDS dated [DATE] documents his active [DIAGNOSES REDACTED]. R3 is cognitively moderately impaired and requires extensive to total assistance of one staff person for transfers, ambulation, eating, dressing and hygiene. R3's care plan with dates of 2/13/14, 2/19/14 and 3/3/14 does not address his jerky movements and the need for the soft helmet. There is a physician order [REDACTED]. The occurrence resolution on the incident report documents R1 was given a low bed with a plastic frame. Will continue the floor mats and wall mats. Facility staff failed to ensure safety measures were in place to protect R3's head during spastic, jerky movements. On 3/27/14 at 12:40 PM, E3 (director of nursing) stated it can be anyone to complete the incident reports. E3 stated they use to have a quality assurance nurse who looks over the incidents. On 4/4/14 at 1:55 PM, E2 (assistant administrator) stated the facility has been without a quality assurance nurse since November 2013. At 2:05 PM, E3 (director of nursing) stated they do have a part-time quality assurance nurse, E7, who works 3 days a week, 8 hours per day. The facility's Accidents and Incidents Policy documents it is the responsibility of the D.O.N./Designee to investigate and ensure appropriate completion, notification and follow-up on all accidents and incidents. It is the responsibility of the Incident Review/quality assurance team to review incidents on a weekly basis. The facility's policy labeled Falls Management Program documents that interventions for the prevention of falls will be individualized to meet the specific needs of the resident. A determination will be made regarding the equipment needs of the resident. A care plan will be implemented that identifies the risk and provides staff with interventions to prevent falls. Interventions will be reviewed and the care plan adjusted as needed.

Based on interview and record review, the facility failed to assess, analyze the circumstances of falls, develop interventions, re-evaluate for the effective of the interventions, attempt alternative intervations and supervise one of 2 residents (R8) in the samples to minimize the risks for recurring falls and injury. Finding Include: R8 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] stated Section C1000- Cognitive Skill For Daily Decision Making Score 2 (Moderately Impaired -decisions poor; cues/supervision required. Section G0110 - Functional Status (B). Transfer (how resident moves between surfaces including to or from bed, chair wheelchair, standing position) was score 3/3 (Extensive assistance- resident involved in activity, staff provide weight bearing support/two plus persons physical assist. .Review of the medical record of R8 on following dates denoted: 09/16/10 at 10:27pm Continuously throwing self out of bed to mattress on the floor. This is done purposely. No apparent injuries noted . When questioned, does not admit to knowing that she does. 09/26/10 at 7:10am Resident slid from recliner chair onto her face. Sustained a hematoma to lift eye. Went to Z2 hospital for evaluation and returned. 10/11/10 at 4:00pm resident attempting to get out of the recliner chair by pushing off the recliner chair. Resident leaned toward the right side causing s shift in body position which lead to a fall. Resident fell causing a hematoma to the right side of the right eyebrow. Resident helped off the floor by nurse and certified nurse aide. Neuro check complete, compleat body assessment, the need for pain management assess,X-ray ordered and recliner chair changed to make sure table is secured. 11/14/10 Send resident to Z3 hospital emergency for possible stitches for the laceration (about 1/2 inch) at the back of the head. 12/3/10 at 8:15pm Resident attempted to ambulate without assistance causing a fall. Resident fell hitting forehead on the floor with no loss of consciousness. First aid was giving immediately, forehead was cleaned and a pressure dressing applied. Resident was sent Z2 hospital. Resident return from the hospital with six suture. The Z4's hospital record dated 11/14/10 denoted Patient was found lying on the floor at the nursing home with small laceration to back of the head. Presenting Problem: Head injury without Lost of Consciousness. Z2's hospital record dated 12/04/10 denoted R8 had facial and scalp contusions. She also had a laceration to the forehead with six suture. E3 (Director of Nurse) on 03/15/11 at 2:00 pm in the conference stated," She push the recliner chair away lean forward and fell out. She would push the ray away. She was kicking and putting her leg over the recliner chair to get out of it. The care did not addressed the problem or specific enough." E11 (Certified Nurse Aide -CNA) on 03/15/11 at 2:40pm in the conference room stated," November 14, 2010. It was after lunch. We put R8 at the nursing station. We put her by the nurse station to keep an eye on her. We transporting resident from out of the sunshine room. As I park her to retrieve the other resident to bring him down the hall. She used to have a safety tray but she take it off. We were not quick enough to get to her. She was on the A wing of the nurse station. The sunshine room is before the double door. Her recliner chair was facing the hall on the A wing. The nurse was down hall passing medication. I could not get to her fast. She was our very confused and combative. If you turn your back, she would get up. I couldn't get to her fast enough." Surveyor asked E11 is R8 to be monitor . E11 stated," R8 was to be supervisor and monitor at all time to keep from falling." E12 (CNA) on 03/15/11 at 2:50 pm in the conference room stated," She was very confused. She had to be redirected many time of the day about not trying to get out of recliner chair without assistance. We had put her in a low bed. She would slip on the floor. She was unaware of she could not walk. She was confused. She needed monitor and supervision at all time. The Fall Management Program dated 06/01/04 stated," It is the responsibility of the charge nurse to ensure that interventions are conducted as per the resident's plan of care. It is the responsibility of the CNA to ensure that the residents identified receive the appropriate interventions per the resident's individual plan of care. The Fall Risk Screening (FEI 1.02.1) will be completed upon admission, quarterly, with a significant change in condition, and whenever a fall occurs. Residents assessed at risk for falls will be placed in the Fall Management Program. Interventions for the prevention of falls will be individualized to meet the specific needs of the residents. Interventions to be implemented can include and assistance needed: (A); Transfer assessment and assistance needed, (C). Fall Risk Screening, (D). Comprehensive fall assessment, (E). Bed mobility Alarm and (F).Chair mobility alarm. A care plan will be implemented that identifies the risk and provides staff with interventions to prevent falls and/or reduce risks. The facility did not provided any documentation that they reassessment and revised the care plan to prevent further fall and injury.

Based on interview with Z3 and Z4 (family of R4), staff interviews, clinical record review and review of the facility's "Safe Lifting and movement of resident policy", the facility failed to assure that one sampled resident (R4) was safely transferred. R4, a [AGE] year old resident with Quadriplegia and vent dependent was transferred by facility staff from chair to bed without the aide of a gait belt or mechanical lift per facility policy. This unsafe/ improper transfer resulted in R4 falling to the floor hitting his head on the ventilator/oxygen machine. Bleeding was controlled by facility staff and R4 was transferrred to a local hospital with a laceration to the head. Findings includes: Closed record review indicated that R4 was a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4 was dependent on a mechanical ventilator. Review of the most recent MDS (minimum data set) dated 10/31/10 indicates R4 scores ''4'' in all areas of care. This score indicates that R4 is totally dependent on facility staff in all areas of care. R4 scores 4/3 in the area of transfer. This score indicates that R4 is totally dependent on staff for transfers and requires a two person lift. As well, R4 scores ''2'' in the area of range of motion indicating that R4 has loss of movement in both arms and legs. On 01/04/11 at 11:50am, Z4 stated to surveyor per phone. "My sister and I were standing outside R4's door when we heard a loud thump like a fall in R4's room". "Right away a nurse aide came running out the room and said she had dropped R4. The aide called for help, when another nurse ran into the room,they called the ambulance right away and they took R4 was taken to the hospital where R4 had to have stitches to the head". Review of the facility's Incident/accident file dated 11/04/10 at 2:00 indicates R4 fell and injured with a laceration to right side of head. Further record review and staff interviews indicated that E8 and E9 (both nurse assistants) were transferring R4 from the Gerichair to the bed when R4 slid from the edge of the bed to the floor hitting the right side of his head, sustaining bleeding and a laceration. On 01/05/11 at 12:20pm E8 was interviewed per telephone regarding the fall incident and the transfer technique utilized. E8 stated, " I was assisting E9 transfer R4 from the gerichair to the bed. I had one of R4's arm on one side and E9 had the other arm on the other side and we were able to do a total body lift using R4's arms". E8 continued, "We had already got R4 out of the gerichair to the edge of the bed when E9 had gone around to the other side to move the gerichair out the way. I continued to stand in front of R4, holding him by the shoulder when R4 slid to the floor hitting his head on the ventilator machine. E9 went in the hallway to get help! Upon further interview E8 stated, "I usually use a gait belt but I didn't have a gait belt that day". E8 added, " I always need two people to help lift R4, but I have gotten R4 up before and didnt need a gait belt or anything! Later this day at 12:43pm surveyor interviewed E9 per telephone regarding R4's fall and transfer technique utilized. E9 stated, "E8 and I had already transferred R4 from the gerichair to the edge of the bed, I had gone around the bed to move the gerichair when R4 slid to the floor, landed on his bottom and hit his head on the oxygen machine. I saw some bleeding and a cut on R4's head, so I went into the hallway, saw E7 and told E7 we needed help! Upon further interview E9 stated, "That was the 1st time I had transferred R4 but I saw that R4 was paralyzed and couldn't move, so I got E8 to help me". Surveyor questioned E9 regarding the transfer technique that was used. E9 stated, "I was on one side and had R4's arm and E8 had the other side and we were able to lift R4 to the edge of the bed ". Surveyor asked E9 how did she usually transfer residents? E9 responded, "I usually use a gait belt, but I didnt have my gait belt on me that day! Surveyor further questioned E9 regarding the use of a hoyer lift. E9 sounding puzzled stated , "no I don't use a hoyer! At approximately 1:25 on this day (01/05/11) surveyor interviewed E4 (assistant Director of nurses) regarding the procedure for staff transferring residents. E4 stated, "All CNAs (certified nurse assistants) must have gait belts, which is part of their uniform. E4 added, "If a person is heavy and requires more than one person to lift a mechanical lift should be used". Upon further interview E4 added, "The CNAs (E8 and E9) should have used a hoyer lift for R4 that day! Review of the facility's policies indicates that the facility has a "Safe lifting and Movement of Residents policy. listing includes as follows: 1. mechanical lifting devices shall be used for any resident needing a two person assist.Except in emergency situations or unavoidable circumstances. 2. staff responsible for direct care will be trained in the use of mechanical lift devices. 5. mechanical lifts shall be made readily available and accessible to staff 24 hours a day. E8 and E9's failure to follow policy and performing an unsafe transfer resulted in injury to R4.

Based on record review and staff interview, the facility failed to : 1) assess and monitor 1 resident (R1) at risk for dehydration, with decreasing appetite, out of 3 sampled residents for signs/symptoms of dehydration; 2) ensure 1 diabetic resident wore appropriate footwear to prevent toe injuries with known behavior of dragging toes on the ground; these failures resulted in R1 being admitted to the hospital on 9/13 with a [DIAGNOSES REDACTED]., as evidenced by the following: Findings include: Review of R1's medical record reflects that R1 is a [AGE] year old male with numerous medical [DIAGNOSES REDACTED]. R1 has impaired cognition and communication, and requires assistance with all ADLs. R1 is on a Regular, No added salt, no concentrated sweets diet. Per R1's MDS (minimum data set) of 7/20/10 he is cognitively impaired. Review of R1's nursing notes reflect that on 9/6, R1 refused lunch, only taking some water, but did later eat some food brought in by a relative.There is no indication how R1 ate on 9/7 or 9/8. A calorie count was begun on 9/9, but nursing notes do not reflect this, or why. A nursing note on 9/9 states R1 ate 100% of breakfast and lunch. Nursing note on 9/10 indicates resident ate 100% of meals and fluids. On 9/11, R1 refused breakfast, only taking juice, and only ate a quarter of his lunch. Throughout this time of R1 exhibiting a decreased and/or fluctuating appetite, there was no nursing assessment of R1's mucous membranes or skin turgor, nor was there any formal dehydration assessment done.. Review of R1's 3 day calorie count reflects the following: No liquids were recorded for day two or day three lunch. Total recorded calories for day one was 1510.5; day two calories recorded was 1225; day 3 recorded calories was 480. During interview with E16 (Dietician) on 10/1, E16 stated that typically, the calorie counts are faxed to her office upon completion. She stated that she had not seen the calorie count for R1, and did not recall getting any phone calls from facility staff expressing concern about R1's decreased appetite. E16 reviewed the calorie count, which was completed on 9/11, and stated that she would have made some type of recommendation based on the calorie count. E16 stated that she is only in the facility twice a month, and relies on the facility staff to be her eyes and ears for the residents. During interview with E6 (ADON) on 10/1, E6 confirmed that the calorie count had been faxed to the dietician's office, She could not explain why E16 had not received the calorie count. Review of nursing notes from 9/13 reflect, "...resident has loss of appetite for today. Encouraged resident to eat and resident didn't want to eat..." Nursing notes further reflect that facility staff transferred R1 to the hospital per physician order, and R1 was admitted with a [DIAGNOSES REDACTED]. Review of hospital records dated 9/13 conform that R1 had a [DIAGNOSES REDACTED]. During interview with E14 (RN), on 9/20, when surveyor questioned E14 about assessing residents for dehydration E14 stated that the facility does not use a formal dehydration assessment, but does assess residents for dehydration on admission, on re-admission, and for significant change. She also stated that nurses can assess a resident's hydration status as indicated, by assessing skin turgor and mucous membranes. Review of R1's nursing notes from 9/6 until the time R1 was sent to the hospital reflects no assessment of R1's hydration status; There was no assessment of R1's skin turgor and no assessment of R1's mucous membranes On 8/5/10, Nursing notes for R1 reflect, ..."...Resident received with skin opening to left great toe and left 3rd digit of unknown origin"...The note goes on to indicate the physician was notified and treatment orders were received and carried out. During interview with E15 (treatment nurse) on 9/30 , E15 stated that she authored the above-referenced note. She reviewed her charting, and stated that she had made an error in her charting, as the open areas were actually on R1's left 2nd and 3rd toes, as R1 has no left great toe.. She stated she was doing random skin checks, and was checking R1's skin because he is diabetic, and that is when she discovered the open areas. Surveyor asked E15 if she knew how this open area had occurred. E15 described that R1 has a behavior of sitting in his wheelchair with his feet turned downwards, so that his toes were almost curled under him, and when his wheel chair was pushed, the tops of his toes would scrape or drag the ground. E15 stated that she believed this was the cause, as she had seen him exhibit this behavior, and had had to redirect him when this occurred. She state that the open areas looked like a skin tear or a burn, as if the skin had been rubbed off. Surveyor asked if R1 had foot rests on his wheelchair, and E15 stated that he did not, because sometimes he was able to self-propel. (R1 was sent to the hospital on 9/29 due to his toe wound, and therefore could not be observed). E15 was asked what R1 typically wore on his feet, and she stated that he always wore the soft blue slipper socks. E15 stated that his wound had deteriorated, and now is a diabetic ulcer, although it started as a skin tear. During interview with E11 (CNA) on 9/30, E11 confirmed that she had also seen R1 sitting in his wheelchair with his toes curled downwards with the tops of his toes resting on the ground. She stated that earlier in his stay, he might have propelled himself but currently, staff must push his wheelchair.She redirects him when she sees his toes dragging. Nursing notes for R1 from 9/28 reflect"...Wound consultant in facility to see resident 2nd digit left foot. Upon entrance to resident room resident dragging foot underneath wheel chair. Consultant again educated resident on importance of picking up feet..." During interview with E15 on 9/30, E15 stated that R1 was sent out to the hospital on 9/29 because his toe wound, which is now classified as a diabetic ulcer, looked worse. Despite the fact that R1 is a diabetic and staff were aware of his propensity for dragging his feet against the ground with his toes curled underneath his feet, staff did not intervene and ensure that R1 wore appropriate footwear for a diabetic resident in order to protect his feet.This behavior was not care planned, nor was the care plan revised upon the skin opening being discovered. Other than providing education to a resident with schizo-affective disorder and [MEDICAL CONDITION] who is cognitively impaired per MDS (minimum date set) of 7/2010, there was no intervention to prevent this behavior, such as trying a different chair, keeping resident well-visualized, using foot rests, different footwear, etc.As recently as 9/28, this behavior is still being documented, with the only intervention education, despite a worsening of R1's wound