Every finding on record at Crestwood Terrace

Based on interview and record review the facility failed to follow their abuse policy and failed to protect a resident during an incident of resident-to-resident physical abuse. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R1 physically assaulting R2 by punching R2 in the head and face and pulling R2's hair. R2 sustained a closed head injury, neck and back pain, facial scratches, and psychosocial harm, including expressing fear that R1 would kill her; R2. Due to the injuries sustained, R2 was transferred to the hospital for further evaluation and treatment.Findings include:R1's and R2's FRI (facility reported incident), dated 7/22/26, documents, in part, Residents (R1 and R2) were involved in an altercation. The facility has started an Investigation.R1's hospital records, dated 7/22/26, documents, in part, Pt (R1) presents for a psychiatric evaluation from the NH (nursing home), pt (R1) hearing voices, thinks she (R1) is pregnant. Displaying bizarre aggressive and threatening behaviors. Patient (R1) stating that she (R1) is hearing voices, thinks that she (R1) is pregnant, noted displaying aggressive and threatening behaviors. Patient (R1) stating that she (R1) is 5 month pregnant and that she (R1) is waiting for her (R1) husband, also given a different DOB (date of birth ) as well as name. Patient (R1) mood/affect appeared guarded, depressed, anxious. Patient (R1) insight and judgement appeared poor. Patient (R1) reports she has been non- compliant w/ mental health meds prior to admission. admitted as inpatient. Clinical Impression: Acute psychosis, Chronic schizophrenia.R2's hospital records, dated 7/23/26, documents, in part, Reason for Visit: Back Pain, Closed Head Injury, Neck Pain. Diagnosis: Injury due to altercation.R1 unable to be interviewed. R1 was transferred and discharged to the hospital for psychiatric evaluation and treatment due to delusions, hallucinations, increased agitation, anxiety, verbal aggression with psychotic behavior, and attempts to become physically aggressive toward peers. R1 also was refusing to take R1's prescribed psychiatric medications.R1's face sheet documents an admission date of 9/24/25 and diagnoses that include but are not limited to schizoaffective disorder.R1's BIMS (brief interview for mental status) score, dated 5/17/26, is 14 which indicates R1 is cognitively intact.R1's care plan, dated 8/10/25, documents, in part, (R1) has symptoms such as mood swings, impulsive behavior, and attention seeking behavior related to diagnosis of Schizoaffective Disorder, with interventions that document, in part, Administer medication as prescribed by the physician; Encourage medication compliance. R1's care plan, dated 8/12/25, documents, in part, (R1) has a history of aggressive, inappropriate , attention-seeking behavior but has demonstrated stability during the admission screening process and is therefore considered appropriate for admission Severe mental illness. (R1) displayed verbal aggression towards staff when she (R1) was asked to enter facility van after appointment. (R1) exhibited aggressive behavior towards a peer. (R1) displayed aggression behavior and get into physical with staff when staff was rendering care for the roommate. (R1) displayed aggressive behavior and attempted to get physical with peers, with interventions that document, in part, Give psycho-active medications as ordered for (R1); Provide (R1) supportive intervention, 2 times per week. (Anger management group, Symptoms Management group, 1;1 or PRN as needed). R1's care plan, dated 8/9/25, documents, in part, (R1) uses psychotropic medications (See pos) r/t (related to) Behavior management, Disease process (schizoaffective disorder), with interventions that document, in part, Administer psychotropic medications as ordered by physician.R1's Aggression and Violence History and Screening Assessment, dated 5/30/26 (prior to altercation with R2), documents, in part, The resident (R1) becoming verbally aggressive and get into physical with staff.R1's Aggression and Violence History and Screening Assessment, dated 7/22/26, documents, in part, The resident (R1) was verbal aggressive and attempted to get physical with peer.Record review of R1's July 2026 Medication Administration Record (MAR) revealed that R1 consistently refused prescribed psychotropic medications. Specifically, R1 refused the 9:00 a.m. dose of Quetiapine Fumarate on every scheduled day in July 2026 except July 13, 2026. R1 also refused the 5:00 p.m. dose of Quetiapine Fumarate on every scheduled day in July 2026 except July 4, July 19, July 21, and July 22, 2026. Additionally, R1 refused Citalopram Hydrobromide on every scheduled day in July 2026 except July 13, 2026.R1's progress note, dated 7/22/26 at 2:18pm, per V5 (Registered Nurse/RN), documents, in part, Writer (V5) was in dining area when I heard another worker saying there was an altercation happening between resident (R1) and another resident (R2) in (R1's room) room. Writer and other staff members hurried to the room to find the resident (R1) with her (R1) hands around another resident's (R2) hair that was trying to take a shower. Resident (R1) was immediately redirected to social service office and has been placed 1 on 1 until resident (R1) can be sent out for evaluation. NP notified and order to send out to (Hospital) was given.R1's progress note, dated 7/22/26 at 12:24pm, per V7 (Psychiatric Rehabilitation Services Coordinator/PRSC), documents, in part, The Resident (R1) presented with delusion, hallucination, increased agitation, anxiety, verbal aggression with psychotic behavior, and attempted to get physical with peers. She (R1) refused to take her medication as prescribed by her (R1) doctors. She (R1) was placed on 1:1 increased monitoring and supervision until she (R1) was discharged to Hospital as per psychiatrist's order. Social Services will continue to follow up for after-care services.R1's progress note, dated 5/30/26 at 3:55pm, per V4 (Registered Nurse/RN), documents, in part, The resident (R1) was physically aggressive to the staff while rendering care to another resident. per the staff, the resident (R1) came behind her (V4) trying to choke and scratches her (V4) face. Resident (R1) placed on one on one, MD notified, and an order to send the resident to psych hospital for psych eval. Social workers wrote the petition, The incident reported to the Administrator.R1's progress note, dated 5/20/26 at 1:58pm, per V5 (Registered Nurse/RN), documents, in part, Resident (R1) got into a verbal altercation with another resident this morning, was having delusions and hallucinations. PRN was declined. Resident (R1) was redirected and has not had any further behaviors on writers shift. MD was notified of resident's (R1) refusal of medications and the altercation. No new orders at this time.R1's progress note, dated 4/16/26 at 9:15pm, per V6 (Psychiatric Rehabilitation Services Coordinator/PRSC), documents, in part, The Resident (R1) presented with delusions, hallucinations and Psychosis behaviors. The resident (R1) was responding to internal stimuli, and she (R1) was verbally aggressive towards a peer. Staff intervened; she (R1) was redirected and placed on monitoring until she (R1) returned to based line. Social Services will continue to monitor and follow up.R2's face sheet documents an admission diagnosis of 4/27/2021 and diagnoses that include but are not limited to paranoid schizophrenia, traumatic brain injury, cerebral infarction, and parkinsonism. R2's BIMS (brief interview for mental status) score, dated 7/13/26, is 13 which indicates R2 is cognitively intact.On 7/24/26 at 11:10am, R2 was observed with a 1-inch scratch to R2's right lower face near R2's chin and a dime-sized scratch below R2's left lower lip. R2 said, Me come here in 2021. Me doing okay today now. Me glad R1 is not here (facility). Me went to the restroom to take a shower. I wanted to go to restroom to take a shower. R1's room is right there. R1's room has the shower. I was standing outside of the restroom by the door. Someone else was going pee pee. R1 hit me in the head and face and choked me. R1 pushed me while I using my walker. No reason just pushed me. Me hurt my foot. Yeah, it hurt. I was crying. R1 wanted to kill me. I'm scared she's (R1) actually going to kill me. For no reason. She (R1) just came up to me and started trying to kill me. R1 pulled my hair. Me kept screaming, Me back and neck hurt. She (R1) scratched my face and punched me in the head and face. She (R1) grabbed my arms. Me just kept screaming. Someone (staff) finally came. Me go to the hospital the next day because my body was hurting.R2's care plan, dated 6/29/26, documents, in part, (R2) a is at risk for abuse/neglect based on the comprehensive assessment as evidenced by: (R2) has a diagnosis of mental illness. (R2) is diagnosed with mental illness and was spit on by a peer, with interventions that document, in part, Assure (R2) that she (R2) is in safe and secure environment with caring professionals. Explain psychosocial adjustment is often facilitated by developing a trusting relationship with another person and verbalizing thoughts, needs and feeling. Encourage (R2) to verbalize Issues or concerns. Provide (R2) 1:1 counseling on boundary issues relating to conflict. Report any incident of abuse to the administrator. R2's care plan, dated 10/17/24, documents, in part, (R2) presents with weakness and limited mobility- currently uses a walker rollator for locomotion. She (R2) benefits from being in an ambulation restorative program.R2's At Risk for Abuse Assessment, dated 6/3/24 (prior to altercation with R1), is 1 which indicates R2 is at risk for abuse.R2's progress note, dated 7/22/26 at 3:25pm, documents, in part, Writer was in dining area when I heard another worker saying there was an altercation happening between resident (R2) and another resident (R1) in (R1's) room. Writer and other staff members hurried to the room to find the resident (R2) in (R1's) room with another Resident (R1) that had her (R1) hands on her (R2) hair. The other resident (R1) was immediately redirected to social service office and (R2) was taken to the nursing station where she (R2) was examined.R2's progress note, dated 7/23/26 at 11:30am, documents, in part, Resident (R2) reported pain in her head due to an altercation with another resident (R1). MD notified. Order received to send to hospital for medical eval (evaluation).On 7/24/26 at 11:33am, V1 (Administrator) said, No. No other residents should be going into that room (R1's room) to shower. There is a central shower. I'm not really sure how she (R2) got into R1's room. There are monitors in the hallways to prevent that.On 7/24/26 at 11:41am, upon observation of R1's room and shower/bathroom with V1 (Administrator), R6 was observed coming out of R2's bathroom. R6 said, Oh. Sorry. I just had to use the bathroom real quick.R6's face sheet documents an admission diagnosis of 11/16/17 and diagnoses that include but are not limited to schizoaffective disorder and type 2 diabetes.R6's BIMS (brief interview for mental status) score, dated 5/08/26, is 15 which indicates R6 is cognitively intact.On 7/24/26 at 11:50am, V1 (Administrator) said, R6 should not be using that bathroom (R1's bathroom). The monitor was right there. I'm not sure how R6 got in there (R2's bathroom). There's plenty of other bathrooms. R1 was originally put in this room because she (R1) was always trying to elope. This room does not have any exit doors by it. Then when her (R1) elopement phase went away, she (R1) didn't want to change rooms. She (R1) was never physical with residents just one or 2 instances with staff. I think there was just one physical altercation with R1 against staff. There were multiple verbal altercation with staff and resident and R1, but not really physical.On 7/24/26 at 11:52am, V8 (Certified Nursing Assistant/CNA) said, We (staff) stand between the hall and walk up and down the halls and making sure no one (residents) is going in and out of people's rooms. Yes, that room (R1's) is always visible. Like I said, I'm walking and charting. They (residents) normally don't get passed me. Probably when I put my head down and charted is when R6 went in there (R1's bathroom).On 7/24/26 at 12:06pm, V9 (Registered Nurse/RN) said that I was on duty and in charge at the time (7/22/26 R1 and R2 altercation). I was at the nurses' station when I heard a loud noise. I ran to see what was happening. R2 had gone into R1's room to take a shower, and the other resident (R1) went after her (R2). By the time we (V10/MDS Coordinator/Registered Nurse/RN and V9) arrived, R2 was already in the hallway. We (V9 and V10) brought her (R2) to the nurses' station and completed an assessment. R2 stated that R1 had put her hands on her (R2). During the assessment, we (V9 and V10) observed redness on the right side of R2's jaw, but not on her neck. Yeah, I think the scratch in her (R1) face is from the incident. That was the only visible injury we (V9 and V10) found. At the time, R2 was very confused. She (R2) was talking about Indonesia and America and was not making complete sense. We (V9 and V10) contacted the physician and continued to monitor her (R2). When we (V9 and V10) asked if she (R2) was in pain, she (R2) said, 'Yeah.' She (R2) complained of pain to her (R2) right jaw. I am not sure whether the incident occurred inside the shower room because R2 was already outside in the hallway when we (staff) arrived. I don't know if other residents are allowed in that room (R1's bathroom) to shower. There's a main shower room the residents use.On 7/24/26 at 12:28pm, V10 (MDS Coordinator/Registered Nurse/RN) said, I was in the MDS office when I heard the CNA (V16/Certified Nursing Assistant) calling for help. I immediately ran toward her (V16) while calling out to see what was happening. When I entered the room, I saw staff separating the two residents (R1 and R2). The incident occurred in R1's room. The residents (R1 and R2) were near the window and dresser when I arrived. I do not know where the altercation started. They (R1 and R2) were just inside the room when I entered. I assisted R2 to the nurses' station. I did not perform an assessment and did not observe any visible injuries. While we (V10 and R2) were walking to the nurses' station, R2 did not complain of pain or say anything to me. I believe V5 (Registered Nurse/RN) had already begun assessing R2 before I escorted her (R2) to the nurses' station. No, other residents should not be going into R1's room. V16 had brought R2 to that area so she (R2) could use the shower. Staff should remain with the resident (R2) and keep the resident (R2) under observation while using the shower. The resident (R2) should not be left unattended. I believe central shower rooms could have been used instead of bringing R2 to the shower in R1's room.On 7/24/26 at 12:52pm, V11 (Certified Nursing Assistant/CNA) said, I worked, but I was on the (the other side). I didn't even know what happened. There room is (on the other side). I was monitoring on the other side. I didn't see them (R1 and R2) at all, even after the fight.On 7/24/26 at 12:52pm, V13 (Certified Nursing Assistant/CNA) said, I worked. I was coming from my lunch. I worked on the men's side. I didn't see anything. I didn't really know what was going on. I didn't see R2, but R1 was getting ready to eat lunch. I didn't see the altercation. I didn't see anything.On 7/24/26 at 1:01pm, V12 (Psychiatric Rehabilitation Services Assistant/PRSA), said, I worked. I was here (7/22/26). So, I was in the dining room when I saw staff V16 (Certified Nursing Assistant/CNA) call a code. I ran in there (R1's room). R1 was on top of R2 and had R2's hair in her (R1) hand. They (R1 and R2) were standing by the dresser when you first walk in. Both were placed on 1:1 monitoring. R1 was sent to the hospital. R2 got sent out the next day to the hospital. I didn't see any injuries. None that I know of. If they (R1 and R2)complained, they probably complained to the nurse. Neither of them (R1 and R2) told me what happened. I think R2 went in there (R1's bathroom) to take a shower. We use that room to shower residents. R1 was already agitated prior to that. R1 was complaining about going to the store and getting something form Walmart. R2 went in there and I think R1 just took her (R1) anger out on her (R2). All the female residents can use that shower. V16 was monitoring that wing.On 7/24/26 at 1:11pm, V7 (Psychiatric Rehabilitation Services Coordinator/PRSC) said, Yes, I know R1. She (R1) is usually isolated and quiet. She (R1) lets us (staff) know if she (R1) has concerns. At times, she (R1) exhibits aggressive behaviors and has complaints about other residents or situations., She's (R1) been refusing her (R1) medications which is making her (R1) worse. I am not aware of her (R1) ever being physically aggressive toward staff or other residents. She (R1) does yell and scream. Sometimes it appears as though she (R1) is about to attack residents or staff. I heard a commotion and saw that security had already separated the residents (R1 and R2 on 7/22/26). They (R1 and R2) were inside the room (R1's room). R2 was taken to the nurses' station. I spoke with R1 and reassured her (R1) that everything would be okay. R1 did not tell me what had happened. Other residents are not supposed to enter another resident's room. No, no one else should be using that shower room.On 7/24/26 at 1:24 p.m., V8 (Certified Nursing Assistant/CNA), stated, Actually, I did not see anything. My partner on the B Wing had just relieved me so I could go to lunch. I did not witness the incident and do not know what happened.R4's face sheet documents an admission date of 3/14/24 and diagnoses that include but are not limited to schizoaffective disorder, anxiety, depression, and obsessive-compulsive disorder.R4's BIMS (brief interview for mental status) score, dated 5/24/26, is 15 which indicates R4 is cognitively intact.On 7/24/26 at 2:17pm, R4 said, Going on 2 years that I've been here. I like it here. I was in the room that day (7/22/26). R1's my roommate. I don't want to get involved though. I'm scared of her (R1) too. She (R1) talks to herself sometimes. She (R1) threatened me once when she (R1) was talking to herself and said she (R1) was going to slap me. I just kept my mouth shut. I can't remember how long ago. No, I didn't tell any staff. About the other day (R1 and R2's altercation 7/22/26). R1 grabbed R2. R1 asked her (R2) to move back from the door. She (R1) didn't want other people to get hit when the door opened. Yes, they (R1 and R2) were in my room. Well, it's R1's room too. We're (R1 and R4) roommates with 2 other people too. No, R2 doesn't stay in my room. She (R1) asked her (R2) to move from the door. Next thing grabbing and punching started because R2 said something smart. I don't remember what R2 said. R1 did all the grabbing and punching, and then I hid behind the curtain. R2 didn't even know what happened. All she (R2) knew was to scream. I just hid. Luckily someone (staff) came cause she (R1) would have gotten me too. I hid behind the curtain. I wish I could have helped her (R2), but I was scared. I was behind the curtains, so I didn't see anything else after the grabbing and punching. I just seen her (R1) grab R2's arms and then punched her (R2) in the face. R1 was grabbing R2's hair and arms. R1's not safe to be around when she's (R1) angry, because it's going to get taken out on someone else. They (staff) tried to move her (R1) before this happened and she (R1) moved herself back in my room. They (facility staff) should've seen something coming. R1 is always yelling and screaming. R1 doesn't like a lot of traffic in the room.On 7/24/26 at 2:38pm, V15 (Certified Nursing Assistant/CNA) said, Yes, I worked, but I wasn't in the building. I went to the hospital with another resident for a doctor's appointment. I was on the schedule but not in the building when the incident happened.On 7/24/26 at 2:57pm, V16 (Certified Nursing Assistant/CNA), Yes, I worked. I checked everybody (residents) who needs to shower. I called everyone (residents) to the shower. I asked R2 to wait for me. The shower is on C wing. I got her (R2) stuff and when I came back she (R2) went to (R1's room) room. They're (residents) not supposed to be going to that room (R1's room). I was supposed to be watching her (R2). No, I'm not to let her alone. I saw R1 holding her (R2) head back. I quickly called a code. I didn't see any injuries. R1 is not usually physical fights. R1 talks a lot to self. R1's not easy to redirect. She (R1) does scream and yell a lot at other residents.On 7/24/26 at 3:10pm, V5 (Registered Nurse/RN) said, I was working (7/22/26). I was relieving one of the CNAs on C wing. Just standing and monitoring the C wing. I didn't see it (R1 and R2 altercation) happen. I heard staff shouting for help. Ran into the room (R1's room). R1 and R2 were in the room and in the corner. I didn't see much. I didn't any punches. The only thing was R1's hands were on R2's hair. When I walked in they (R1 and R2) separated. R2 was brought to nurse's station and told me basically R1 pulled her (R2) hair and her (R2). I didn't see any injuries. R2 said she was going to take a shower. They (residents) usually don't take a shower in that room (R1's room).On 7/24/26 at 3:20pm V6 (Psychiatric Rehabilitation Services Coordinator/PRSC) said, I was not on the schedule when the incident (R1 and R2 altercation) happened. I came when R1 was going to the hospital. R1 is aggressive sometimes. Part of her (R1) behavior. Verbally aggressive and attempts to get into physical. All I know about her (R1) is she's (R1) verbally aggressive and tried to get physical, but never really did get physical except for the one staff she (R1) tried to choke.On 7/24/26 at 3:36pm, V1 (Administrator) said, Residents are allowed to visit. They (residents) are allowed to have friends. They (residents) cannot just go into other residents' rooms. Every resident has a bathroom in between their rooms. So, they (residents) can just use their own bathroom. We (facility) have a centralized shower room. I feel like we (facility) have staff in place and enough of them (staff), but somebody missed or left the resident (R1) which caused this (R1 and R2 altercation on 7/22/26). According to V16 (Certified Nursing Assistant/CNA), she (V16) said that she (V16) gathered her (V16) residents to take a shower and went to get the supplies. When she (V16) came back, R2 had gone in that room (R1's room) without guidance to do so. I feel the staff should have gotten supplies, then gathered the residents. The resident (R2) should not have been left there while she (V16) went to get the supplies. Staff should have been with her (R2).Record review of facility policy titled, Abuse, dated 3/2021, documents, in part, This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, 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 and mistreatment of residents. This will be done by: Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again (42 CFR 483.12 Interpretive Guidelines). Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation (42 CFR 483.12 Interpretive Guidelines). 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 or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis, and update as necessary. Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of residents, including assigned staff who have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Incidents that do not meet the definition of abuse, neglect, exploitation, misappropriation of property or mistreatment will be handled through counseling, training and, if necessary or repeated, the facility's progressive discipline policy. 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. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents.Record review of facility policy titled, Behavior Management, dated 3/2021, documents, in part, Mental and psychological adjustment difficulties may be experienced by a resident, due to problems adapting to changes in life's circumstances. A resident may experience difficulty adjusting and therefore demonstrate signs and symptoms of mood distress or behavioral disturbance. Residents who display mental or psychological adjustment difficulty should receive appropriate services, in an attempt to minimize risks. New or worsening behaviors should be communicated to other departments, as needed.Record review of facility policy titled, Care Plan Development, dated 3/2021, documents, in part, A person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process, is developed and implemented for each resident. The facility's Interdisciplinary Team, in consultation with the resident and his/her representative, develops and implements a person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process. Each resident's care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any services that would otherwise be required based on Quality of Life, Quality of Care, or Behavioral Health Services regulations but are not provided due to the resident's exercising of Resident Rights, including the right to refuse treatment. The services provided or arranged by the facility, as outlined by the comprehensive care plan will meet professional standards of quality and be provided by qualified persons in accordance with each resident's written plan of care.

Based on interview and record review, the facility failed to supervise a resident who was diagnosed with bilateral eye blindness, used a white cane and required supervision and touching assistance with ambulation to prevent an avoidable accident and altercation. This affected two of three residents (R1, R2) reviewed for supervision. This resulted in R1 tripping over R2's wheelchair and the resident engaging in a resident-to-resident altercateion.Findings Include:R1 was diagnosis with category five blindness to the right eye, category four blindness to the left eye, atrophy of globe of right eye. Minimal Data Set Section B (vision) document severely impaired. Section C (cognitive pattern) dated 12/29/25 documents: brief interview for mental status summary score of fifteen which indicate cognitively intact. Section GG (functional abilities) documents mobility device: cane/crutch. Walk ten (10) feet: Once standing, the ability to walk at least 10 feet in a room, corridor or similar space documents a score of (04) four. 04 indicates: supervision or touching assistance- helper provides verbal cues and or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R1' s care plan initiated 12/5/2024 documents: R1 has an activities of daily living (ADL) Self Care Performance Deficit related to diagnosis of legal blindness. R1 uses a white cane for ambulation. Intervention: Assist R1 with ambulation, transfer, etc as necessary. Ensure R1 uses his white can when up and about.Incident note dated 1/7/25 documents: Writer was alerted by staff that resident (R1) was punched in the abdomen by a co-resident. R1 states that he was going to put his coffee back at the kitchen window, he accidently bumped into another resident (R2) which caused his co-resident to become agitated and punched him in the abdomen. Resident (R1) stated he retaliated and hit co-resident (R2) with his ambulating device.Physical Aggression Received report dated 1/7/26 documents: Writer was alert by staff that resident (R1) was punched in the abdomen by another resident. Was this incident witnessed: N (which indicates no.)Facility Initial reportable incident dated 1/7/26 documents: Residents (R1/R2) were involved in an altercation.On 1/8/26 at 1:43pm, R1 who was assessed to be alert and oriented, said, he went to put his coffee cup up in the window. R1 said, he bumped into something and almost fell. R1 said, he can see shadows. R1 said, he asked the resident (R2) he bumped into why was he sitting there. R1 said, he did not see R2. R1 said, R2 punch him in the chest with his fist. R1 said, he hit R2 two or three times with his cane.R1's witness statement dated 1/8/26 documents: I was putting my cup in the window, that guy was there in his wheelchair. I can't see that good, I bumped into the chair. I tried to say that I was sorry but he (R2) started yelling f**k you, f**k you. The he (R2) hit me, so I hit him back. Social service note dated 1/7/26 documents: The resident (R1) was seen trying to get past another peer, in which he lost his step and hit the peer with his cane.On 1/8/26 at 1:48pm, R2 who was assessed to be alert and oriented to person, place and time said, he was getting ready to put his coffee cup away and R1 hit him in the mouth with his cane. R2 said, R1 busted my lips. R2 showed surveyor the inside of his upper top lip. R2's upper lip was observed with a redden raised area the size of a dime with a white soft tissue middle that was consistent with a busted lip. R2 said, he did not hit R1.R2's witness statement dated 1/8/26 documents: He (R1) bumped into my chair and got mad and hit me.Daily note dated 1/7/26 documents: Resident (R2) was involved in a physical altercation with another resident (R1) where he was hit. A superficial scratch was observed on the right upper lip.On 1/8/26 at 2:13pm, V6 (medical records) said, she saw R1 hit R2 on the head with his stick. V6 said, R2 was sitting in his wheelchair covering his head. V6 said, V3 (social service aide) was the first staff member to intervene. V6 (medical record) witness statement dated1/8/26 documents: I was doing big bank. I heard an uproar with resident and staff. I saw that R1 was striking R2 with his walking stick. V3 came and intervened and separated them.On 1/8/26 at 2:18pm, V4 (activity aide) said, she was wrapping up from making coffee. V4 said, she looked up after hearing residents arguing. V4 said, she heard R1 who is legally blind ask R2 what are you sitting here. R2 got upset and replied f**k your mom, f**k you. R1 was taking his coffee cup to the window. Normally we take, R1's coffee cup up to the window. V4 said, she saw R1 hit R2 a few times with his cane. V4 said, R1 hit R2 in the mouth with his cane.V4 (activity aide) witness statement dated1/8/26 documents: I was making fresh coffee for the resident. I hear verbal communication between R1 and R2. I placed the coffee on the cart while yelling to get the residents attention as well as staff. R1 was swinging his stick. By the time, I got over there, hits were being thrown. I continue to get louder so other people can hear me from afar.On 1/8/26 at 2:27pm, V3 (social service aide) said, he was monitoring the smoking break. V3 said, he was in the doorway between the outside patio and the main dining room. V3 said, he heard a commotion. V3 said, he heard cursing. V3 said, he saw R1 having a physical altercation with R2. R1 hit R2 the face. R2 had blood coming from his mouth.On 1/8/26 at 4:04pm, V2 (PRSD) said, the incident between R1 and R2 could have been prevent had the resident's been supervised.On 1/9/26 at 10:12am, V1 (administrator) said, she does not have access the video footage from 1/7/26 involving R1/R2's incident. V1 said, it's an IT issue.On 1/9/26 at 11:20am, R3 who was assessed to be alert and oriented to person, place and time, said R1 was returning his coffee cup. R3 said, the facility wants residents to pick up after themselves. R3 said, R1 fell into R2's wheelchair. R3 said, R1 got tangled in R1's wheelchair. R3 said, he saw R2 hit R1. R3 said, R1 had his cane folded up in his pocket. R3 said, R1 keep his cane folded in his pocket when it's not in use so he won't loss it. R3 said, he saw R1 take his cane out of his pocket and hit R2 with the leather piece on his cane. R3 said, R1 stumbles over residents and walks into their wheelchairs daily. R3 said, whenever R1 gets entangled or bumps into someone, R1 will walk forward verses backing up.On 1/9//26 at 1:03pm, V5 (nurse) said, she did not witness the incident between R1 and R2. V5 said, it was at the change of the shift. V5 said, she heard staff calling nursing. V5 said, she cannot say which staff called her. V5 said, staff was yelling staff/nurse. V5 said, when she reached R1 and R2 the incident had happened and was over.On 1/9/26 at 2:43pm, V1 said, she does not have a supervision policy, but her staff has been educated on supervising and monitoring the resident that included a post test.On 1/9/26 at 3:00pm, V2 (DON) said, R1 is legally blind and ambulates with a cane (mobility tool) to detect obstacles or objects. V2 said, R1 does not need anyone to walk with him. V2 said, if a resident requires supervision with ambulation staff needs to be within arm's reach of the resident. V2 said, if a resident requires touching assistance with ambulation, then the staff needs to physically touch the resident to assist. On 1/9/26 at 3:34pm, R1 said, he was walking without his cane. R1 said, on the day of the incident, no staff was helping him returned his coffee cup. R1 said, staff helped today. R1 said, he cannot see until he gets right up on a person/resident or object. The top portion/ handle of R1's assistive ambulation device (cane) was observed with leather wrapping.On 1/9/26 at 3:40pm, V1 said, R1 has been a resident for a while and is acclimated to the facility. V1 said, R1 has walked from his room to her office without his cane sometimes. V1 said, she was unaware if R1 should be walking without his cane. V1 said, when R1 comes to her off without his cane she will redirect him to go get it. On 1/9/26 at 3:44pm, V8 said, R1 should always have his cane when he is ambulating. Facility Supervision and Monitoring of Resident safety tracking education package without a dated document: Focused safety monitoring. Who will monitor the resident? Everyone: Social service, Nursing, Housekeeping, Activities and Managers. Everyone is expected to monitor the residents. Our goal is to keep our resident and staff safe. Prevent Incidents. Prevent any altercation and/or physical contact before it happens. Prevent Abuse.

Based on observation, interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R3) from both physical and sexual abuse by R2. This failure affected one (R3) of seven residents (R1, R2, R3, R4, R5, R6, and R7) reviewed for abuse. These failures resulted in R3 being physically and sexually assaulted by R2 and R3 also suffering psychosocial harm stating feelings of fear and nightmares. Findings include:R3's face sheet documents diagnose that include but are not limited to major depressive disorder and suicidal ideations.R3's Final Report titled, Final Investigation of Allegation of Abuse, dated 12/24/2025, documents, in part, R3 reported that on 12/20/25 she (R3) went into the shower room after breakfast to take a shower. Reportedly while in the shower R3 stated that she (R3) heard the door open and that she (R3) saw some shoes. R3 stated that she (R3) yelled get out I'm in here. R3 stated that the male co- resident R2 came into the shower and forced himself (R2) on her (R3). R3 stated that she (R3) yelled for help and another co-resident opened the door, R5 stated that he (R5) yelled for staff. Staff intervened immediately and separated both residents. Conclusion of Investigation: Based on the investigation conducted, review of the medical records, and the residents involved, it could be concluded that R2 did enter the shower while female co-resident (R3) was taking a shower. R2 reported that they had sex. Resident (R3) stated that she (R3) did not consent and that she (R3) was forced. Resident (R2) appeared to be having symptoms related to his (R2) diagnosis of mental illness schizoaffective disorder.On 12/25/2025 at 12:28pm, R3 said that R3 was showering and had drawn the shower curtain when the bathroom door opened. R3 observed someone wearing black shoes enter the area. R3 told the person to leave; however, the individual did not comply and drew the shower curtain back. R3 then seen R2 and then R2 removed R2's pants. R3 reported that R2 used physical force to restrain R3 against the wall and grabbed R3 by the neck, causing fear of I thought he (R2) was going to snap my neck. R3 stated, that R2 demanded a kiss, and R3 complied due to fear. R3 reported being forced into a corner and that a sexual assault occurred. R3 said, I'm (R3) not sure if he (R2) penetrated the anus or vagina. I was so scared. R3 stated that another resident (R5) entered the shower room and ran for help. Staff came and helped. R3 stated that R3 then went to the bathroom and observed blood when wiping both the front and back of the body's private area. R3 stated that the blood was collected by staff. R3 reported that law enforcement responded and that R3 was transported by ambulance to the hospital, where an interview was conducted. R3 stated that a sexual assault forensic examination was completed. R3 reported that staff typically supervise residents during showering but could not recall which staff member provided shower supplies on that date. R3 stated that shower supplies are accessed through staff. R3 expressed feeling unsafe in the facility and stated concern that the incident could occur again. R3 said, I'm scared someone else might do this to me again. The nightmares are horrible. R3's BIMS (Brief Interview Mental Status) score, dated 11/20/25, is 14 which indicates R3 is cognitively intact.R3's At Risk for Abuse Assessment, dated 6/08/25, is 3 which indicates R3 may be at risk for abuse. R3's At Risk for Abuse Assessment, dated 12/22/25, is 2 which indicates R3 may be at risk for abuse. R3's care plan, dated 6/08/2025, documents, in part, (R3) is at risk for abuse/neglect based on the comprehensive assessment as evidenced by: (R3) has a diagnosis of mental illness. (R3) has experienced recent incident of sexual assault.R2's face sheet documents diagnoses that include but are not limited to schizoaffective disorder, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, suicidal ideations, and pervasive developmental disorder.R2's BIMS (brief interview mental status) score, dated 11/30/25, is 15 which indicates R2 is cognitively intact.R2's progress note, dated 12/20/25 at 10:40am, per V9 (Licensed Practical Nurse/LPN) documents, in part, Writer was notified that resident (R2) enter the shower room where a female resident (R3) was taking a shower and force himself (R2) on her (R3). Resident (R2) was immediately place on one-on-one monitoring and 911 called. Police arrived and resident (R2) was taken into custody.R2's Aggression and Violence History and Screening Assessment, dated 1/15/25, documents, in part, Did resident (R2) have a recent/have a history of aggressive/agitated behavior? (destruction of property, physical altercation with others, fire setting, or other violent acts): YES.R2's CHIRP (Criminal History Information Response Process, dated 8/05/25, documents, in part, HIT: Charges of Battery/Makes Physical Contact; Burglary; and Criminal Trespassing.R2's care plan, dated 1/15/2025, documents, in part, (R2) displays socially inappropriate and maladaptive behavior. R2 attempted to come out from shower room undressed.R2's care plan, dated 3/30/2025, documents, in part, (R2) display aggressive, inappropriate, attention-seeking behavior. (R2) has verbal altercation with staff.R2's progress note, dated 12/22/25 at 2:16pm, documents, in part, Psych doctor, medical doctor, and medical director informed about residents sexually inappropriate behaviors. New order was given for involuntary discharge.R2 no longer resides at the facility. R2 was issued a notice of involuntary discharge.R5's face sheet documents diagnoses that include but are not limited to schizoaffective disorder and major depressive disorder.R5's BIMS (Brief Interview Mental Status) score, dated 11/30/25, is 10 which indicates R5's cognition is moderately impaired.R5 is a witness to the sexual assault, however R5 was unable to be interviewed due to R5 being on community pass during the time of the survey.R5's interview per V1 (Administrator) during the investigation, dated 12/20/25, documents, in part, Resident (R5) stated that he (R5) saw R3 go into the shower, then he (R5) saw co-resident R2 go into the shower after R3. Resident (R5) reported that he (R5) was pacing in the C wing hall, he (R5) reported hearing some yelling for help coming from the shower door. Resident (R5) reported that he (R5) opened the door and saw female resident (R3) standing in the shower naked with male resident (R2) with her. R5 stated I (R5) went to get the staff for help.On 12/25/25 at 1:32pm, V1 (Administrator) stated that V1 is the abuse prevention coordinator and completed the investigation regarding R2 sexually assaulting R3. V1 stated that the facility substantiated that sexual abuse occurred to R3 and R2 will not be returning to the facility. V1 (Administrator) said, Usually the residents are able to say that they are going to take shower. There are linen carts as well that the residents can take supplies needed to shower. It's the central shower. The central shower is not in the men's wing, its preceding the men's wing. Staff are usually there. A CNA (certified nursing assistant) is assigned to the C wing to monitor the central shower as well as another CNA that is assigned to the dining room. A and B wings are women and C, D, and E wings are all men. C wing is in the middle of the building right by the dining room. The CNA is usually standing right at the entrance of the hall, where the bathroom is. They (staff) are supposed to be monitoring the whole hall. Yes, that included the bathroom. I questioned V11 (Certified Nursing Assistant/CNA) who was assigned to monitor the central bathroom, and V11 told me (V1) that at some point he (V11) went to the bathroom. There's another CNA right in the dining room that V11 should have notified before going to the bathroom to get coverage. If they (staff) go to the bathroom, there is a CNA for A wing and a CNA for B wing that V11 could have asked to cover his (V11) monitoring while he (V11) went to the bathroom. I mean, The CNA is right in the dining room, V11 should have asked her. We (facility) have staff. There is activity staff, social services, they are here to help with coverage and monitoring. Yes, That is my expectation. They (staff) need to get someone to cover. It's a behavior health facility. Coverage and monitoring are very important.On 12/25/25 at 2:02pm, V7 (Medical Records) said, So on Saturday (12/20/25), breakfast just finished, helped clear out the dining area, went back to my (V7) office, got a knock on my (V7) door, that a resident (R3) was raped. Went and had R3 explain to me (V7). R3 said that R2 went in the shower room, R3 told him (R2) to get out, R3 was screaming for help, R2 pinned R3 against wall, and raped R3. I talked with R2 and R2 said R2 went in. I asked what went in meant, and R2 said had sex. I spoke with R5. R5 said he (R5) heard R3 in the bathroom screaming for help, and R5 got V5 (Psychiatric Rehabilitation Services Coordinator/PRSC) who was in the office.On 12/25/25 at 2:14pm, V8 (Registered Nurse/RN) said, I was one of the nurses that day. I was working on the part of D and E wing. 3 nurses for the day. I finished my med pass in the E wing when the manager on duty, V7 (Medical Records), came to me (V8) to see what happened. We (V8 and V7) came back to the nurse's station and confirmed the same information that R2 raped R3 in the shower room. We (staff) reached out to Administrator and called the police and EMS (emergency medical services). EMS took her (R3) to hospital and the cops took R2. Been here since 2023 and never experienced a rape here before. On 12/25/25 at 2:25pm, V9 (Licensed Practical Nurse/LPN) said, Okay, I was one of the nurses working when R2 raped R3. I finished passing meds, came back and seen staff talking to R3. R3 said R2 entered the bathroom and forced himself (R2) on her (R3). We (staff) then called police and called the administrator. The police and police came and left with the male resident (R2).On 12/25/25 at 2:24pm, V10 (Certified Nursing Assistant/CNA) said, I worked that day. The day was Saturday I was in the dining room monitoring. I was watching a patient. I was monitoring in the assistant area of the dining room, sitting in a chair. I didn't hear any screaming. Where I was is not close to the bathroom. It's more by the kitchen area. I don't know where V11 (Certified Nursing Assistant/CNA) was. He (V11) never said to watch his post or told me (V10) he (V11) was going to go to the bathroom. V11 was assigned to that area to see who is going in and out of the bathroom. Someone is always supposed to be on your wing until you come back from break or bathroom.On 12/26/25 at 9:51am, V11 (Certified Nursing Assistant/CNA) said, We (staff) had finished passing meal trays. I usually work afternoon shift, but I was working a double that day. Breakfast was served around 8:00 a.m., but some residents arrived late, so we (staff) were still collecting trays. While I was in C wing near the supply store, where lotions, diapers, and other items are kept, R3 approached me and stated that she (R3) wanted to take a shower. I asked her (R3) to get her (R3) CNA, but she (R3) said that the staff were very busy and asked if I could help her (R3) instead. I went to the supply store to get soap, and she (R3) then requested washcloths and towels. I had to go to the laundry room to retrieve them. Then some residents go for cigarettes. I usually go to bathroom, a number 2, around 7:30am, 8:00am, or 9:00am every morning. I was pressed. I had to rush to go to bathroom. I was gone 5 minutes. I was later told that during that time, R2 went into the bathroom and raped R3. I was not present when this occurred, and I was not responsible for monitoring the bathroom at that time. No, I didn't tell anyone I was going to the bathroom, I was pressed and went fast. The bathroom is not locked for safety reasons, in case a resident has a seizure. Staff are responsible for ensuring the bathroom is clean and for checking residents' skin, but at that time, staff were very busy. Even if I had not stepped away to use the restroom, I would still have been occupied with collecting trays and cleaning up.On 12/26/25 at 10:27am, V5 (Psychiatric Rehabilitation Services Coordinator/PRSC) said, The resident (R5) came to my (V5) office and said I need to check the shower room and because R5 heard a woman screaming help me. I went to the shower room and seen R3 was naked, and the male resident (R2) was trying to put on his (R2) clothes. I escorted them out. I did not hear any screaming. R2 admitted it to me (V5) and V4 (Activity Director) that he (R2) raped R3. She (V4) asked him (R2) and R2 admitted that he did do it. He (R2) said he (R2) wanted sex. V4 asked R2 if R3 asked R2 to come in and R2 said no. V4 asked R2 did R3 say she (R3) wanted to engage in sexual activity and R2 said no, but R2 said he (R2) went in and kept going. R2 admitted that he (R2) was not invited to shower room and not invited into R3's personal area.On 12/26/25 at 11:10am, V4 (Activity Director) said, I called R3 into the office and asked R3 if R3 was okay and to explain to me (V4) what just happened. She (R3) was rattled, and I had to slow her (R3) down. She (R3) said she (R3) went to take her shower, and when taking shower, someone opened the door. She (R3) told them to get out cause someone is there. She (R3) seen shoes and recognized the shoes. R2 pulled the curtain open and started kissing her (R3). She (R3) told him (R2) that she (R3) didn't want him (R2), and he (R2) continued and raped R3. She (R3) said that she (R3) was burning in her (R3) behind and in pain and bleeding. She (R3) had a tearful sound in her (R3) voice as if she (R3) was trying to fight back the tears. On 12/26/25 at 12:26pm, V3 (Registered Nurse/RN) said, I was completing medication pass on A wing, and was told to go see R3. R3 stated that while she (R3) was taking a shower, R2 forced himself (R2) on her (R3). She (R3) was screaming at the time. I provided her (R3) with a clean towel and instructed her to wipe from front to back. There was some blood noted on the towel. We (staff) then contacted the administrator, followed by calling 911, and the doctor was also notified.On 12/26/25 at 3:04pm, V12 (Psychiatric Mental Health Nurse Practitioner) said, At this time, she (R3) appears to be doing well. She (R3) stated that she (R3) just wants to move on with my life now. She (R3) also stated that it doesn't feel good, and that she (R3) was given several STD (sexually transmitted disease) medications and is moving forward. I am going to prescribe some medications because she (R3) is experiencing nightmares. I will meet with her (R3) once a week to process these experiences with her (R3) so that she (R3) can work through them and continue to heal.Record review of facility policy titled, Abuse, dated 3/2021, documents, in part, This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, 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 and mistreatment of residents. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means {210 ILCS 45/1-103). Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident (42 CFR 483.5). This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish (42 CFR 483.12 Interpretive Guidelines). The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. (42 CFR 483.5). Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault (42 CFR 483.12 Interpretive Guidelines).Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on interview and record review, the facility failed to follow hospital orders for a fluid restriction after a resident (R1) was hospitalized for low sodium and failed to complete additional laboratory work for a resident's (R1) low sodium levels for one out of three residents reviewed for improper nursing care in a total sample of three. This failure resulted in R1 suffering a syncopal episode twice within four days and needing to be hospitalized each episode for low sodium and bradycardia. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, type 2 diabetes, schizoaffective disorder, bradycardia, and syncope/collapse.R1 no longer resides in the facility. A Nursing note dated 5/ 31/ 25 document R1 was found lying on the floor in R1's room. The fall was unwitnessed. Vital signs were within normal limits except the heart rate. The heart rate was 49 (normal heart rate is 60-100 beats per minute). R1 was not able to stand. The doctor was called and ordered to send R1 to the hospital. A call was made later to the hospital to check on R1's status. R1 was admitted with a diagnosis of low sodium. A Nursing note dated 6/2/25 documents R1 returned from the hospital with the discharge diagnosis of low sodium. R1's heart rate upon admission was 68. R1 was able to ambulate with a steady gait. The physician was made aware of R1's return and the medication that was given during the hospital including insulin. No new orders were received.The Hospital Records dated 6/2/25 document R1 was admitted with a diagnosis of low sodium. R1 was ordered a regular diet with a fluid restriction of 800 mL. Sodium levels were 124 on presentation to the emergency room and raised to 131 the next morning after receiving IV fluids overnight. This is consistent to volume depletion which is likely a component of SIDAH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) due to psych medications.Per the National Library of Medicine, an article titled, Clinical management of SIADH, dated 04/2012 documents, Hyponatremia is the most frequent electrolyte disorder and the syndrome of inappropriate antidiuretic hormone secretion (SIADH). SIADH should be treated to cure symptoms. Therapeutic modalities include nonspecific measures and means (fluid restriction, hypertonic saline, urea, demeclocycline), with fluid restriction and hypertonic saline commonly used. (https://pmc.ncbi.nlm.nih.gov/articles/PMC3474650/)A Laboratory note dated 6/13/25 documents the sodium level was 134. All lab levels were reviewed by the physician and no new orders were received. The Laboratory Report dated 6/13/25 documents a sodium level of 134 mEq/L. The reference range for a normal level is 138-147 mEq/L. No other laboratory levels were tested again after this. A Transfer to Hospital note dated 6/25/25 documents R1 was observed having a near syncopal episode in the dining room. R1 was taken back to R1's room and assessed. R1's pulse was 58. The physician ordered to send R1 to the hospital. A Nursing note dated 6/25/ 25 at 8:37 PM documents arrived back to the facility. Vital signs are within normal limits. Diagnosis from the hospital was low sodium and slow heart rate. R1's discharge instructions include wearing a cardiac monitor for seven days continuously then returning it back to the hospital. The physician was called several times and the nurse was not able to get a hold of the physician for any new orders. This will be endorsed to the next shift. A Nursing note dated 6/26/25 documents the physician ordered an electrolyte panel for R1 to follow up on the hyponatremia diagnosis. A Nursing note dated 6/29/25 documents R1 fell in the dining room. Vital signs were within normal limits except heart rate was 38. R1 was picked up off the floor and assisted to a private room to be monitored. The physician was notified in order to send R1 to the hospital. The pulse was rechecked while waiting for the ambulance and R1 was still bradycardic. R1 was admitted to the hospital with a diagnosis of syncope and bradycardia. R1 was admitted for monitoring. There is no documentation that the psychiatrist or primary physician adjusted any medications to address the low sodium levels or that a fluid restriction was ordered.Vital signs from 5/31/25-6/29/25 were reviewed. A heart rate of 46 beats per minute was documented on 5/31/25 and a heart rate of 30 on 6/29/25. Vitals signs are not documented each shift every day per the care plan intervention. The Physician Order Summary was reviewed. There is no order for a fluid restriction, a cardiac monitor for one week, or a medication adjustment in the psychiatric medication. R1 has an order for carbamazepine 100mg three tablets twice a day and one 200mg tablet once a day, phenytoin 100mg two capsules three times a day, invega sustenna 11mg injection once a month, seroquel 300 mg two tablets twice a day, and metformin 500mg tablet once a day. All these medication especially when used in combination can cause SIADH. None of these medications have had dosages lowered within the last six months. On 7/18/25 at 12:37PM, V1 (Nurse) stated V1 received notification that the labs were abnormal so V1 notified the physician. V1 reported the facility uses the reference numbers in the laboratory report to tell if a laboratory level is low, high, or normal. V1 stated all abnormal lab levels must be reported to the physician by a phone call and faxing the numbers over to the physician. V1 stated if no new orders are given by the physician that it must be documented. V1 reported the physician was looking for hyponatremia in this lab draw, and it was a previous issue R1 kept having. V1 stated no new orders were put in for this lab level per the physician's request. V1 reported R1 had a near syncopal episode on 6/25/25 where R1 was dizzy when R1 tried to stand. V1 stated R1 was sent to the hospital by the physician and came back with a cardiac monitor. V1 reported R1 fell again on 6/29/25 after having another syncopal episode. V1 reported R1 did have a low heart rate in the 30s at the time of this fall. V1 stated hospital paperwork is reviewed by the nurses and a medication review as well as any other changes in orders have to be reviewed with the physician when the resident is readmitted . V1 reported all new orders have to be reviewed with the physician so any changes can be made to the current orders at the facility. V1 stated a nurse documents in the computer system that a physician was notified of any new orders or changes from current orders after returning from the hospital. V1 reported if it is not documented, it means it didn't happen. V1 stated a fluid restriction needs to be documented in the computer system as well as an order be put in. V1 was not able to show the surveyor in the computer system where the fluid restriction documentation for R1 was. V1 denied being aware that R1 was on a fluid restriction. On 7/18/25 at 1:07PM, V2 (CNA) stated staff was monitoring R1 due to recent episodes dizziness and falls. V2 denied R1 having a fluid restriction while R1 was at the facility. V2 reported if a resident is on a fluid restriction then it is charted in the computer system.On 7/18/25 at 1:38PM, V3 (ADON/Restorative Nurse) stated it is the admitting nurse's responsibility to review the hospital paperwork and inform the physician of any changes. V3 reported the DON should also be made aware of any changes to the plan of care. V3 stated r1 was having low heart rate and low sodium but was unaware of what was causing it. V3 reported the nurses have to document any conversation with a doctor to let the oncoming staff what is going on with the resident. V3 stated if a resident is on a fluid restriction, staff have to monitor them and document the amount of fluids. V3 reported the CNAs will document in the computer under the meals tab which allow staff to watch how much the resident is drinking. V3 was not sure not if R1 was supposed to be on a fluid restriction. V3 stated if a resident was on a fluid restriction from the hospital then it needs to be continue at the facility. V3 reported the doctor will be called for an order, the dietitian will come to evaluate the resident, and the dietary department will be notified.On 7/18/24 at 2:34PM, V4 (Former Nurse) stated V4 took care of R1 the day of the first fall on 5/31/25. V4 reported R1 was too weak to stand and R1's pulse being low at the time of the fall. V4 stated that R1 was diagnosed with low heart rate and low sodium while at the hospital, but was unaware of the cause. V4 reported when a resident is readmitted from the hospital, orders must be reviewed, and the physician must be called to carry out any new orders. V4 confirmed a fluid restriction must be ordered so everyone knows that a fluid restriction is in place for that resident. V4 stated a fliud restriction must be documented in the computer system so continuing shifts know how much fluid a resident is having throughout the day. V4 denied ever seeing an order for a fliud restriction. V4 reported a physician must be notified of any new orders from the hospital or any changes while the resident was in the hospital so the doctor is aware of the plan of care. V4 denied remembering a fluid restriction was ordered after R1 returned from the first hospitalization. On 7/18/25 at 2:45PM, V5 (Nurse) stated V5 readmitted R1 back to the facility after the second admission to the hospital. V5 confirmed R1 was diagnosed at the hospital with low heart rate and low sodium levels. V5 reported the physician (V7) was called to get orders after R1 arrived, but the physician did not return a call, so this task was endorsed to the next nurse. V5 reported an administrator or DON should notified if the nurses cannot get in contact with the physician. V5 admitted that V5 was busy and probably forgot to notify the administrator or DON that V5 could not get in contact with the physician for any new orders. V5 denied R1 ever being on a fluid restriction. V5 was unaware why R1 would need a fluid restriction. V5 denied being aware that the last sodium level drawn was trending low. On 7/18/25 at 3:13PM, V6 (DON) stated R1 was admitted to the hospital after a fall due to a syncopal episode where R1 was diagnosed with bradycardia as well as low sodium. V6 reported after a resident is readmitted from the hospital, the physician must be notified of their return and makes the physician aware of any new orders from the hospital. V6 stated the nurse must document this conversation and if any orders have changed. V6 reported the nurse is responsible for letting the physician know of any diet change orders. V6 stated R1 did have a redraw of labs to check the sodium level. V6 stated V6 knows the sodium level was low but close within normal range so no additional orders were put in. V6 denied the sodium level was monitored again or any additional orders put in place until R1 went to the hospital on 6/25/25. On 7/18/25 at 7:00PM, V7 (Primary Physician) stated R1 is a diabetic and also takes psych medication and this combination can cause low sodium. V7 reported it is caused by a disturbance in electrolytes due to the hormones being imbalanced. V7 stated a blood test was completed about one week later after the first hospitalization and the sodium level was normal. V7 stated the sodium level was only one point out of normal range at 134. V7 reported V7 did not feel like it needed to be checked again because it was near normal. V7 stated V7 was aware that R1 went out to the hospital a second time for bradycardia and low sodium and was readmitted to the facility with a cardiac monitor. V7 stated V7 told the admitting nurse to continue all treatments from the hospital after each readmission. V7 reported V7 cannot adjust the psychiatric medications so the nurses were informed to get in contact with psych to adjust R1's medication to help with low sodium levels. V7 was unaware why a fluid restriction was done and was unable to explain how a fluid restriction would increase a sodium level. V7 said, Whatever maneuver they used in the hospital to get normal sodium is what they did. V7 stated it is the nurse's responsibility to speak with the psych physician about changing medication. V7 reported V7 was not aware of a third admission for bradycardia and low sodium. On 7/22/25 at 10:26AM, V8 (Psych Nurse Practitioner) stated V8 saw R1 in May and June of this year. V8 reported R1 was not having any new delusions or behaviors so no medication adjustments were needed. V8 stated V8 did not know about R1's low sodium. V8 confirmed psych meds can cause low sodium from SIADH. V8 denied being aware that R1 was ever treated for that condition while at the hospital. V8 stated that low sodium is a medical condition and the medical doctor (V7) would've handled that. V8 reported the medical doctor would've handled this because the medical doctor has access to the laboratory levels. V8 stated low sodium levels can cause generalized weakness and if the sodium gets low enough, it can cause a person to have seizures. V8 reported that condition is usually managed with a fluid restriction before adjusting any medications because adjusting the medications can have a negative effect on behaviors. V8 stated if V8 were told about the low sodium, then it would have been documented in the progress notes in June. The surveyor asked if V8 was aware about the low sodium, what changes to the medication would V8 have made? V8 reported that V8 would have had to have a discussion with the medical physician before making any changes to any medications. On 7/22/25 at 11:14AM, V6 stated if the primary physician and psych physician need to discuss a resident's plan of care then they will communicate with each other. V6 stated that V7 is a medical doctor so V6 was under the impression that V7 was managing the low sodium level. V6 denied V7 ever asking the facility to get psych involved for R1's medication adjustments. V7 denied being aware why a fluid restriction wasn't re-ordered after R1 was readmitted . V6 reported if the facility does not agree with the doctor's orders or feel a resident needs additional orders than another physician can be contacted that sees that resident. V6 denied any other physicians being contacted for R1's low sodium level. The Fall Report dated 5/31/25 documents R1 was found lying on the floor in R1's room. Vital signs were within normal limits except heart rate was low at 49. R1 reported hitting R1's head. R1 was not able to stand on R1's own. An order was received to send R1 to the hospital. There are no predisposing environmental or physiological factors that caused the fall. The Fall Report dated 6/29/25 documents R1 fell in the dining room. R21 reported R1's legs gave out while R1 was going to the bathroom. The physician ordered R1 go to the hospital. R1 was bradycardic. There are no predisposing environmental or physiological factors except change in condition that caused the fall. The Care Plan dated 6/3/25 documents R1 is at risk for falls after sustaining a fall on 5/31/25. An intervention includes to endure R2 drinks water throughout the day. The Care Plan dated 6/26/25 documents R1 present with decreased cardiac output related to a diagnosis of bradycardia as evidenced by near fainting episodes. An intervention includes that R1 will wear a cardiac monitor as ordered by the physician and vital signs will be documented every shift. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as a 12 (Moderate cognitive impairment). There were no hospital records available from the hospitalization on 6/25/25 or 6/29/25.Intake and output or fluid restriction documentation was requested during this survey but none was provided. The policy titled, admission Process, dated 03/2021 documents, .2. When a resident arrives at the facility.utilize accompanying hospital records for detailed information. The policy titled, Change in Condition, dated 03/2021 documents, Guideline: To keep the physician or extender, who is in charge of medical care, responsible party, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. Standard: Notification of the physician, legal representative, or responsible party, should occur when there is a change in the resident's condition. Change in condition is defined as (notify parties immediately in the event of death): an incident or accident that involved the resident which results in injury and requires physician intervention; a change in the resident's physical, mental or psychosocial status; a need to alter treatment; and/ or a decision to transfer or discharge the resident from the facility. The policy titled, Physician Orders - Verbal and Fax, dated 03/2021 documents, .Procedure: 1. Verbal Orders: Verbal orders are those given to the nurse by the physician or extender in person or by telephone, however are not written in the medical record. Follow this process: a) Write the orders verbally given by the prescriber in the medical record.d) The prescriber should sign the according order according two state guidelines. e) Follow through with the orders as required. If the orders are unable to be followed the provider should be made aware and then additional orders received.3. Outside Appointment Orders:.b) If the resident returns with orders from the consulting physician, the orders must be verified with the attending physician before they can be carried out.d) If the attending position is not in agreement with the orders, the consulting physician must be notified by the nurse. e) It is the responsibility of the physicians to come to agreement on which orders are to be followed.

Based on interviews and record reviews the facility failed to follow their abuse policy and procedures by restricting a resident from returning to their room with their personal items and physically restraining them against their will. This failure applies to one of three residents (R1) reviewed for abuse. Findings include: R1 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Recurrent Severe Major Depressive Order with Psychotic Symptoms, PTSD, Generalized Anxiety Disorder, Brain Cancer, and Suicidal Ideations who was admitted to the facility 01/14/2025. On 03/31/2025 at 1:00 PM V3 (Psychosocial Services Rehabilitation Services Assistant/Security Guard) stated on 03/19/2025 between approximately 7:15 AM and 7:20 AM during smoke break, he heard social services being paged to the front desk and when he arrived R1 was in the middle of screaming, yelling, and cursing at V5 (Receptionist) and stating no one could check his things and they didn't have a right to check his belongings. V3 stated the delivery driver didn't bring R1's groceries all the way in the facility and had left them in the vestibule area between the front doors of the facility. V3 stated he walked into that area and grabbed the groceries delivered for R1, brought them back near the social services office and asked R1 to give him a second because he didn't have the key to the social services office. V3 stated he turned around briefly and by the time he turned back around R1 had grabbed all the groceries in his hands and was attempting to go back to his room, so he stood in front of him and told him he couldn't go back to his room. V3 stated R1 had a case of pop that was starting to break apart and when he went to grab the can to prevent it from falling R1 thought he was attempting to take it from him and began screaming at him, lunged at him, then physically attacked him. V3 stated when he got up after being attacked by R1, R1 had grabbed all his belongings again, took his belongings to the dining room table and sat there for approximately 10 seconds. V3 stated R1 then attempted to get his belongings again and head to his room but wasn't able to and then became loud and began screaming and yelling at V4 (Psychosocial Services Rehabilitation Services Assistant/Security Guard). V3 stated V4 was in the dining room with R1 during this time he believes attempting communicate with him and keep him calm. V3 stated when R1 began approaching his room V4 stopped him and then R1 became aggressive with V4 and attempted to push his way through him. V3 stated then he and V4 took R1 belongings out of his hands, put him in a CPI hold and took him to the ground. V3 stated he and V4 had R1's arms and took him to the ground. V3 stated he had R1's arms above his head and V4 had his legs, then the police arrived. V3 stated R1 was being held for about 45 seconds to a minute before the police arrived. V3 stated when he no longer felt any resistance from R1 arms he let them go and when V4 no longer felt any resistance with R1 legs he let them go. V3 stated at this point the police were involved, they took some statements and then R1was sent to the hospital. On 03/31/2025 at 1:50 PM V6 (Registered Nurse) stated on 03/19/2025 she observed R1 and V3 (Psychosocial Services Rehabilitation Services Assistant/Security Guard) standing in the hall between the social services office and the nursing station and V3 was explaining to R1 that he needed to check in R1 belongings. V6 stated R1 became upset because he didn't want his belongings checked in while V3 continued to explain the facilities policies. V6 stated she then observed R1 physically attack V3. V6 stated afterwards V4 (Psychosocial Services Rehabilitation Services Assistant/Security Guard) and other staff gathered around and physically separated R1 and V3 and were verbally redirecting R1. V6 stated she next observed R1 on the floor in the dining room but she did not see why he ended up on the floor. V6 stated V4 had restrained R1 because he was attempting to go to his room. V6 stated V4 was in the dining room near R1 and does believe she saw V4 trying to restrain R1. V6 stated V4 had R1 pinned to the floor by his arms. V6 stated the police then arrived. The facility's Final Abuse Investigation report and corresponding witness statements submitted to the state agency on 03/28/2025 regarding an allegation of abuse from R1 against staff on 03/19/2025 documents R1 was involved in a physical altercation with an employee, does not include any witness statements from V3 (Psychosocial Services Rehabilitation Services Assistant/Security Guard) nor any information reported from V6 regarding R1 being restrained. On 03/31/2025 at 3:52 PM V2 (Psychosocial Rehabilitation Services Coordinator) stated residents belongings are searched whenever they place orders for outside packages or food. V2 stated they don't dig through the residents belongings but rather ask to observe their items with their assistance. V2 stated staff doesn't touch the resident's belongings such as their bags and if they receive items that are delivered, they will ask the resident to open the bag and allow them to look inside and explain this is for safety purposes. V2 stated R1's groceries that were delivered on 03/19/2025 needed to be searched for safety purposes. V2 stated the procedure for receiving groceries is to notify the resident that the groceries have arrived which are left with the receptionist. V2 stated the receptionist will page social services staff to come and search the resident's groceries with the resident present. V2 stated once social services staff respond to the page, they then notify the resident that the groceries need to be checked and after checking them offer assistance to bring groceries to their room. V2 stated while searching resident's groceries the residents are asked if any of the items are glass wares or perishable. V2 stated the staff asks the resident to open the grocery bag and they then just look through it. V2 stated R1 did have the right to collect his own groceries they just needed to be checked. V2 stated V3 (Psychosocial Services Rehabilitation Services Assistant/Security Guard) likely grabbed R1's groceries from inside the front doors for safety purposes because of where they were located. V2 stated if R1 insisted he didn't need help collecting his groceries after the items were removed from the doorway, staff should just allow him to collect them as long as he was not attempting to take his belongings to his room without being searched. V2 stated if R1 insisted on collecting his own groceries and continued refusing to have them searched staff should just monitor him and ensure he is not attempting to hurt himself or others. V2 stated no staff should be putting their hands on the resident. V2 stated staff monitoring after a behavioral incident would include speaking to them in a calm manner and checking on them once in a while because the resident may still be upset after a physical altercation and may not even want to speak to anyone. V2 stated staff should not have blocked R1 from getting to his room when attempting to take his groceries to his room after the physical altercation with staff and at that point his bags had been on the floor and all of his belongings would have been observed. V2 agreed there was no reason to physically restrain R1 when attempting to take his groceries to his room. V2 stated if V3 and V4 held R1 down on 03/19/2025 it should have been reported however it wasn't. V2 stated all physical interventions should be a last resort. V2 stated the facility does not even use the term physical restraint to describe handling residents. The facility's Abuse Policy received 03/31/2025 states: This facility affirms the right of our residents to be free from physical abuse or mistreatment. This facility therefore prohibits abuse and mistreatment of residents. Abuse is unreasonable confinement. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Unreasonable confinement means the separation of a resident from her/his room against the resident's will.

Based on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse (R2) from another resident with known history of aggressive behavior (R3) for one (R2) of five residents reviewed for abuse in a sample of eight. This failure resulted in R2 being physically assaulted and emergently transferred to the hospital for evaluation of facial trauma. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder, Bipolar Type; Malignant Neoplasm Of Skin; Morbid (Severe) Obesity Due To Excess Calories; Age-Related Nuclear Cataract, Bilateral; Hypermetropia, Bilateral; Presbyopia; Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms; Schizophrenia; And Chronic Viral Hepatitis C. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 14 indicating, indicating intact cognition. R2 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms; Other Polyosteoarthritis; Polyp of Colon; Unspecified Hemorrhoids; Unspecified Abdominal Pain; Hypertensive Heart Disease Without Heart Failure; and Other Hyperlipidemia. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition. R2's abuse care plan dated 09/10/2024 reads in part, (R2) is at risk for abuse/neglect based on comprehensive assessment as evidenced by: (R2) has a diagnosis of mental illness. (R2) is not able to make her needs known. Interventions: Assure (R2) that she is in safe and secure environment with caring professionals. Explain psychosocial adjustment is often facilitated by developing a trusting relationship with another person and verbalizing thoughts, needs and feeling. R2's anxiety care plan dated 09/12/2024 reads in part, (R2) has exhibited or has history of anxious behavior such as: Evidenced by Apprehension in response to severe and persistent mental illness. Excessive and persistent daily worry about life circumstances. Concentration difficulty such as losing a train of thought. Persistent and unreasonable fear of a specific object or situation. Interventions: Assist in identifying actual life situations. R3 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but limited to Schizoaffective Disorder, Bipolar Type; Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms; Hypertensive Heart Disease Without Heart Failure; Morbid (Severe) Obesity Due To Excess Calories; Chronic Obstructive Pulmonary Disease, Unspecified; Suicidal Ideations; and Insomnia, Unspecified. According to R3's MDS (Minimum Data Set) assessment dated [DATE] under section C, R3 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition. According to R3's MDS (Minimum Data Set) assessment dated [DATE] section E shows R3 has been demonstrating potential indications of psychosis such as hallucinations and delusions, and daily occurrence of threatening and screaming at others. R3's aggression care plan dated 06/26/2024 reads in part, (R3) has a history of aggressive, inappropriate, attention seeking behavior due to Severe mental illness. (R3) becoming physical inappropriate and verbal aggressive with peer. (R3) becoming verbally aggressive with staff when redirected. Interventions: Intervene when any inappropriate behavior is observed. Communicate assertively that (R3) must exercise control over impulses and behavior (Social skills training). R3's delusional statements care plan dated 3/16/2028 reads in part, (R3) has shown evidence of making delusional statements related to diagnosis of severe mental illness. Interventions: Assess ability to maintain reality orientation. Provide reality orientation as needed. Per record review, R2 was discharged from the facility on 01/10/2025 and is not available for observations or interview during this investigation. Per record review, R3 was hospitalized for behavioral evaluation on 12/22/2024 and later discharged the facility and is not available for observations or interview during this investigation. On 03/20/2025 at 1:41 PM V8 (Certified Nurse Assistant) said, I worked 7:00 AM - 3:00 PM on 12/22/2024. R3 was walking and talking to herself, like usual. I was monitoring A wing which is right across from B wing. R3 got to the end of B wing and that's where R2 was. Out of nowhere, R3 grabbed R2 from behind, put her in a choke hold and started punching her head and then face. R2 did not say anything to R3 before R3 attacked her. I was standing maybe 5 feet away from them. There was no other staff there. I was trying to pull R3 off R2, but I couldn't. I started to yell, Help! Help! Help!. After about 5 minutes, V9 (Certified Nurse Assistant) and R4 came up and we were able to pull R3 off R2. R2 was beat up pretty bad. I didn't see any blood and R2 didn't lose consciousness, but it was pretty extreme. After more staff showed up, I had to step away, the incident upset me. R3 attacked R1 a few months prior to December 2024. R1 had a concussion because of the attack. There was nothing special we had to do for R3 as far as monitoring. PRSAs (Psychiatric Rehabilitation Service Aids) is supposed monitor R3, that's what they're there for. R3 was acting like always that day, I didn't see any signs that she might attack someone. On 03/20/2025 at 02:34 PM V11 (Psychiatric Rehabilitation Service Coordinator) said, I worked as a PRSA (Psychiatric Rehabilitation Service Aids) on 12/22/2024. PRSAs are considered security in the facility. I saw the incident between R2 and R3 but didn't see the escalation of it. Code orange was called shortly after lunch. I responded to the code and saw R2 yelling, Get off me! while R3 was pounding on her. Other staff and I separated R2 and R3, and R3 was escorted to the social service office. I think, R2 suffered concussion after the incident. I've never seen R3 to have a behavioral outburst like that, but I heard that she's aggressive. There was nothing special related to R3's monitoring, all I was told was not to come too close to R3 because she might have aggressive behaviors. It was like walking on eggshells around R3. On 03/21/2025 at 10:29 AM V12 (Psychiatric Rehabilitation Service Director) said, I wasn't here at the time of the incident (12/22/2024) because it happened on a Sunday, and I don't work on Sundays. When I came on 12/23/2024, R2 came to talk to me and told me that R3 was talking to herself and thought R2 was talking to R3 and then R3 attacked R2. R2 was in the facility for only 3 months (admitted [DATE]) whereas R3 had been a long-term resident in the facility, admitted in 2018 at the time of the incident. R3 was hospitalized for behavioral evaluation multiple times while in the facility. Surveyor asked about R3's previous physical attack on R3's roommate, V12 (PRSD) said, It might have happened, I don't remember. R3's behavior was always deceitful, she didn't really have escalating behaviors, so it was hard to tell when R3's aggression might escalate. You would ask R3 if everything is ok, and R3 would respond, Yes, everything is fine. Some of the interventions to prevent R3's behavioral escalation were group therapy, 1:1 tele-health program with psychiatrist, and day program. If R3 refused any of the interventions, it was a good indication that she might escalate her aggressive behaviors. On 03/21/2025 at 12:06 PM V14 (Family Nurse Practitioner) said, R3 had delusions at the baseline. R3 was taking psychotropic medications. R3 was often hiding her symptoms or downplayed them, you could tell she's responding to an internal stimulus but when asked, R3 would deny. R3's medications could manage her behaviors unless R3 refused them. R3 didn't refuse her medications often but it happened on occasion, and that's when she would act out. We don't put in an order for behavioral monitoring, the nurses should document in progress notes if any behavioral changes occur. With R3, it was hard to predict behavioral outbursts because she was downplaying her stimuli. R3's more frequent monitoring would be recommended. Staff should definitely place someone like R3 on 1:1 observation if they saw any concerning behaviors. Before a resident with mental illness hits someone, they usually show signs such as pacing and talking to self. Staff should request PRN (as needed) medications from us as well to help manage the symptoms. On 03/21/2025 at 12:20 PM R1 said, In June (2024), R3 punched me in my eye. I didn't do nothing. R3 came up to me while I was sleeping, around 3:00 AM and just hit me. We were roommates at the time. R3 was aggressive. They didn't do anything about it. On 03/21/2025 at 12:28 PM V9 (Certified Nurse Assistant) said, On 12/22/2024, I was in the dining room, on resident's 1:1 monitoring. I heard code orange, so I responded to the code and broke up R2 and R3. I was under the impression V8 (CNA) was getting attacked. R3 always walked up and down the hallway, it was the norm for her. If anything, R3 was talking to herself a little more than usual that day. I don't really know what triggered R3 that day. After the two residents were separated, I walked away and went back to monitoring. On 03/21/2025 at 12:38 PM V6 (Registered Nurse) said, I worked on 12/22/2024. R3 was really quiet, except for when she would have an outburst in her room. R3 usually was yelling and cursing in her room. I don't remember R3 talking excessively or pacing on the day of the incident. The only thing that I remember that day, was seeing R2 sitting at the nursing station and R3 in the social service office. I was told what had just happened. Generally speaking, we document residents' behaviors in progress notes. We document when resident displays abnormal behavior, but it also depends on the nurse. Some nurses document both, abnormal and normal residents' behaviors. R3 was generally compliant with taking her medications and she took her psychotropic medication on the day of the incident (12/22/2025). On 03/21/2025 at 1:09 PM V1 (Administrator/Abuse Prevention Coordinator) said, On 12/22/2024, staff called me and told me that there was an incident, that R3 hit R2. I asked if there was a CNA in a monitoring spot at the time of the incident, I was told that V8 (CNA) was there. I assured that both residents are safe, nobody is hurt, and all staff is monitoring their areas. I asked for V8 (CNA) to talk to me then. V8 (CNA) told me that R2 was walking and R3 came up to her, said something out loud, hit R2 from behind, and pushed R2 to the floor. V8 (CNA) was trying to intervene, and other staff responded to code orange and came to help. The following day (12/23/2024), I interviewed V8 (CNA) and R2. I did speak to few more staff, but they all stated that they came after the escalation. There were no residents who witnessed the incident. I did not have a chance to talk to R3 because she was hospitalized for behavioral evaluation at that time. R2 was hospitalized for medical evaluation and returned to the facility after a few hours. R2 called the police while she was getting assessed by the nurses before facility staff had a chance to do so. R2 came to me after she returned from the hospital and said she wanted to go home for holidays, and she said that she doesn't know why R3 attacked her. R2 said she felt safe in the facility because R3 was not there. The conclusion of the internal investigation was that R2 was hit by R3 as a result of R3 exhibiting symptoms of her mental illness. R3's Medication Administration Record for December 2024 does not show any requests for PRN psychotropic medications for behavioral management. Absent are any progress notes or behavioral assessments to show R3's escalating behaviors that led to an altercation on 12/22/2024. R1's progress note dated 06/26/2024 reads in part, Writer was informed by social service that (R1) was punched on her face by her roommate. Upon assessment (R1) stated that she was on the toilet when roommate walked up to her and punched her on her face, leaving her with left cheekbone swelling. Ice was applied. (R1) room was changed, and MD ordered that resident go to the ER for medical evaluation of her face. R3's progress note dated 06/26/2024 reads in part, This writer was informed that (R3) punched her roommate on the face, and left roommate's face swollen. (R3) stated that roommate was verbally aggressive towards her, and she proceeded to call her names, she ask her to stop but she didn't and she punched her on the face. At this time (R3) was separated from her roommate, roommate is assigned to a new room and her swelling is treated with ice. We will continue to monitor and document. R2's progress note dated 12/22/2024 reads in part, Writer was informed of the altercation between (R2) and (R3). Situation was immediately deescalated, head to toe assessment done. Skin discoloration and a scratch noted to the right side of the face. Vitals are (Blood Pressure) 128/86, (Temperature) 98.3, (Pulse) 82, (oxygen level) 98% on room air. (R2) denied pain. Police called. (Physician) notified. (R2) transferred to (local hospital) via EMS (emergency medical service) for medical evaluation. R3's progress note dated 12/22/2024 reads in part, (R3) was reported for initiating an altercation with another resident. Removed the receiver (R2) of the altercation from the initiator (R3) of the altercation. Writer assessed the initiator (R3) of the altercation for any injuries or cognitive changes. Resident that initiated the altercation (R3) VS's (vital signs) were (Blood Pressure) 156/97, (Respiratory Rate) 18, (Temperature) 97.5 (Oxygen level) 98%, (Pulse) 92. (R3's) eyes were round and equal, normal chest rise, skin intact and warm & dry. No bruising, lacerations, scratches or abrasions. (R3) is verbally responsive. Psychiatric physician was called. Initially, writer was ordered to send the resident to (local hospital). (Local hospital) rejected intake of the initiator (R3) because facility capacity was full. (R3) taken to (another local hospital) via (transport) ambulance. R2's hospital record dated 12/22/2024 reads in part, (R2) presenting for evaluation of physical assault. (R2) report that she was walking down the hallway at (the facility) and got assaulted by another resident. (R2) reports of the resident slammed her face to the ground. (R2) is complaining of pain to the right side of the face and her jaw. Physical exam: (R2) appears anxious but non-toxic; multiple bruises noted to the right side of the face, tenderness to palpation to the right maxilla. Police report requested on 03/20/2025, unable to obtain it during course of the survey. The facility Abuse policy dated 03/2022 reads in part, The facility affirms the right of our consumers to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of consumers. In order to do so, the facility has attempted to establish a consumer sensitive a consumer 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 and mistreatment of consumers. This will be done by establishing an environment that promotes consumer sensitivity, consumer security, and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment.

Based on interviews and record review, the facility failed to prevent a physical altercation between a resident (R1) with a history of delusions, agitation, and aggressive behavior towards peers, and his roommate (R2) by failing to adequately monitor the two residents inside their room with the door closed, during lunchtime. This lack of supervision resulted in a failed opportunity to identify delusional and aggressive behavior from R1 that led to R1 hitting R2 in the head with his hands, grabbing him by the shirt, and pulling him out of his room. Findings include: R1 is a [AGE] year-old former resident of the facility with diagnosis listed in part, but not limited to, schizoaffective disorder, schizophrenia, suicidal ideations, alcohol abuse, and cannabis abuse. On 12/09/2024 at 10:52 AM, V1 (Administrator) said on 10/20/2024, R1 had an altercation with his roommate, R2. V1 said R2 wanted to use their bathroom, but R1 had placed a sheet on the floor in front of the entrance to the bathroom. V1 said R1 told R2 not to move his sheet; however, R2 picked the sheet up to be able to walk into the bathroom. V1 said R1, then, started to scream at R2 and walk towards him. V1 said when R2 tried to open the bathroom door, R1 hit him, grabbed him by his shirt, and tried to pull him out of their room. V1 added once R1 and R2 were in the hall, staff stopped what they were doing, and ran to break up the altercation. V1 said both residents were separated and placed on increased monitoring. V1 said the facility doctor was notified, and ordered R1 be sent to a local psychiatric hospital for evaluation and R2 be sent to a local hospital for medical evaluation. V1 said when the ambulance arrived, R1 refused to go, and threatened the paramedics, saying, if you touch me, it's not going to end well. V1 said R1, then, opened an emergency exit door, setting off the alarm, and ran out of the facility; but the paramedics had called the police, who were already outside, and were able to subdue R1 and accompany him to a nearby hospital for medical evaluation. On 12/10/2024 at 9:55 AM, R2 said R1 would always get mad after placing a sheet on the floor. R2 said on 10/20/2024, R1 attacked him, straight on, when he tried to go into the bathroom, and hit him on the left side of his face. R2 said he, then, pushed R1 back, and R1 knocked his TV down. R2 said R1 didn't hurt him, but made him mad. R2 said R1 also grabbed him by his shirt, but did not recall if R1 tried to throw him out of the room. R2 said staff stopped the fight when he and R1 were in the hallway. R2 said he ended up with a black eye. Finally, R2 said he felt better at the facility now that R1 was gone. On 12/10/2024 at 11:16 AM, V5 (CNA) said she was there the day of the altercation between R1 and R2. V5 said she and the staff were in the dining room when a staff member went over to let them know there was an altercation between R1 and R2. V5 said she went to the hallway and saw R1 pulling R2 by the shirt in the hallway. V5 said staff separated R1 and R2 and that was it. V5 added R2 looked like he had been in an altercation and R1 was worked up. V5 said she was not sure what caused the altercation. On 12/10/2024 at 10:45 AM, V3 (Psychiatric Rehabilitation Services Coordinator ) said she was at the office on 10/20/2024 when she heard something, and went to investigate. V3 said R1 had put something on the floor, R2 had removed it, they got into an argument, and started to fight. V3 said she and the staff, then, separated R1 and R2, and she called her supervisor. V3 said R2 had a swollen eye, so they sent him to the hospital to have his eye treated. On 12/10/2024 at 2:20 PM, V1 said she was not aware that R1 had a habit of placing a sheet on the floor; had never seen it, herself; and no one had ever reported that type of behavior to her. V1 said she believed it may have been one of the housekeepers delivering laundry that first noticed the altercation between R1 and R2. V1 said the altercation happened on 10/20/2024 during lunchtime. V1 said the laundry lady and V5 were on the floor, and the rest of the staff was helping out with lunch. V1 said R1 and R2's door was closed when they began yelling at each other. V1 said the laundry lady delivering clean clothes to the residents passed by the room where R1 and R2 were fighting, heard them, went to their door, and motioned V5 for help. V1 said she felt that the staff responded quickly, and handled the situation, pretty well, considering that they were passing food at the time. V1 added the two residents were separated, and there was no injury. Finally, V1 said R2 had some redness on the side of his face, but there were no fractures and no new orders from the hospital for R2. Per progress notes in R1's electronic health record, hallucinations, delusions, increased agitation, and aggressive behavior towards peers were noted on 04/21/2024 (involved in altercation with peer); 08/04/2024 (tried to take food from a peer); and 09/29/2024 (physically aggressive towards peer). A facility educational in-service titled, Supervision and Monitoring of Residents, provided to staff members on 11/26/2024 stated, in part, the facility's goal was to prevent any altercation and/or physical contact before it happened; monitor the halls during meals; walk to each room to check residents; and monitor the halls between walking rounds.

Based on interview and record review, the facility failed to identify a resident (R1) as a high fall risk after new onset shuffling of gait and failed to put interventions on the care plan in regards to the shuffling. This affected one of three residents (R1) reviewed for fall prevention interventions. This failure resulted in R1 getting up unassisted and falling causing a laceration to the forehead that needed repair at the hospital with three to four stitches. Findings include: R1 is a [AGE] year old with the following diagnosis: dementia, schizophrenia, and epilepsy. A Nursing note dated 8/16/24 at 6 AM documents the CNA reported to the nurse that R1 fell in R1's room. R1 stated that R1 lost R1's balance while trying to use the bathroom. R1 had a small laceration to the right forehead. The wound was cleaned and R1 was sent to the hospital via 911. An Admission Summary note dated 8/16/24 documents R1 returned from the hospital with 3 to 4 stitches noted and facial bruising. The Hospital After Visit Summary Record dated 8/16/24 documents R1 was seen in the emergency room for a fall from the bed and was diagnosed with a head injury. There was a cut on the forehead. R1 had stitches/tape to repair the laceration. On 11/14/24 at 12:30PM, R1 was sitting in the dining room waiting for the lunch meal. R1 did remember falling but was unable to state the date. R1 was able to report the fall happened at night. R1 stated R1 fell while getting up from bed but was not able to remember why R1 was getting out of bed. R1 reported R1 did have an injury to the head that required stitches. There was a scar about one inch long above R1's right eye brow. R1 confirmed this was from the fall. R1 was not able to remember what happened after that fall except that R1 went to the hospital. R1 stated that R1 walks fine and denied needing any help. R1 reported R1 now uses a wheelchair to get around the facility. R1 then stood up and walked over to the wheelchair. R1 has a shuffled gait. R1's mental status was checked and R1 was alert and oriented times two. R1 stated that date and location correctly but was not able to name the current president. On 11/14/24 at 1:15PM, V2 (Restorative Aide) stated R1 has been in restorative programs for about one year along side with getting therapy on and off. V2 reported R1 moves very slow and has a shuffled gait so R1 is a high fall risk. V2 stated the shuffling is a new development within the past four or five months and that is why therapy has been working with R1. V2 reported R1 walked with a normal gait before the shuffling began. V2 stated the DON is responsible for putting in interventions in the care plan for fall safety and educating staff on the interventions. V2 stated therapy worked with R1 before the falls but V2 denied being aware of any other interventions put in place before the fall on 8/16/24. On 11/14/24 at 1:52PM, V3 (Nurse) stated R1 fell on the overnight shift, but was unable to remember a time. V3 reported checking on R1 around midnight and then one more time before the fall occurred, but could not remember the timeframe of when R1 was last check to the time R1 was found on the ground. V3 stated R1 was sleeping on both occasions during rounds before the fall. V3 reported the CNA (V4) told V3 that R1 fell . V3 stated R1 told V3 that R1 was getting out of bed while trying to use the bathroom. V3 stated this was not a witnessed fall. V3 reported R1 had a cut to the forehead and was sent out to the hospital. V3 stated at the time of the fall R1 could get up and walk around alone, but does have an unsteady gait. V3 was unsure if R1 is a high fall risk and could not state why R1 would be a high fall risk. V3 was unaware of R1 shuffling R1's feet when walking. On 11/14/24 at 2:08PM, V4 (CNA) stated V4 was doing hourly checks and saw R1 on the floor and immediately went to tell the nurse. V4 reported R1 did have some bruises and a cut on the face and was sent to the hospital. V4 stated R1 was found on the ground around 3 or 4 AM. V4 reported checking on R1 around 11 PM and then one more time before R1 was found on the floor but was not able to give an exact timeframe. V4 stated R1 was a high fall risk at the time of the fall because does not walk normal and is not steady. V4 reported R1 is only supervision with assistance and does everything with without much help. V4 was unaware of any interventions put into place before the fall occurred due to the shuffling gate. On 11/14/24 at 2:23PM, V5 (Director of Therapy) stated R1 was picked up on 6/28/24 for physical therapy. V5 reported R1 was referred because R1 presented with decreased standing balance and safety with ambulation. V5 reported R1 was at high risk for falls at the time R1 was admitted to therapy. V5 stated R1 also had occasional shuffling, and therapy worked with R1 so R1 could improve walking patterns and posture as well as increase lower extremity muscle strength. V5 stated R1 was discharged from therapy on 8/15/24 because R1 met R1's goals to the best of R1's ability and was referred to restorative. V5 reported restorative completes their own assessment to see what programs are appropriate. V5 stated R1 was picked up again on therapy on 8/22/24 for the same reasons that R1 was picked up in June. V5 stated R1 is a contact guard assist while, indicating someone should be physically touching R1, but, they are not doing any work. V5 reported staff hold R1 walking in case there is a loss of balance. V5 stated the therapy department is always in communication with staff at the facility to let them know what level the resident is at or what they need. V5 reported upon discharge the facility staff are made aware of any safety concerns with the residents. On 11/14/24 at 2:56PM, V6 (DON) stated the CNA told V6 that R1 was found on the floor while doing rounds. V6 reported interviewing R1 and R1 told V6 that R1 was trying to go to the bathroom. V6 stated R1 is supervision with limited assist for some things. V6 was unable to specify what R1 needed more assistance with. V6 defined limited assist as needing more help and supervision means someone only needs to be watching. V6 reported after the fall on 8/16/24, staff educated R1 to call for assistance before getting up. V6 stated R1 was working with therapy around the time of this fall. V6 reported the fall was caused by R1's shuffling gait. V6 stated this shuffling has been occurring for about four or five months and is the reason R1 was referred to physical therapy. V6 reported putting in an intervention of physical therapy and notifying the physician about the shuffling. V6 stated any new interventions are put on the care plan and staff will be told verbally. V6 reported R1 was not a high fall risk at the time of the fall. V6 stated some risk factors to be considered a high fall risk would be previous falls, taking medication that can increase risk for falls, or any type of change that would affect ambulation. V6 denied putting in any other interventions because R1 continued to ambulate at the same level. On 11/14/24 at 3:09PM, V1 (Administrator) stated nursing completed the investigation for the falls. V1 reported R1 had a fall while getting up to the bathroom unassisted. V1 stated if there is any kind of changing condition, V1 would expect the staff to investigate and find out the reason why there is a change as well as put in interventions to prevent any falls. On 11/15/24 at 10:26AM, V7 (Primary Physician) stated V7 vaguely remembered R1 had a fall and had some type of injury to the head requiring R1 be sent out to the hospital. V7 reported R1 does not walk normally and has some type of knee problem or leg problem but was unable to elaborate any further. V7 stated being aware there was a change in R1's gait, and R1 was referred to physical therapy but denied R1 needing any other fall interventions. V7 reported R1 was a fall risk, but not a high fall risk. When asked what makes a resident a high fall risk, V7 stated problems with walking or an abnormal gait can make someone a high fall risk. V7 reported the gait issue is why R1 was referred to therapy, but no other interventions were needed to prevent falls. The Physical Therapy Evaluation dated 6/28/24 documents R1 was referred to therapy due to new onset shuffle in walking and decrease in lower extremity strength. The Fall Scale dated 7/5/24 documents a total score of 15, indicating R1 is at low risk for falls. Anything higher than a 24 indicates a resident is at high-risk for falls. It is documented incorrectly that R1 has a normal gate. The shuffling of the gait was noted by staff sometime before R1 was referred to therapy on 6/28/24. There is no documentation in the nursing notes as to when the shuffling began. The Physical Therapy Treatment note dated 8/5/24 documents R1 completed a session of physical therapy and is able to perform all functional tasks, however, R1 requires constant cuing for proper foot clearance during ambulation to avoid shuffling gait and increasing risk for falls. The Physical Therapy Treatment note dated 8/9/24 documents R1 completed a session of physical therapy and tolerated treatments well with improved strength noted. R1 remains with shuffling gate during ambulation tasks. The Follow Up Fall note dated 8/16/24 documents R1 experienced a fall and is able to ambulate independently without an assistive device. There is no documentation in this note that R1 has a shuffled gait. The Fall Report dated 8/16/24 documents the CNA reported to the nurse that R1 fell in R1's room. R1 stated that R1 lost R1's balance while trying to use the bathroom. R1 has a small laceration on the right forehead. R1 was transferred to the hospital. No predisposing environmental or physiological factors are checked as contributing to the fall. The Post Fall Observation dated 8/16/24 documents R1 fell on R1's room but this was not a witnessed fall. R1 reported trying to use the bathroom and slid to the floor. R1 was previously lying in bed prior to the fall. It is documented that R1 is able to ambulate independently without an assistive device. R1 continued therapy after the fall on 8/16/24 and continued to show the shuffled gait was an issue when ambulating. The Occupational Therapy Treatment note dated 8/22/24 documents R1 is in the fall prevention group. R1 presents with shuffled walk and was instructed to pick up feet and take bigger steps with 100% carryover. R1 was observed with crossing feet and shuffling small steps when turning. R1 required consistent cues to ensure R1 was not crossing feet and taking bigger steps while turning in the bathroom. The Final Investigation Fall Report dated 8/23/24 documents R1 sustained a small cut to the right forehead as a result of losing R1's balance and falling while walking to the bathroom. The incident was unwitnessed. The floor was checked and noted to be dry. R1 was wearing shoes at the time of the incident. Upon return from the hospital, R1 was placed on increase monitoring for safety. R1 was also counseled to seek assistance from staff as needed. The Care Plan was reviewed and there is no documentation of R1 having a shuffling gait or a care plan and/or interventions addressing safety for the change in gait. The Care Plan dated 8/29/24 documents R1 is at risk for falls due to having a fall on 8/16/24. The only intervention documented on this care plan is to educate R1 on using caution when ambulating and paying attention to surroundings. The Minimum Data Set (MDS) Section GG dated 7/5/24 documents R1 needs supervision or touching assistance with all ADLs, bed mobility, transfers, and walking. The policy titled, Fall Program, dated 04/2020 documents, All residents will be evaluated for falls. The following is the schedule for these evaluations: on admission/readmission, quarterly after admission, change in condition, and after a fall. Upon completion of the fall evaluation, if a resident is identified at risk for falls, the following may occur: a care plan is developed or updated, new fall interventions are reviewed with the resident and/or responsible and applicable staff, and education regarding the resident's risk of falls or interventions to prevent falls is provided.

Based on interviews and record reviews the facility failed to follow their policy and procedures for developing a comprehensive care plan by not updating care plan interventions as needed and not implementing personalized and effective care plan interventions for a resident exhibiting a pattern of increasing anxiety, agitation, and verbal and physical aggression. This failure applies to one of four residents (R4) reviewed for care planning. Findings include: R4 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Schizophrenia, Suicidal Ideations, Cannabis Abuse, and Alcohol Abuse who was admitted to the facility 03/28/2024 and discharged from the facility against medical advice 10/21/2024. R4's progress note dated 4/9/2024 documents he was observed with loud speech in dining area and came to the nurse's station to asking to be given something to calm him down because he was very anxious and was given a Sedative as prescribed. R4's progress note dated 4/21/2024 documents he was involved in an altercation with a co-peer and reported that co-peer walked up on him from behind and raised his fists at him; R4 exhibited delusional ideations stating that he handles things around here and believed he is a superhero. R4's progress note dated 4/28/2024 documents he became verbally and physically aggressive with staff resulting from attempting to redirect him after he was observed throwing items around his room, and with loud banging noises were coming from his room; R4 refused his prescribed as needed antipsychotic medication and staff were not able to redirect him; R4 was observed with increased agitation with staff and continued aggressive behaviors of throwing items in his room; R4 was then sent to the hospital for a psych evaluation. R4's progress note dated 6/15/2024 documents R4 was observed using marijuana and also exhibited symptoms of anxiety, pacing back and forth and aggressiveness stating he wants to harm himself; R4 was eventually sent to the hospital after resisting going. R4's progress note dated 7/2/2024 documents he came to nurse station in the afternoon with complaints of feeling agitated and when writer asked what caused his symptoms he replied, I really don't know. I feel worked up; R4 was administered his prescribed as needed antipsychotic medication. R4's progress note dated 8/4/2024 documents he was observed engaging in inappropriate behavior of trying to take food from another resident and when redirected by staff redirected became aggressive and threw the laundry down a hallway in the facility, the physician was notified and an order to placed to send him to the hospital for psych evaluation; R4 presented with delusions, hallucinations, characterized by increased agitations, he attempted unauthorized departure from the facility was not yielding to redirection and has no insight into his disorder; R4 refused to go to the hospital and 911 was called for intervention. R4's progress note dated 9/29/2024 documents he presented with mental status changes characterized by hallucinations, delusions and increased agitations; R4 was becoming verbally aggressive and attempted physical aggression with peer. R4's progress note dated 10/20/2024 documents he was observed dragging and hitting another resident in the head, he attacked another resident, refused to go to the hospital when the paramedics arrived and 911 was called he attempted to leave the building through the a back door and was apprehended by the police and staff before he was discharged to the hospital for psychiatric evaluation. R4's Aggression and Violence History and Screening assessment dated [DATE] documents he was physically aggressive toward peers and his Aggression and Violence History and Screening Assessments dated 04/28/2024, 08/04/2024, and 09/29/2024 documents he has a history of aggressive behavior with the assessment dated [DATE] noting his care plan will be updated. R4's current behavior care plan initiated in 03/28/2024 documents he has a history of aggressive, inappropriate , attention-seeking behavior, presented with delusions and became physically aggressive towards a peer on 4/21/2024, and presented with delusions and aggressive behavior toward staff on 4/28/2024 with a target goal of: behaving in a manner consistent with resident conduct policies through the next target review date of 09/24/2024; Interventions implemented 03/28/2024 include conduct a review of his past behavior and evaluating the likelihood for aggressive/inappropriate behavior during the initial assessment process, refer him to a mental health professional, administer his psycho-active medications as ordered and monitor for effectiveness and side effects, and provide supportive intervention as needed by resident. R4's most current activities care plan initiated 06/24/2024 documents he is involved in activities little to none of the time and is disinterested, he has been coming to activities after getting new glasses, he doesn't like crowds, and is starting to participate; Interventions implemented 06/24/2024 include encourage resident to express response to activity after attending. R4's most current behavior care plan initiated 08/04/2024 documents he has a history of aggressive behavior and has exhibited verbally/physically abusive behavior related to and manifested by being challenged by mental illness, Ineffective coping mechanisms, Physically abusive behavior when agitated, Poor verbal skills and inability to express self in more appropriate language., Racial, ethnic, religious, gender slurs, Use of profanity, demeaning statements, verbal threats and yelling at others, verbally abusive behavior when agitated with a target goal of: refraining from verbally and/or physically abusive behavior following staff intervention by next target review date of 09/24/2024; Interventions implemented 08/04/2024 include avoid getting in power struggle with him, Refer to psychosocial group to improve on deficient skills, Utilize the use of behavior contract if needed, and utilize the use of as needed medication for agitation. R4's most current abuse risk care plan initiated 08/04/2024 documents he is at risk for abuse related to historical and current behavior of physical abuse or threatening physical aggression towards others, and having a diagnosis of mental illness; Interventions implemented 08/04/2024 include establish a counseling schedule with him and encourage him to verbalize or share thoughts, anxieties, fears, concerns and general feeling, and provide one to one counseling on boundary issues relating to conflict. On 10/30/2024 at 3:48 PM V1 (Administrator) stated care plans are reviewed every quarter and as needed and if the IDT (Interdisciplinary Team) feels it is necessary, the care plan will be updated. V1 stated if interventions are in place for a resident and it's felt they are not effective the care plan will be updated as well. V1 stated R4 was observed using marijuana in June 2024. V3 (Psychosocial Rehabilitation Services Director) agreed residents do have an increased risk for violence with the use of substances. V3 stated care plans are updated within 24 hours of a behavior happening such as exhibiting verbal or physical aggression, substance use, and increased agitation and/or anxiety which leads to aggression which will also prompt an aggression assessment to be completed. V3 stated if R4 does not get his way he will become frustrated and aggressive. V3 stated R4 also likes to control others even behaving as if he is staff and will attempt to tell others what to do. V3 stated R4 likes money and once it's spent, he would become agitated. V1 stated R4's family would leave him with money and the facility would encourage him not to spend all his money, however he would spend it up. V3 stated these behavioral triggers should be a part of R4's care plan and believed they were currently included in his care plan. V3 stated care planned interventions for R4 included money management group. V1 stated R4 likes computers, phones, video games, technology, and is very intelligent and you would never know he would become verbally or physically aggressive because he doesn't present that way. V1 stated she didn't feel at any given moment R4 would become aggressive because he did not typically present that way and would respond appropriately to interventions such as his ordered as needed medications and redirection. V3 and V1 agreed that R4's medical records including documentation of mood and behaviors from April - October 2024 that indicated there was a pattern of increasing behaviors including agitation and aggression. R4's most current care plan does not include updated interventions for his exhibited behaviors of anxiety, agitation, verbal and physical aggression documented in his medical records on 04/09/2024, 04/21/2024, 04/28/2024, 06/15/2024, 07/02/2024, and 09/29/2024; does not include information or personalized interventions regarding reported behavioral triggers of not getting his way and wanting to be in charge or control, or difficulty managing money; and does not include personalized activity interventions involving his preference for technology related activities. The facility's Care Plan Development Policy received 10/31/2024 states: Guideline: A person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, that are identified in the evaluation process, is developed and implemented for each resident. Care plan interventions are designed after critical consideration of the relationship between the resident/patients problem area and their causes. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require data gathering, sequencing of events and clinical decision making. Evaluations of the resident are ongoing and care plans are reviewed and revised by the interdisciplinary team after each evaluation including both the comprehensive and quarterly reviews and as information about the resident condition changes. The Care Planning/Interdisciplinary Team is responsible for the reviews and updating of care plans; when the desired outcome is not met, when the resident has been readmitted to the facility from the hospital stay, and at least quarterly.

Based on interview and record review, the facility failed to prevent an employee from engaging in verbal abuse with a resident and failed to follow their abuse policy of immediately reporting abuse to the abuse coordinator. This failure affects two (R4 and R5) of four residents reviewed for verbal abuse and has the potential to affect all 109 residents currently in the facility. Findings include: Facility provided Census upon entrance that documents 109 residents currently in the building. R4 is [AGE] years old, has been residing in the facility since 8/22/13. R4 has diagnoses that include but are not limited to schizoaffective disorder. According to the electronic health record, R4 is alert oriented and does not have any documented cognitive deficits. R5 is [AGE] years old and was recently readmitted to the facility 8/15/24 with diagnoses that include schizoaffective disorder bipolar type. An interview was attempted with R5 during this investigation, however R5 refused to interact with the surveyor. R4 was interviewed 10/8/24 at 1:57pm and said one night a few weeks ago, R4 was siting in the social services office to use the telephone. V6 and V7 are PRSCs (Psychosocial Rehabilitation Services Coordinator) and were in the office at this time. R4 said, V6 PRSC told R4 to get out of the office, and R4 responded by calling V6 a bitch. R4 said V6 responded by saying your mother is a bitch and when R4 got up to leave slammed the door closed. V7 PRSC was interviewed on 10/8/24 at 3:19pm and said they witnessed the altercation as R4 described during the evening of 9/4/24. V7 said they went to check on R4 after the incident, however R4 was so upset in their bedroom, that R4 refused to talk to V7. V7 did not notify V1 the abuse coordinator or supervisor of the incident. On 9/4/24 V7 said they wrote a statement the following day when asked to do so by V1 Administrator. On 10/9/24 at 1:03pm, V8 PRSC said they were getting ready to leave for the day when V8 heard the verbal exchange between R4 and V6 the evening of 9/4/24. V8 said they heard V6 yelling and being disrespectful to R4, that this has happened before and R8 believed it was verbal abuse. V8 also said if they witnessed abuse or a resident alleged abuse occurred, they should immediately inform their supervisor- V5 PRSD (Psychosocial Rehabilitation Services Director) or V1 Administrator. V8 said usually when V6 yells at R4 or other residents V8 tells V6 that (staff) don't need to yell at the residents. V8 said when they left the facility V6 was still in the facility. V1 Administrator was interviewed on 10/8/24 at 3:32pm and said R4 came to the administrator's office on 9/5/24 to inform V1 about the altercation that occurred between R4 and V6. V1 said they were not notified by any staff member that the allegation occurred 9/4/24. According to V1, when R4 brought the allegation, R4 was not clear on when the incident occurred. V1 said they consulted with V5 PRSD (Psychosocial Rehabilitation Services Director) to determine how to initiate investigating R4's allegation and while discussing the issue, another resident (R5) approached V1 to complain about a verbal altercation that occurred on the smoking patio immediately prior. R5 said to V1 '(V6) don't know how to talk to people'. V1 said V6 was suspended pending additional investigation and was ultimately terminated after substantiating the allegation of verbal abuse. V6 PRSC was interviewed on 10/9/24 at 1:44pm and denied any allegation of verbal abuse. V6 said they were in the social services office the evening of 9/4/24, when R4 came to the door and said 'she called my mom the B word'. V6 said it was unknown who R4 was referring to, and did not investigate any further. V6 said although R4 was not on V6's case load, V6 interacts with all of the residents in the facility. V6 said they worked the rest of the shift and returned the following day as scheduled on 9/5/24. V6 said on 9/5/24 during smoking break with the residents on the patio, V6 had words with R5 related to opening a new pack of cigarettes. V6 was soon after called to the Administrators office and was suspended pending an allegation of verbal abuse. V6 said the following week on 9/10/24 V1 called to terminate V6 after substantiating the allegations. Witness statement written by V7 PRSC on 9/5/24 notes that V7 witnessed the employee (V6) being disrespectful to the resident (R4) on 9/4/24 at about 9:00pm. V8 PRSC wrote: 'the resident (R4) came to the office to ask for something or questions. The staff (V6) yelled at (R4) to go to the dining room or come back when we are less busy. The staff (V6) sometimes yells at residents in order for them to listen.' According to time sheet report, V6 PRSC left the faciity on [DATE] at 9:27pm and worked on 9/5/24 from 12:33pm to 4:32pm. Employee Report dated 9/10/24 stated Employee (V6) displayed discourteous behavior toward a resident (unprofessional behavior). (V6) was suspended pending investigation. Based on the facility's investigation, the allegation was substantiated. Consequently, the employee is hereby terminated per rule No. 19 of the employee crew book (handbook). This report was signed by V1 Administrator. The facility's employee handbook was review and states in part; The following shall qualify as Discharge upon 1st Offense: 8. Physical, mental, sexual, or verbal abuse, neglect, or attempting to injure resident/residents or other persons, including any other Crew, supervisor, or manager. 19. Unprofessional Behavior. The facility's abuse policy effective 4/20/20 (no revision) states in part; This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, ad mistreatment of resident. 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 and mistreatment of resident. This will be done by: orienting and training employees on how to deal with stress and difficult situation, and how to recognize ad report occurrences of abuse neglect, exploitation, and misappropriation of property. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Identifying occurrences and patterns of potential mistreatment. Immediately protecting resident involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property. Implementing systems to promptly and aggressively investigate all report and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of a individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Procedures: Internal Reporting Requirements and Identification of Allegations: (V) Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated.

Based on interview and record review, the facility failed to address the pharmacist recommendation for a gradual dose reduction of anti-depressant medication and failed to ensure the pharmacist recommendations were readily available to review in the resident's electronic health record. This failure applied to one (R1) of three residents reviewed for unnecessary medications. Findings include: R1 is [AGE] years old and admitted to the facility 5/15/23 with diagnoses that include but are not limited to Schizoaffective disorder, Major Depressive Disorder, Bipolar Disorder and Epilepsy. R1 transferred from the facility on 5/20/24 as a Resident initiated discharge. On 10/7/24 at 1:04PM R1 was interviewed and said they believed the facility was overdosing R1 with medications while living in the facility. The monthly Medication Regiment Review (MRR) conducted by V4 Pharmacy Consultant 2/20/24 was not located in the electronic health record, however, was available on request. The report for R1 on this day recommended a dose reduction of trazodone 100mg (milligrams) to 75mg every night. On 10/9/24 at 1:31pm V4 said, all the facility's residents are reviewed for drug interactions, appropriate laboratory orders associated with medication management and compliance with regulatory standards. V4 said residents are also reviewed for gradual dose reductions every six months, particularly if there have been no medication changes. V4 said there are occasions when the facility does not address the recommendations and V4 regularly works with the facility to increase the percentage of responsiveness by providing a report with the monthly reviews. On 10/9/24 at 3:01pm V3 Psychiatrist said that the MRR should be accessible in the Resident's Health Record to be easily reviewed. V3 said they typically visit the residents and conduct assessments monthly. When V3 comes to the facility, V3 relies on the nursing staff to provide the MRRs to be reviewed and signs them once reviewed. V3 determines whether they the Pharmacist's recommendations for a gradual dose reduction are agreeable, or if they deem the recommendation as a contraindication based on the Resident's condition at the time of assessment and review medication changes within six months. V3 said that regardless of the decision to reduce or maintain the medications if available to review, the MRR is addressed in V3's Physician Progress Note at the time of the assessment. Progress Notes reviewed for R1 indicate that R1 was not assessed by the Psychiatrist until 4/28/24- two months after the recommendation was made by V4 to decrease trazodone. The progress note does not mention that the recommendation was reviewed, and no changes were made R1's medication regiment. The facility was also unable to provide a copy of the R1's February MRR signed by V3. Facility Policy Psychotropic Medication Use (no revision) states in part; Guideline: 2. To avoid the use of unnecessary drugs. Standard: II. e) The consultant Pharmacist may be consulted to assist with utilization of the appropriate medications, and the appropriate geriatric dosages. F) The interdisciplinary team should review the resident's response to treatment and consult with the attending physician or extender as needed. G) Psychotropic medication reductions should be attempted unless the reduction is clinically contraindicated. III Reduction: a) Gradual dose reductions, and behavioral interventions, should be utilized in an attempt to discontinue the use of these drugs, unless clinically contraindicated. B) Clinically contraindicated means the resident NEED NOT undergo a gradual dosed reduction or behavioral interventions if certain conditions exist. Clinical contraindications for reduction should be documented by the physician or extender in the medical record.

Based on observation, interview, and record review the facility failed to update care plan of residents with COVID infection. This deficiency affects all six (R1, R14, R16, R53, R54 and R89) residents in the sample of 23 reviewed for Care plan revision. Findings include: On 8/20/24 at 7:55AM to 9:23AM, Rounds made to the units with V20 Infection Preventionist and V8 PRSD ( Psych Rehab Service Director). Observed R1, R14, R16, R53, R54 and R89 were on droplet precaution due to COVID infection. Review medical records of R1, R14, R16, R53, R54 and R89. No care plan intervention developed for all residents with COVID infections. R89 tested positive for COVID infection on 8/12/24 while R1, R14, R16, R53 and R54 acquired on 8/13/24. On 8/20/24 at 10:18AM, Informed V20 Infection Preventionist that all six (R1, R14, R16, R53 and R54) residents did not have care plan developed for COVID infection. On 8/20/24 at 10:27AM, V2 DON (Director of Nursing) said that MDS (Resident Assessment) Care plan coordinator updates the care plan. Care plan is updated when there are changes in resident conditions such as having COVID infection because resident must on isolation precaution and add appropriate nursing interventions to prevent spread of COVID infection. Informed V2 that all the above six residents did not have an updated care plan. On 8/20/24 at 12:20PM, V1 Administrator said that Care plan coordinator is not available for interview because she is on vacation. Facility's policy on Care plan development effective 4/2020 indicates: Guidelines: A person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the evaluation process, is developed, and implemented for each resident. Procedure: 9. The Care planning team is responsible for the review and updating of care plans: * When there has been a significant change of condition.

Based on observation interview and record review the facility failed to implement infection control protocol for resident with COVID infection and implementation of COVID surveillance in the facility. This deficiency affects all ten (R1, R6, R14, R16, R41, R50, R53, R54, R89 and R103) residents in the sample of 23 reviewed for Infection Control Prevention Program. Findings include: On 8/20/24 at 7:55AM, Rounds made to D unit with V20 Infection Preventionist (IP). Observed R14, R53, R54 and R1 were on droplet precaution due to COVID infection. V20 went inside of these rooms to check for isolation bin without wearing gloves, gown, and facial shield. On 8/20/24 at 8:20AM, V20 Infection Preventionist said that staff should wear N95 mask, face shield, mask and gloves when entering the room of resident with COVID (+). V20 said that they should have red plastic bag inside the isolation room. On 8/20/24 at 8:53AM, Rounds made to B and E units with V8 PRSD (Psych Rehab Service Director). Observed R89 and R16 were on droplet precaution due to COVID infection. Review medical records of R1, R14, R16, R53, R54 and R89. No droplet precaution order in written in active physician order sheet for all six residents with COVID infections. R89 tested positive for COVID infection on 8/12/24 while R1, R14, R16, R53 and R54 tested positive on 8/13/24. On 8/20/24 at 10:18AM, Informed V20 Infection Preventionist that all six (R1, R14, R16, R53, R54 and R89) residents with COVID infections did not have order for droplet precaution order in their chart. V20 IP said that they don't need to have a written order, they have a standing order for isolation. Requested for policy. On 8/20/24 at 10:27AM, Informed V2 DON (Director of Nursing) that all six residents (R1, R14, R16, R53 and R54) with COVID infections did not have order for droplet precaution in chart. On 8/21/24 at 11:00AM, Review facility's policy on Infection Control: Isolation initiation with V20 Infection Preventionist. V20 said that the nurse should enter the order in resident chart for the type of isolation precaution needed. On 8/22/24 at 10:56AM, V20 Infection Preventionist and V25 ADON (Assistant DON) said that residents on COVID infection were monitored daily, and assessment were documented on nursing COVID screener form in resident's e-chart (electronic chart). Review all six residents (R1, R14, R16, R53 R54 and R89) medical records with V20 and V25. Observed daily monitoring and assessment were not done consistently. R1 was not done on 8/10 to 8/12/24. R14 was not done on 8/10 to 8/12/24. R16 was not done on 8/10 to 8/12 and 8/18/24. R53 was not done on 8/10 to 8/13, 8/15 to 8/19/24. R54 was not done on 8/10 to 8/12 and 8/18/24. R89 was not done on 8/9 to 8/11/24. V20 and V25 said that they do COVID testing for all non-COVID positive residents twice a week. Both said that COVID testing is documented in resident's e-chart under nursing COVID screener form. Review random non COVID residents- R6, R41, R50 and R103 with V20 and V25. Observed COVID testing twice a week is not done consistently. R6 last done on 8/16/24. R41 was only done once on 8/17/24 for the week of 8/11 to 8/17/24. R50 was only done once on 8/17/24 for the week of 8/11 to 8/17/24. R103 last done on 8/17/24. Both presented generic policy on infection outbreak not specific for COVID outbreak. Both said that this is what their nursing consultant gave to them and this what they have. Surveyor suggested to refer to COVID CDC, CMS and IDPH guidelines. On 8/22/24 at 12:15PM, Informed V2 DON of above concerns of implementation of COVID surveillance in the facility. On 8/23/24 at 10:46AM, V25 ADON and V20 Infection Preventionist provided Guidelines from CDC effective date 11/1/23: Residents confirmed with COVID 19. V25 said that they should be following the guidelines listed such as monitoring resident with COVID every 4 hours for clinical worsening. Both said that they started monitoring all residents daily beginning 8/7/24 because one of the residents was sent out to the hospital tested positive for COVID and some residents presenting respiratory symptoms. Both said that they don't have COVID surveillance monitoring/tracking log/contact tracing log. Both said that they don't have documentation of COVID testing plan for both residents and employees to investigate for their COVID outbreak. Facility's policy on Infection Control: Isolation initiation effective date: 4/2020 indicates: Guidelines: To provide guidance to licensed nurses regarding the initiation of isolation. Procedure: Initiating: 2. The nurse should enter the order in the resident record for the type of isolation precaution needed. Facility's policy on Outbreak effective date 8/2022 indicates: Guideline: To provide a process of an outbreak in the facility. Process: 1. Once a new case of any contagious disease is identified, the resident is isolated per policy regarding the organism 2. The facility will utilize information from the local and state health department as well as facility policy regarding the organism to determine the step to take. Facility's policy on Infection Control and Surveillance Program indicates: Program goals and oversight: The IPCP emphasizes the prevention and management of infections. Program oversight involves establishing goals and priorities for the program, planning, and implementing strategies to achieve the goals, monitoring the implementation of the program (including the IDT infection control practices), and responding to errors, problems pt other issues. This is done by the Infection Preventionist and approved by the IDT QAPI committee including the Medical Director. Components of an Infection Control Program: 2. Program oversight including planning, organizing, implementing, operating, monitoring, and maintaining all the elements of the program and ensuring that the facility's IDT is involved infection prevention and control. 3. Surveillance, including process and outcome surveillance, monitoring, date analysis, documentation, and communicable disease reporting (as required by State and Federal law and regulation) CDC guidelines for COVID 19 effecting date 11/1/23 indicates: Out break testing: Facility can choose to investigate an outbreak using contact tracing or a broad based. Abroad based approach includes the unit, floor, or other specific area of the facility where the positive COVID 19 case was identified (this could be where the resident resides or where the facility should follow a broad-based approach. 15. Testing plan: the facility has written testing plan which provided initial whole house testing and subsequent follow up testing determined by IDPH. CMS, and the local health department. Residents confirmed with COVID19: *Monitor the residents every 4 hours for clinical worsening. Include an assessment of symptoms, vital signs, oxygen saturation via pulse oximetry and respiratory exam to identify and to quickly manage serious infections. * Staff must wear full PPE (N95 respirator, gown, gloves, eye protector) when providing care.

Based on interview and record review, the facility failed to follow their policy in notifying the residents' family when the resident was sent out to the hospital. This failure affected one (R63) of four residents in the sample of 23 reviewed for discharge. Findings include: On 3/16/2024, R63 was sent out to the hospital. Review of R63 nurses note did not show any documentation as to the residents' transfer to the hospital. On 8/22/2024 at 1:00 PM, V29 (RN) said that when a resident is sent out to the hospital after receiving the order from the doctor, the nurse is supposed to notify the administrator, and the residents' family. On 8/21/2024 at 12:54 PM, V25 (Assistance Director of Nursing) said that when the nurses send a resident out to the hospital, the nurse is expected to notify the administrator, director of nursing, and residents' family. On 8/22/2024 at 12:54 PM, V2 (Director of Nurses/DON) said that the nurses are expected to notify the administrator, DON, and the residents' families when residents are sent out to the hospital. Guidelines: Emergency transfers should occur only for medical reasons, or for the immediate safety and welfare of a resident, or other residents. Procedure: 1. The nurse will assess the injury or change in condition and determine whether it is an emergency medical situation or a non-emergency situation. a. Notify the family, and physician or extender of change in medical condition and hospital transfer.

Based on observation, interview, and record review the facility failed to ensure residents are free of any significant medication error. This deficiency affects 1 (R55) of 6 residents in a sample of 23 reviewed for medication administration. Findings include: On 8/20/2024 at 8AM during medication pass, V12 (Registered Nurse) stated R55 will be given scheduled Insulin medication later when morning tray is available. R55 ate breakfast in the room. Surveyor followed up multiple times regarding insulin administration. On 8/20/2024 at 11:25AM, Surveyor was informed by V12 that R55 morning scheduled insulin was not administered as ordered and recorded as a missed dose. V12 stated that insulin medication was not given to R55 because medication was not available in her medication cart. On 8/20/2024 at 11:33AM, V2 (Director of Nursing) stated medication should be given as scheduled per physician order. Medication Review Report: Diagnoses: Type 2 Diabetes Mellitus Without Complications Order Summary: Admelog Injection Solution 100Unit/ML (Insulin Lispro) Inject 10 unit subcutaneously with meals. Care Plan: Focus: R55 has a dx of Diabetes Mellitus and is risk for complications. Interventions: Diabetes medication as ordered by doctor. Policy Name: Medication Administration, 4/2020 Guideline: To ensure that administration of medications is performed in a safe manner to prevent medications errors. Standard: Medications are administered according to state and federal law. Medications are only administered with an order. Procedure: 5. Follow special directions (take with food, before meals, after meals, sitting upright, etc.)

Based on interview and record review the facility failed to provide effective supervision to monitor and intervene before a resident-to-resident verbal altercation escalate into an avoidable physical altercation. This affected two of four residents reviewed for supervision and monitoring. This failure resulted in R1 and R2 having a verbal disagreement, escalating into a physical altercation, resulting in R1 observed with bleeding at back of head. R1 was sent to hospital with diagnosis of subdural hematoma and facial contusions. Findings include: R1 face sheet shows R1 has diagnosis of mild intellectual disabilities, disruptive mood dysregulation disorder, impulsive disorder and schizophrenia. R1's quarterly MDS assessment dated [DATE] section C for cognitive pattern denotes a score of 8 (cognitive impairments), section E for behavior, potential indicators of psychosis denote hallucinations and delusions. Zero (behavior not exhibited) is noted for physical behavioral symptoms directed towards others and zero (behavior not exhibited) is noted for behavioral symptoms not directed toward others. Facility final report sent to the department dated 4/26/24 denotes in-part R1, R2 resident to resident altercation, date of incident 4/21/24, time of occurrence 10:00am, location of incident resident room, immediate action taken resident separated and monitored, residents assessed for injuries, MD (medical doctor) notified, family notified, administrator notified, investigation initiated. Brief description of original allegation: resident R2 reported that co-resident R1 approached him stating that he was [NAME] and that he would fight him, R2 reported being hit by co-resident. Residents were separated both residents were placed on increased monitoring. The facility started an investigation. Medical doctor and families' guardians notified. No injuries. Both residents declined a police report. R1 is alert with a BIMs (brief interview mental status) score of 15 and is able to make his needs known. R1 displays behaviors related to his diagnosis. R1 presents with increased agitation, hallucinations, verbal delusions and physically aggressive with staff and peers. R1 is medication compliant and attends groups and activities. All behaviors are addressed in his plan of care. R2 is alert with a BIMS of 15 and is able to make his needs known. Resident displays behaviors related to his diagnosis. R2 presents with increased agitation, verbalized delusional thoughts, isolative behavior and physical aggression. R2 is medication compliant and attends activities with encouragement. All behaviors are addressed in the plan of care. Summary of investigation/ facts determined: according to resident R2 Co-resident walked up to him stating I am [NAME] Ali; I will fight you, then hit him, so he hit back. According to R1 co-resident he does not remember what happened. Staff reported that resident R1 approached co-resident, R2, and stated I am [NAME] Ali, I will fight you then hit R2. Reportedly resident R2 was wearing his superhero cape at the time and stated I handle things around here, then hit R1 back. Staff intervened. While attempting to box R1 loss his balance and fell to the floor. R1 sustained a small cut to the back of his head as a result of the fall. First aid given by the nurse. R1 was assessed and treated for pain. R1 was sent to the hospital for medical evaluation per medical doctor orders. R1 admitted to the hospital with a diagnosis of subdural hematoma. R1 return to the facility and remains on increased monitoring. R2 was assessed by the nurse and was given medication per MD (medical doctor) orders for increased agitation. Both residents have been counseled regarding seeking staff assistance as needed. Residents room assignment are in opposite halls of the facility and both residents were placed on increased monitoring, all behaviors were addressed in the plan of care. Based on investigation conducted, review of the medical records and interviews of staff and residents involved, it could be concluded that both residents did not have any willful intent of causing harm or physical abuse. Both appear to be exhibiting behaviors related to their diagnosis. Both to be verbalized delusional thoughts, one believing that he is [NAME] and the other believing that he is a superhero. Necessary, care plans, medication reviews and assessments were completed and updated for both residents. Both residents have been notified of the outcome of investigation. Family and medical doctors notify accommodation. Both residents remain on increased monitoring. V6 (administrator) name is noted at bottom of page. On 5/23/24 at 11:48am R1 was escorted to the conference room guided by V11 (social services), R1 observed alert to person, R1 observed with confusion. R1 said a guy came in his room and began hitting him. R1 don't recall the date, time, or who the person was. R1 touched the back of his head stating he hit his head. R1 said he lost vision in his right eye when shampoo got into his eye. R1 don't recall going to the hospital. R1 said he was ready to leave the conference room. R1 escorted back to his room by V11. R1 observed with shuffle gait, and tremors to right hand. On 5/23/24 at 1:08pm R2 observed alert and orient to person, place, time, situations, and events. R2 said he was walking up and down the hallway in the C wing, listening to his headphones, when R1 came up behind him and said, I will knock yo retarded ass out. R2 said he took off his headphones, placed them on the floor, R2 said he responded to R1 by saying do it. R2 said R1 then punched him. R2 said they began to fight. R2 said this started in the hallway. R2 said R1 landed in his room on the floor because they were fighting. R2 said he didn't walk away because R2 said I'm from the [NAME] area, you don't let anyone put their hands on you. R2 said R1 had the gall to hit him. R2 said the staff keep telling him that R1 does not have the intellect to comprehend his actions. R2 said he does get angry and is destructive of things/items. R2 said he goes to group, and he is taught coping strategies to manage his anger, R2 said he knows all that stuff. R2 said he will not hit anyone unless they hit him first. On 5/23/24 at 12:25pm V12 (CNA-certified nursing aide) said she was the aide assigned to the C on 4/21/24. V12 said a resident came and got her, he was pointing, and she followed that resident, that resident took her to R1 room. V12 said she observed R2 swearing and yelling, R2 was in the hallway. V12 said she observed R1 in his room, sitting on the floor. V12 said initially she didn't see any injuries on R1. V12 said she went and got the nurse and upon further assessment R1 was observed with some bleeding and laceration to the back of the head. V12 said R1 could not communicate what happened. V12 said it is difficult to understand R1. V12 said the nurse rendered first aide. V12 said she was sitting at the front of the C wing. V12 said the position that she was sitting in she could not see down the hall where the incident occurred. V12 said R1 does have a behavior where he is shadow boxing, and while saying [NAME] Ali. R1 would come to the doorway of his room and do this behavior also. V12 said R1 would approach staff and motion his hands like he's boxing while saying you know [NAME] Ali. V12 said R1 is a very tall man, over 6 feet tall, and if he approaches someone with his stature, it would be intimidating, V12 said R1 doesnt mean any harm to anyone. V12 said after R1 was assessed R2 was assessed but she doesn't recall the details of what R2 said how the incident occurred. V12 said she remembers R2 was in the hallway swearing, she did separate the two residents. On 5/23/24 at 2:06pm V13 (Nurse supervisor) said she was summons by V12 and when she went into R1 room she observed R1 sitting at the bedside, V13 said the staff had picked R1 up from the floor. V13 said she assessed R1 and observed laceration to the back of his head and something on his forehead, V13 said she don't recall exactly what was on R1 forehead, but R1 defiantly had bleeding to the back of his head. V13 said R1 said he hit his head on the wall. V13 said when she interviewed R2, R2 said he told R1 to hit me then. V13 said R2 asked R1 to hit him, provoking the fight. V13 said R2 made a statement about he handles things around here. On 5/23/24 at 3:18pm V11 (social services) said he is aware that R1 has this behavior of shadow boxing (punch the air) while saying [NAME] Ali. V11 said R1 would walk up to people and do this behavior, he has seen R1 come to his room door doing this behavior. V11 said this behavior can intice an altercation, it puts R1 at risk for abuse and fighting. V11 said the facility has implemented monitoring for R1 because of his behavior. V11 said staff should make rounds on R1. V11 said the staff monitor R1 by making rounds on R1 every hour, the aides monitor the hallway, and they should be observing for this behavior and intervene if they see R1 doing this. V11 said the staff should redirect R1 when R1 is doing this behavior. V11 said R1 has been referred to the psych doctor for his delusions of thinking he's [NAME] Ali. V11 said R1 care plan has been updated for this behavior with interventions. V11 said this is new behavior for R1. V11 said the interventions of monitoring R1 was not effective because R1 got into a physical altercation due to his behavior, sustaining an injury. V11 said R1 was sent to the hospital after the altercation with R2. V11 said R1 has had a decline in mental capacity during his stay at the facility. V11 said R1 was in therapeutic programing however R1 would not benefit from programming due to his decline in mental capacity. V11 said R1 BIMS score is not 15, R1 has mental function decline. V11 said R1 has been displaying this behavior of shadow boxing and approaching other with motion of shadow boxing since February 2024. Review of R1 care plan with V11, V11 said R1 care plan has not been updated with R1 behavior of thinking he's [NAME] Ali, approaching others with shadow boxing motion, and the interventions related to the plan to monitor R1 for this behavior to prevent escalation, abuse and promote safety of R1 behavior. On 5/23/24 at 3:53pm V6 (Administrator) said the facility camera located in the C wing is used to focus on the exit door, she reviewed the camera, but she could not determine if the altercation started in R1 room or in the hallway. V6 was asked how this altercation start in the hallway and the staff was monitoring the hallway 12-15 feet away from R1 room and did not observe this altercation or hear this altercation that started in the hallway. V6 said she was not there, and the staff said they did not witness the incident. V6 said she did review the cameras in the dining room and the altercation did not happen in the dining room. At 1:56pm during a tour of the C wing with V3 (ADON-assistant director of nursing), the aide V14 (CNA) was sitting with his back facing down the hall of the C wing. The front of the C wing was within 15 feet of R1 room, where R1 was found on the floor. V14 said he's watching the dining room too, when asked if he could monitor the hall from his position (back facing the hall). V3 did not respond if he could see down the hall with his back facing the hall. R1 progress note dated 4/21/24 resident involved in an altercation with co-peer. R1 noted with delusional ideations stating that he is [NAME] and is unable to give description as to how the altercation occurred. R1 and co-peer were immediately separated. R1 was assessed for injuries. Noted small laceration to occipital head and small laceration near right eye. First aid rendered. Neuro checks initiated. R1 is alert and verbal with confusion per his norm. Pupils equal and reactive to light. R1 denies pain at this time. No nausea or vomiting noted. Doctor notified and gave orders to send resident to hospital for medical evaluation. Ambulance called, ETA 45 minutes. Placed call to resident sister who is #1 emergency contact-no answer. Placed call to #2 emergency contact and made him aware of above information. R1 remains one on one with staff until arrival of ambulance. Writer received call from Hospital per resident's status update. Writer was made aware that resident's admitting diagnosis is subdural hematoma. R1 hospital records dated 4/21/24 denotes in-part chief complaint head injury without loss of consciousness, patient 54year old male with history of schizophrenia, dystonia and Diabetes mellitus presenting to ED via EMS for evaluation after a head injury without loss of consciousness. Patient currently resides at assisted living facility. Per EMS patient was in a physical altercation with his roommate and was struck in the face with fists followed by hitting his head on the wall. There was no report of loss of consciousness. Denies any other injuries or trauma. Examination: head-contusions present, multiple facial contusions and abrasions. Clinical impression subdural hematoma, contusion of face. CT impression denotes, small extra-axial hematoma along the left temporal lobe likely representing a small subdural hematoma. R2 face sheet shows diagnosis of schizoaffective disorder, schizophrenia. R2 MDS dated [DATE] denotes a score of 15 (cognitively intact). R2 plan of care denotes in-part R2 has a history of aggressive, inappropriate attention seeking behavior but has demonstrated stability during the admission screening process and is therefore considered appropriate for admission, severe mental illness and substance abuse. R2 will behave in a manner consistent with resident conduct policies. Interventions: intervene when any inappropriate behavior is observed. R2 has a history of aggressive behavior and has exhibited verbally/physically abusive behavior related to manifested by being challenged by mental illness, ineffective coping mechanism, physical abusive when agitated, poor verbal skills and inability to express self in more appropriate language. R2 will reframe from verbally and or physically abusive behavior following staff intervention to avoid getting into power struggle with residents. Facility policy titled behavior management date 4/2020 denotes in-part mental and psychological adjustment difficulties may be experienced by a resident due to problems adapting to changes in life circumstances. A resident may experience difficulty adjusting and therefore demonstrate signs and symptoms of mood distress or behavior disturbance. Residents who display mental or psychological adjustment difficulty should receive appropriate services in an attempt to minimize risk the social service department may assist with arrangements for outside professional consultation services such as psychologists or psychiatrists when ordered by the attending health care provider. Mental health disorders should be identified through MDS/RAI care planning process that is completed after admission and periodically the residence service department may conduct further assessments to identify and manage alter mental status dementia delirium and depression. The plan of care should be developed by the interdisciplinary team. The interdisciplinary plan of care communicates care instructions to staff. Problem behaviors identify in the comprehensive assessment and plan of care should be documented. New or worsening behaviors should be communicated to other departments as needed.

Based on interviews, observations, and records reviewed the facility failed to prevent one resident (R3) from being physically attacked by another resident with identified anger problems and mood swings. This affected two of four residents (R3, R4) reviewed for physical abuse. This failure resulted in R4 physically attacking R3 resulting in visible, bleeding, scratches on her chest, arms, and head. The findings include: The facility Final Investigation date of incident 4/19/24 states R3 sustained a small scratch on her chest. R4 did swing at R3 with her left arm. R3 did sustain a small scratch. R3's diagnosis includes, but are not limited to, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Generalized Anxiety Disorder, and Suicidal Ideations. R3's Cognitive assessment dated [DATE] notes a score of 14, intact. R4's diagnosis includes, but are not limited to, Bipolar Disorder, Major Depressive Disorder Severe with Psychotic Symptoms, Alcohol Abuse, and Hemiplegia Affecting Right Dominant Side. R4's Cognitive assessment dated [DATE] notes a score of 15, intact. On 5/23/24 at 10:27AM R3 said on 4/19/24 when I opened the bathroom door, R4 was there screaming at me what's your problem! R3 said she started hitting me and I fell on my roommate's bed. R3 said, I got scratches on my chest and head. R3 is able to ambulate without devices and independently. R3 pointed to the top of her head along her right hairline/forehead region. R3 pulled her t-shirt neck and showed the surveyor a raised, flesh tone, T-shaped scar to her right chest. On 5/23/24 at 12:11PM R4 said I went into R3's room. R4 said when I saw R3, I started hitting her. R4 said I was jealous of R3. R4 said I'm over it! It just happened. R4 said she had got a call and they said something to me. R4 becoming agitated and interview was ended. R4 observed to have right arm tucked near her body and not using right arm. R4 making gestures with her left arm/hand. R4 observed wearing a ring on her left hand with a white stone and raised setting. R4 able to ambulate without devices and independently. On 5/23/24 at 10:32AM V2, Certified Nursing Assistant, said R4 thought R3 was with her boyfriend and went to R3's room to see about it. V2 said we (staff) were all in the dining room and not able to see when R4 went into R3's room. V2 said I didn't see any of the fight. On 5/23/24 at 11:12AM V4, Housekeeping Manager, said when I walked into the room, I saw R4 swinging on R3. V4 said they were pressed up against the wall by the dresser. V4 said R4 has use of one arm. V4 said R4 said R3 got smart with her. V4 said both R3 and R4 were standing and R3 had her arms up (V4 demonstrating her arms crossed over her face) and R4 was swinging. V4 said no one else was in the room. V4 said we were getting ready for lunch, that is why no CNAs were on the unit. V4 said R3 was returning to the facility when R4 saw her and went after her. On 5/23/24 at 11:29AM V1, Licensed Practical Nurse (LPN), said I was notified by V4 that R3 and R4 had an altercation. V1 said V4 brought R3 to the nurses' station. V1 said I asked R4 what happened, and she said she was asking R3 to use the room mates phone. V1 said R3 would not say anything. V1 said when I went to the room there was no one in the room. V1 said this happened around the lunch time, around 12:00 or 12:30PM. V1 said I was surprised that R4 was in the room asking to use someone else's phone, they are not usually friends. At 11:39am V1 said I looked at the scratches on R3's chest. When I saw them on 4/19/24 it was red, raised, and had been bleeding, we cleaned it up. Surveyor asked V1 to look at R3's chest and if it is the same injury from the altercation on 4/19/24. V1 said the scratches are now healing, it now looks like a scar on her chest. V1 said yes, those are from 4/19/24. On 5/23/24 at 1:45PM V3, Assistant Director of Nursing, said R3 had scratches on her, one on her chest and a couple of on her face. V3 said I spoke to R3 and helped clean her up. V1 said R3 said she didn't know why R4 started hitting on her. V1 said the residents are not supposed to share phones, they know they can use the phone in the social services office. V1 said the resident should not have the opportunity to hit another resident. V1 said one CNA needs to be observing the hall, one should be always watching. On 5/23/24 at 1:55PM V7, CNA, said on 4/19/24 when R3 and R4 had the incident, I was in the dining room. V7 said V2 was with her in the dining room. V7 said I saw R3 after the incident and she had blood on the front of her shirt. On 5/23/24 at 2:25PM V6, Administrator, said R3 said R4 scratched her. V6 said I don't know if R3 was bleeding from the scratch. On 5/24/24 at 11:16AM V5, (PRSC), Psychiatric Rehabilitation Service Coordinator, said I only saw R4 after the incident. V4 said R4 was in the office, she said she was trying to use the phone and R4 had got hostile with her. V5 said R4 does not have a history of being physically aggressive. V5 said R4 has had verbal exchanges with R3 before. V5 said the verbal altercation happened once before. V5 said R4 curses when she is angry, she has no other anger symptoms, just cursing. The surveyor asked V5 what is a potential striker as mentioned in R4's care plan. V5 said because R4 has one good arm and was using it on R3. The surveyor said the intervention is dated November 2022, V5 said striker means to start a physical altercation. The surveyor asked V5 about the ring observed on R5 and V5 said yeah, she wears that ring. R3's progress notes dated 4/19/24, written by V1, sates a fell ow peer was aggressive towards R3. Upon assessment R3 has some scratches on her chest area, right eyebrow area, and left arm. R3 sent to hospital. R3 returned the same day. R3's 72 hour follow up record states R3 has new injuries on her chest, no other description is listed. R3's Behavior assessment dated [DATE] indicates she has delusions, hallucinations and verbal behaviors directed towards others. R3's care plan initiated on 9/24/23 stated R3 is at risk for abuse based on comprehensive assessment, R3 has diagnosis of mental illness. R3 is disruptive, insensitive, and disrespectful to staff and peers. R3 displayed disrespect towards a peer. R3's hospital record dated 4/19/24 states chief complaint cough and abrasion. Patient with scratches and abrasion to the right forehead and right arm. R4's progress notes dated 4/19/24, written by V1, states resident was being aggressive towards a peer. Physician ordered a psych evaluation at the hospital. R4 hospitalized thru 4/23/24. R4's Behavior assessment dated [DATE] indicates she has delusions and verbal behaviors directed towards others. R4's Functional Abilities dated 4/30/24 identifies she has impairment on one upper extremity. R4's care plan dated 9/24/23 indicates she has mood swings and impulsive behaviors. R4's care plan dated 11/11/22 identifies she has anger problems and is also a potential striker. R4's care plan dated 4/19/24 (the date of the incident) stated R4 became verbal/physical with a peer. Care plan identifies R4 has history of aggressive behavior with verbal and physical abusive behavior when agitated. R4's hospital record, provided by the facility, dated 4/19/24 states sent for having increased delusional thinking, hallucinations, mainly witnessed because she has been more agitated, aggressive with peers, not being redirectable. Patient states she is here because I was fighting. The facility policy titled Abuse dated 4/2020 denotes in-part this facility affirmed the right of all residents to be free from verbal, physical, sexual, mental, neglect, exploitation, misappropriation of property, involuntary seclusion, and 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 and mistreatment of residents. The resident rights for people living in long term care denotes in-part as a long-term care resident in Illinois, you are guaranteed certain rights, protections, and privileges according to state and federal laws. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.

Based on interview and record review, the facility failed to ensure a lab draw for an antiseizure medication was completed as ordered for two residents (R1, R2) out of three reviewed for physician orders in a total sample of five. This failure resulted in R2 suffering a seizure and being sent to the hospital where the antiseizure medication level was low. Findings Include: R2 is a [AGE] year old with the following diagnosis: idiopathic epilepsy and paranoid schizophrenia. On 3/13/24 at 12:00PM, R2 was unable to remember when R2 went to the hospital last, but reported it was due to having a seizure while at the facility. R2 stated R2 was born with seizures and R2 has to take medications to control them. R2 was not aware of any missed blood draws. R2 does not remember the last time R2's blood was drawn at the facility. R2 was unaware if any seizure medication levels were low. On 3/14/24 at 11:29AM, V10 (Nurse) was not able to remember a date but stated one day R2 was not responding and staring off while sitting in the dining room. V10 reported 911 was called for R2 having a seizure longer than one minute. V10 denied being aware of any missed laboratory work for R2. V10 was not aware the last time R2 had laboratory work completed for Dilantin levels. V10 stated a physician will put in an order for what date the laboratory work should be completed and then a requisition should be sent over to the outside laboratory company so they know what to draw when they come to the facility. V10 reported the outside laboratory company comes to the facility every Wednesday and Friday and collects from the residents that are on the collection list. V10 stated if the physician ordered the laboratory work then the order must be followed. On 3/14/24 at V11 (Primary Physician) stated the Dilantin level is usually drawn every three months. V11 reported Dilantin is a very sensitive medication that must be tested to see if it is within normal limits. V11 stated the laboratory works must be completed so they know how to treat the seizures. V11 stated V11 had over 50 residents in the facility and was unable to report when R2's Dilantin level should have been drawn. V11 reported it is the responsibility of the nurse to keep track of orders in the system and complete them. V11 stated if the Dilantin level was tested as ordered and low then V11 would have treated the abnormal value. The Physician Order Summary documents an order for Dilantin (anti-seizure medication) laboratory blood work on 10/20/23 and 1/20/24. Both of these orders were placed on 10/19/23. The Laboratory Report dated 10/20/23 documents the Dilantin level was 14.8 ug/mL (normal is 10.0-20.0 ug/mL). There is no Dilantin level laboratory work documented after this date. A Daily note dated 1/21/24 documents the nurse observed R2 with seizure activity this morning. R2 was unresponsive in the day room in a wheelchair. R2 was assisted to the floor and placed on the left side. R2 had seizure activity for about five minutes. 911 was called and R2 was transported to the hospital. The Hospital Discharge Summary dated 1/21/24 documents the reason for visit was a seizure reevaluation and the diagnosis was seizure. The Dilantin level was measured while in the hospital and is documented as 2.6 ug/mL. This level is low. R2 was given an injection of Dilantin and sent back to the facility. The Care Plan dated 8/23/23 documents R2 has seizures/an epilepsy disorder and is it risk for complications. An intervention for this care plan is documented to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. R1 is a [AGE] year old with the following diagnosis: schizophrenia disorder, bipolar disease, and epilepsy with seizures. On 3/13/24 at 11:46AM, R1 reported R1 takes an antiseizure medication (Dilantin) to manage the seizures. R1 reported at the hospital R1's blood was taken and the Dilantin level was low but R1 did not know what the level was. R1 stated the hospital gave Dilantin via IV and sent R1 back to the facility. R1 was unaware how frequently the Dilantin levels need to be tested . R1 does not remember when R1 was last tested before being at the hospital. On 3/13/24 at 12:35PM, V5 (Nurse) stated V5 was not aware how often a Dilantin level should be checked. V5 reported all the orders the nurses need to follow are in the POS (Physician Order Summary) and will tell you what labs need to be drawn when. V5 stated the facility uses an outside laboratory company and a requisition must be sent to the company so the resident will have the lab draw completed. V5 reported this medication level must be checked to make sure it is therapeutic. V5 stated a resident could have a seizure if the medication is not within range. On 3/13/24 at 12:52PM, V2 (Interim DON) stated R1's antiseizure medication levels are monitored through laboratory work ordered by the physician. V2 reported Dilantin levels are measured every three months. V2 stated R1 had Dilantin levels drawn in 10/2023 and other labs were ordered but did not have a result for 01/2024. V2 reported V2 nurses are responsible for checking and carrying out all the orders in the system. V2 denied being aware why these labs were not collected. On 3/13/24 at 1:35PM, V7 (Nurse) stated all orders must be completed as the physician order requires. V7 denied being aware of any missing laboratory works for R1. V7 stated the importance of checking the laboratory work is to see what is going on with a resident. On 3/13/24 at 1:49PM, V8 (Nurse) stated R1 is on Dilantin for seizures. V8 reported the level of this medication must be checked to make sure it is not too high or too low. V8 stated nurses must check the order sheet every day to ensure no new orders were placed on any residents. V8 denied being aware of any missed laboratory work for R1. V8 stated if any laboratory work is missed on the date it is to be collected then the physician should be notified. On 3/13/24 at 4:37PM, V9 (Primary Physician) stated R1 has a history of seizures and takes Dilantin. V9 reported that medication level needs to be collected every three to six months depending on what the previous levels were at. V9 stated the levels for this medication must be checked so make sure they are within a therapeutic range to prevent any seizures from occurring. V9 reported if there are no results for the lab that was ordered in 01/2024 then that means it was not completed. V9 denied being aware that R1's Dilantin levels were low while R1 was in the hospital. The Physician Order Summary documents an order for laboratory work to be collected on 10/20/23 and 1/20/24. Both of these orders were placed on 10/19/23. A Physician note dated 10/20/23 documents R1 was assessed on this day by the physician. A blood test was ordered for a Dilantin level on this day. The Laboratory Report dated 10/20/23 documents R1 had a Dilantin level drawn on this day and it is documented at 7.8 ug/mL which is considered low (normal is 10-20 ug/mL). There is no documentation the facility provided to the surveyor during this survey that any lab work was drawn on 1/20/24 as ordered. A Nursing note dated 3/9/24 documents an ambulance was called per request of R1's family. The ambulance attendants arrived to the facility around 9:45 AM to transfer R1 to the hospital. R1 denied any complaints of pain and had no signs or symptoms of distress upon transfer. The Hospital Records dated 3/9/24 documents R1 present of the emergency department for evaluation of possible seizure. R1 had a Dilantin level drawn while at the hospital. The Dilantin level was 8.1 ug/mL which is considered low. R1 was given Dilantin via an injection to bring the level to normal and sent back to the facility. The Care Plan date 5/15/23 documents R1 has a seizure disorder related to disease process and is at risk for complications. In intervention documents to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The policy, titled, Laboratory and Diagnostic Testing, dated 04/2020 documents, Guideline: To accurately report and monitor laboratory and diagnostic testing. Standard: Laboratory and diagnostic testing are performed according to the order; Testing is based upon the resident condition and/or to monitor therapeutic blood levels for medication management. Oversight in coordination is completed by the Director of Nursing or designee .Procedure: 1. The nurse receives the order for laboratory or diagnostic testing, and; c) Completes requisitions according to the date the test is to be completed. Laboratory requisitions are filed in designated accordion folder . 2. Laboratory and diagnostic results are received and reviewed by the licensed nurse. 3. The nurse receiving the laboratory or diagnostic results a) The nurse documents in the medical record communication with the physician and/or extender regarding results.

Based on interview and record review, the facility failed to report to the physician a low lab level for an antiseizure medication for one resident (R1) out of three reviewed for physician notification in a total sample of five. Findings Include: R1 is a [AGE] year old with the following diagnosis: schizophrenia disorder, bipolar disease, and epilepsy with seizures. On 3/13/24 at 11:46AM, R1 stated R1 takes an antiseizure medication (Dilantin) to manage seizures. R1 denied being aware R1 had a low level of Dilantin when R1 had laboratory work on 10/20/24. R1 reported R1 went to the hospital on 3/9/24 and then R1 discovered R1 had a low level Dilantin after the hospital completed laboratory work. R1 stated R1 was giving an injection of Dilantin in the hospital before returning to the facility. On 3/13/24 at 12:35PM, V5 (Nurse) stated all abnormal labs must be called into a physician so they are aware. V5 reported based on the labs the physician could put in more orders for a resident. V5 denied being aware of any abnormal labs that were not reported to a physician for R1. On 3/13/24 at 12:52PM, V2 (Interim DON) stated when the lab results come back then the nurse must call the physician and fax over the results to be reviewed. V2 reported the facility follows this practice so if a lab level is abnormal a physician can put in a new order if needed. V2 stated a low level of this medication could cause a resident to have a seizure. V2 denied being aware R1 had a low Dilantin level until R1 printed the laboratory report from 10/20/2023. On 3/13/24 at 1:35PM, V7 (Nurse) stated nurses are responsible for calling the physician after the laboratory results come in. V7 reported the physician needs to be notified so an order can be put in place for what to do next. On 3/13/24 at 4:37PM, V9 (Primary Physician) stated V9 does not remember if V9 was notified of the 10/20/23 laboratory results for R1 but reported the facility should either call in the results to the physician or fax them over. V9 confirmed a Dilantin level of 7.8 ug/mL is on the low end. V9 reported if a lab level is abnormal then a physician should be notified immediately. V9 stated if the Dilantin level is subtherapeutic then an extra dose or an adjust to the medication is made with a follow up laboratory work. A Physician note dated 10/20/23 documents R1 was assessed on this day by the physician. A blood test was ordered for a Dilantin level on this day. The Laboratory Report dated 10/20/23 documents R1 had a Dilantin level drawn, and it is documented at 7.8 ug/mL which is considered low (normal is 10-20 ug/mL). There is no documentation that a physician was notified of this low lab value. The Care Plan date 5/15/23 documents R1 has a seizure disorder related to disease process and is at risk for complications. In intervention documents to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The policy titled, Change in Condition, dated 04/2020 documents, Guidelines: To the physician or extender, who is in charge of medical care, responsible party, responsible for healthcare decisions, informed of the resident's medical conditions, so they may direct the plan of care as needed. Standard: Notification of the physician or extender, legal representative, or responsible party, should occur when there is a change in the resident's condition. Changing condition is defined as: . A need to alter treatment. The policy, titled, Laboratory and Diagnostic Testing, dated 04/2020 documents, Guideline: To accurately report and monitor laboratory and diagnostic testing. Standard: Laboratory and diagnostic testing are performed according to the order; Testing is based upon the resident condition and/or to monitor therapeutic blood levels for medication management. Oversight in coordination is completed by the Director of Nursing or designee .Procedure: 1. The nurse receives the order for laboratory or diagnostic testing, and; c) Completes requisitions according to the date the test is to be completed. Laboratory requisitions are filed in designated accordion folder . 2. Laboratory and diagnostic results are received and reviewed by the licensed nurse. 3. The nurse receiving the laboratory or diagnostic results a) The nurse documents in the medical record communication with the physician and/or extender regarding results.

Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by other residents. This failure applied to four of four (R1, R2, R3, and R4) residents reviewed for abuse and resulted in R3 sustaining a nosebleed after being punched by R4 and resulted in R2 sustaining a closed fracture of the right ankle, which required a surgical procedure, after being involved in a physical altercation with R1. Findings include: R2 is a [AGE] year-old male who was admitted to the facility on [DATE], past medical history includes, but not limited to schizoaffective disorder bipolar type, bacterial infection unspecified, Epilepsy, unspecified fracture of right lower leg subsequent encounter for closed fracture with routine healing, conversion disorder with seizure or convulsion, etc. On 11/17/2023 at 11:35AM, R2 was observed sitting in the dining area, alert and oriented and stated that he just returned from an orthopedic appointment, they removed the staples from his leg. R2 was noted with a cast to his right leg and crutches for ambulation. R2 stated that the day his leg got injured, he got into a fight with his roommate who has always been picking on him; R2 could not remember what the argument was all about but he said that they both got loud and started fighting. R2 said that he punched R1 real hard, he got dizzy and pushed him, R2 fell to the floor, his right leg was sticking out and R1 fell on his leg with his weight. R2 stated that the fight went on for a while before staff came and separated them, his leg was so painful, the nurse gave him some pain medicine, but it did not help, he was then taken to the hospital. Aggressive behavior assessment dated [DATE] shows that R2 does not have history of aggression. Risk for abuse assessment dated [DATE] scored R2 as 1, at risk for abuse. Progress note dated 9/24/2023 at 07:30 by V7 (RN) reads: The resident was involved in a physical altercation with his peer roommate this evening. Resulted in a possible dislocation of the right ankle. Ambulance called and pending transfer to hospital emergency room at this time. At 09:56:58, V7 documented, observed the resident sitting upright on the floor complaining of pain after a physical altercation with his former peer roommate. Both residents reported the incident began over a television. The resident complained of 10/10 pain at this time and received acetaminophen 650mg PO PRN at 20:59 for his right ankle pain and reported ineffective an hour later. Other vital signs within normal limits. Writer immobilized the right leg. Attending physician called and requested that resident be sent to the emergency room for evaluation. Progress note dated 10/25/2023 states: Resident returned to facility from hospital. alert and oriented x3. V/S 116/72-78-20-97.8-97% on room air. Resident is NWB to Rt leg. Surgical wrap in place, not to be removed until follow up appointment with surgeon in 2 weeks. On 11/17/2023 at 3:51PM, V10 (Attending physician/ Medical Director) said that he is the attending physician for R2, he was called the day he had an incident with another resident, they reported that R2 broke his ankle, he was seen by the orthopedic doctor who recommended surgery due to some displaced fragments. A cast would not be sufficient to heal the injury, resident had some staples and screws and had a cast on his right leg the last time V10 saw him. V10 added that R2 is not aggressive and he is not aware that the other resident is aggressive, if someone was watching them, this may not have happened. R1 is a [AGE] year-old male who resided at the facility since 2022, with past medical history of schizoaffective disorder bipolar type, opioid abuse uncomplicated, generalized anxiety disorder, congenital deformity of feet, other hyperlipidemia, vitamin D deficiency, etc. R1 is no longer at the facility at the time of the investigation, he was transferred to the hospital on 10/2/2023 for psychiatrist evaluation after documented behavior of increased agitation, yelling/screaming, kicking hitting, verbally threatening etc. Aggressive risk assessment dated [DATE] documents that R1 has history of aggression. Care plan initiated 11/25/2022 states the following R1 has a history of aggressive behavior and has exhibited verbally/physically abusive behavior related/manifested by: Ineffective coping mechanisms and physically abusive behavior when agitated. 8/9/23 sent out to hospital due to a physical altercation with a peer The resident got into a physical altercation with peers-9/24/2023. The resident got into a physical altercation with peers on 10/03/2023. Interventions include assist in identifying coping skills for anger control, avoid getting in power struggle with resident, encourage verbalization of concern and make clarification if needed, etc. On 11/17/2023 at 3:11PM, V1 (Administrator) said that it was reported to her that R1 and R2 were involved in altercation over a TV that was loud, they got into a fight, both fell and R2 broke his leg. V1 said that R1 has been involved in verbal and physical altercation before, nobody was in the room but someone from social services was in the dining room, The way the incident was explained to her, it seems like an accident but if the fall resulted in an injury, it could be considered an abuse. On 11/17/2023 at 2:43PM, V7 (RN) said that the assigned CNA reported to her that R1 and R2 got into a physical altercation. R2 was on the floor when she got to the room, he was complaining of pain and holding his ankle, she took his vitals and assessed him to realize that he was in severe pain, she called the doctor and got an order, called the ambulance, and put resident on 1:1 and told him to immobilize his leg. V7 said that she is not sure if the CNA was in the room before she got there or if there is anyone monitor the hallway. The monitors are supposed to be in the hallway all the time, R1 has been involved in altercation numerous times with other residents, he is always agitated. On 11/17/2023 at 1:28PM, V4 (CNA) said that she has worked at the facility for one year. The day R1 and R2 had an altercation, she was coming down the hallway from hall A going to hall C to get some towels for a resident when another resident informed her that R1 and R2 were fighting; by the time she got to the room they were already separated , she does not remember seeing any monitor in the hallway. On 11/17/2023 at 1:38PM, V5 (CNA) said that she was assigned to monitor the C hall the day R1 and R2 had an altercation, she went to get towels from the A hall and was asked to assist with two residents over there, she was assigned to monitor the C hall but also responsible for two residents on the A side. V5 went to check on those (A hall) residents when the incident occurred and by the time she got to the room the nurse was already there, she stayed with R2 until paramedics arrived. V5 added that R1 is always involved in an altercation with other residents and staff. R3 is [AGE] years old and has resided at the facility since 2008, past medical history includes schizoaffective disorder, depressive type, Epilepsy, unspecified involuntary movements, major depressive disorder, other polyosteoarthritis, other asthma, etc. On 11/17/2023 at 3:40PM, R3 was observed in the common area and interviewed privately at the office, alert and oriented and stated that he is doing okay. R3 said that he recalls the day he was attacked by R4, he was sitting in the dining area, he looked at him and got up and (R4) hit him three times in the back of his head and his nose started bleeding. R3 said that he did not say anything to R4, staff were in the dining area and just walking around, they eventually separated them. Progress note dated 8/31/2023 20:42:46, documented by V6 (RN) reads: CNA reported resident was hit on the face and the back of his head by another resident. Resident was observed bleeding from his right nostril. Resident was assisted to a sitting position, RN applied pressure to the right nostril. Doctor contacted, ordered PRN extra strength Tylenol Q8HRS, cold compress on the nostril. RN to keep monitoring resident. Aggressive risk assessment dated [DATE] documented that R3 does not have any history of aggressive behavior. R4 is [AGE] years old and has resided at the facility since 2022, with past medical history of schizoaffective disorder bipolar type, iron deficiency anemia, major depressive disorder severe with psychotic symptoms, paranoid schizophrenia, etc. On 11/17/2023 at 11:44AM, R4 was observed ambulating around the facility, surveyor interviewed him in the office regarding the resident-to-resident altercation. R4 appears alert and oriented but with some confusion, stated that he recalls the incident, he hit the other resident (R3), but it was a mistake, he did not provoke him or say anything to him before the incident. Aggressive risk assessment dated [DATE] indicated that R4 has a history of aggressive behavior, care plan initiated 10/10/2022 states that R4 has a history of aggressive behavior and has exhibited verbally/physically abusive behavior related/manifested by: Ineffective coping mechanisms, and physically abusive behavior when agitated. R4 became physical with a peer in the dining room while dinner was being served on 08-31-23. Interventions include assist in identifying coping skills for anger control, avoid getting into a power struggle with residents, encourage verbalization of concern and make clarifications if needed, etc. On 11/17/2023 at 12:28PM, V3 (PRSC) said that the day R3 and R4 had an altercation, R3 was eating in the dining area, R4 was having behaviors, talking to himself, he stood up and went behind R3 and punched him on his head. V3 said that she was not in the dining area, she was in her office but could see the dining area through the window. V3 added that both residents were sitting at the same table, R4 was waiting for his tray, the security was in the dining area but she could not see him at the time of the incident. R4 is always involved in verbal altercations with other residents and staff, have not witnessed R3 in any altercation with anybody. On 11/17/2023 at 3:11PM, V1 (Administrator) said that the incident between R3 and R4 occurred because R4 did not want to sit at the same table with R3, he stood up and hit him, R3 did not provoke him in any way; that is considered abuse. On 11/17/2023 at 2:37PM, V6 (RN) said that she recalls the incident between R3 and R4, was the assigned nurse for both resident but did not witness the incident. The CNA reported to her that R4 hit R3, she does recall who the CNA was. Both residents were in the dining area. R3 had some blood coming from his nose, she applied pressure on the nose and used a cold pack to stop the bleeding. R4 was sent to the hospital for evaluation. On 11/17/2023 at 3:32PM, V9 (PRSA/Security) said that he was helping in the dinning room the day R3 and R4 had an incident. V9 heard the altercation, went, and separated the two residents, both were sitting at a table with no other resident. R3 was eating at the time and R4 was still waiting for his tray. V9 said that he made R4 sit at the office until the ambulance came; he was taken to the hospital for evaluation. Abuse policy with an effective date of 4/2020 states in part, the facility affirms the right of our residents to be free from verbal, physical, sexual .misappropriation of property and mistreatment of residents. To do this, the facility has attempted to establish a sensitive and resident secure environment.

Based on interview and record review, the facility failed to provided a resident (R1) with proper footwear to prevent or reduce the risk of a fall incident. This affected one of three residents (R1) reviewed for fall prevention interventions. This failure resulted in R1 falling in the hallway and sustaining a fracture to the right arm. Findings Include: R1 is a [AGE] year old with the following diagnosis: paranoid schizophrenia, alcohol abuse, and fracture of shaft of right humerus. On 8/9/23 11:53AM, R1 was interviewed. When asked why R1's arm was in a sling R1 stated R1 fell to the floor and broke R1's arm. R1 endorsed being sent to the hospital after that. R1 was not able to give any other details what happened after the fall. R1 then endorsed that 2 other staff were present but was not able to give any names. R1 endorsed staff gave R1 a pair of shoes without any laces when R1 returned to the facility. On 8/9/23 at 12:39PM, V2 (Nurse) stated that V3 (CNA) and V4 (Manager on Duty/Director of Housekeeping) said R1 fell down because R1's shoe laces were untied. After R1 tripped, the facility got R1 new shoes and always make sure they are now tied. The facility makes sure R1 has the appropriate footwear when R1 is up and walking. V3 endorsed that R1 doesn't wants to tie the shoes so R1 just leaves them undone. On 8/9/23 at 12:47PM, V3 stated V3 was on the D wing doing rounds and was near the end of the hallway. V3 heard a whine and turned around. R1 was on the floor when V3 turned around. When V3 walked over to R1, R1's shoe laces were untied and V3 just assumed that R1 fell over the shoe laces. V3 doesn't think R1 can tie the shoes alone. R1 walks around with the shoe laces undone a lot. V3 reported staff tells R1 to tie them or ask R1 to tie them and R1 just keeps walking. On 8/9/23 at 12:57PM, V4 stated the fall was after lunch and V4 was doing rounds on the D wing. V4 endorsed being was in the middle of the hall and R1 at the doorway when you come down the hall. V4 stated it happened so fast but all of the sudden I just saw R1 go down. V4 reported another V3 and V4 walked up to R1 to see what happened and R1 was on the floor on R1's right side. V4 endorsed R1 had red gym shoes on and both of them were untied. V4 stated R1 must have tripped and fell over R1's shoes that time. V4 stated R1 always has them untied though. V4 reported R1 gets the shakes sometimes so V4 doesn't think R1 can tie them without assistance. V4 endorsed V1 asked V4 to get him a pair of shoes out of storage without any laces. The facility had some in there so I know R1 was given shoes without laces in them since R1 has a hard time tying them. On 8/9/23 at 3:09PM, V1 (Administrator) stated V1 got a call on the weekend saying that a fall occurred with R1. V1 then spoke with the nurse and was sending R1 to the hospital because R1 was having pain in the right arm. V1 endorsed staff told V1 that R1 stepped on R1's shoelace and fell . R1 had x-rays taken at the hospital that noted a fracture. V1 stated for this fall, the facility got R1 shoes that did not have any laces. V1 endorsed R1 can tie them, but it requires extra time and queuing. Sometimes R1 would tell staff that R1 does not want the shoes tied. Staff would tie them when they noticed they were undone. V1 stated R1 didn't have any issues regarding falls and R1's shoes being untied before this fall. On 8/9/23 at 3:33PM, V6 (MDS Coordinator/Fall Team) stated this fall was related to R1 tripping on R1's shoes because the shoelaces weren't done. After the fall, the facility got R1 shoes without shoestrings. V6 endorsed staff try to encourage R1 to wear the shoes without laces. V6 reported R1 also had a fall in February that was due to poor coordination where he tripped. V6 stated staff gives the same amount of monitoring to everyone in the facility because no one is considered a high fall risk. V6 endorsed staff do basic interventions for everyone that hasn't had a fall like watching their gait to make sure residents are steady and making sure they have on appropriate footwear. Having appropriate footwear on can reduce your chance of falling. Like in this case, if R1 had R1's shoelaces tied, maybe R1 would not have fallen. A Nursing note dated 6/10/23 at 2:57 PM documents the manager on duty (V4) came to the nurse's station and reported R1 fell on the right side. The nurse (V2) assessed R1 and noted slight swelling in the right hand and arm. R1 complained of pain to the upper right shoulder. An x-ray was ordered to the right arm STAT. A Nursing noted at 6/11/23 documents R1 returned back to the facility after the hospital visit with a fracture to the right lower humerus. R1 is currently wearing a sling immobilizer with slight swelling. R1 is ordered to follow up with a general orthopedic physician. The Fall Report dated 6/10/23 documents R1 fell on to the right side. R1 reported pain when being assessed with slight swelling noted to the right hand. The physician was called and ordered x-rays to the right arm. It is incorrectly documented that there are no predisposing situation factors. Improper footwear should have been documented as a pre-disposing situation factor to this fall. The Hospital Records were requested but were not received in time. The Final Investigation Report dated 6/10/23 documents R1 was in the hall attempting to get in line for smoke break when R1 stepped on R1's shoelace and tripped and fell to the floor. As a result of the fall, R1 sustained a fracture to the right lower humerus. R1 reported that R1 fell while walking in the hall towards the patio for smoking. The fall was witnessed by staff. Staff reported that R1 was walking towards the patio while in line and R1 was wearing shoes with shoelaces untied at the time of the fall. R1 was sent to the hospital for medical evaluation and return with a splint to the right hand in a sling. R1 had follow up orthopedic appointments scheduled. R1's shoes have been replaced with slip on style without tie up laces. The Care Plan dated 4/6/23 documents R1 is at risk for falls related to psychoactive drug use and other underlying medical conditions. On 4/13/23, R1 slid to the ground while in the dining room, but had no injuries. Interventions were placed after this fall. There is no intervention addressing R1 ambulating with shoes untied. The Care Plan dated 6/26/23 documents R 1 sustained a fall on 6/10/23 with an injury. An intervention placed on this date documents that R1 will wear appropriate footwear and shoes will be tied when ambulating.

Based on interviews and record reviews, the facility failed to follow its abuse policy to prevent a resident-to-resident physical assault. This affected 2 of 3 residents (R2, R3) reviewed for physical abuse. This failure resulted in R2 being assaulted by R3. R3 hit R2 in the face multiple times causing R2 to sustain facial lacerations and facial fractures. Findings include: On 4/13/23 at 3:50pm, V7 CNA (certified nurse aide) stated that V7 worked on 4/6/23 from 3:00pm to 11:30pm. V7 stated that R2 will occasionally curse at staff or peers if R2 does not like what the person is saying to R2. V7 denied R2 involved in any resident-to-resident physical altercations previously. V7 stated that R2 uses a cane and can ambulate with some difficulty. V7 stated that R2 usually goes between R2's room and dining room. V7 stated that R3 was being very vocal on 4/6/23. On 4/14/23 at 7:41am, V10 (nurse) stated that V10 worked 11:00pm 4/6 to 7:30am 4/7. V10 stated that V10 did not witness the event involving R2 and R3. V10 stated that V10 was at the nurses' station getting ready to pass medications. V10 stated that R2 was moving around a lot that night in his wheelchair. V10 stated that the last time she saw R2 was at 2:30am. V10 stated that the CNA during rounds, saw what happened and came and got her. V10 stated that she went to room immediately with the CNA. V10 stated that V10 observed R2 sitting on R2's bed with blood on face, cuts to left eyebrow and below left eye. V10 stated that R3 was standing not far from R2's bed; appearance was threatening. V10 stated that R3 was next to R2's bed, directly facing the door, and smiling with fists clenched at sides of his body. V10 stated that it was difficult to get into room to assess R2's injuries. V10 stated that V10 called EMS (emergency medical services) 911 requesting police and ambulance services. V10 stated that police came and took control of the situation. V10 stated that the police officers had to barricade R3 against the wall with R3's bed so paramedics could get to R2. V10 stated that V10 asked R2 what happened, R2 responded 'he did it' pointing at R3. When V10 asked R3 what happened, R3 just smiled. V10 stated that the paramedics took R2, and the police officers took R3 out of the building at the same time. On 4/14/23 at 8:10am, V11 CNA stated that she worked on D wing on 4/6/23 from 11:00pm to 7:30am. V11 stated that R2 was awake all night, self-propelling in wheelchair from R2's room to dining room. V11 stated that V11 did hourly rounding on all residents in D wing. V11 stated that R3 was in bed awake all night. V11 stated that V11 was assigned three residents to assist with their showers. V11 stated that she got these residents starting at 4:30am. At that time, R2 was coming from dining room to his room. V11 stated that after showers were completed, V11 rounded on residents; between 5:30am and 6:00am. V11 stated that before she did rounds at 6:00am, V11 informed V12 CNA on adjacent wing she was going to the bathroom. V11 stated that V12 found R2 bleeding during that time. V11 stated that V11 heard overhead page for code white and ran to R2 and R3's room. V11 stated that R3 appeared mean, and no staff could get into room to assist R2. V11 stated that when the police arrived, they had to barricade R3 against wall using R3's bed in order to get to R2. On 4/14/23 at 8:20am, V12 CNA stated that V12 worked on the E wing, which is adjacent to D wing on 4/6/23. V12 stated that on night of 4/6, R2 didn't sleep. V12 stated that R3 remained in R3's room all night. V12 stated that V12 observed R2 bleeding during code white. V12 stated that V12 rounded on all residents on D and E wing at 6:00am. R2: Review of R2's medical record notes R2 was admitted to this facility on 9/9/2022 with diagnoses including schizoaffective disorder-bipolar type, major depressive disorder, borderline personality disorder, and schizophrenia. Review of R2's risk for abuse screening, dated 4/13/23, notes R2 is at risk for abuse as evidenced by mental illness diagnoses and requiring extensive assistance with ADLs (activities of daily living). Review of R2's BIMS (brief interview of mental status) score, dated 3/2/23, notes R2's score is 14 out of 15. R2 is able to make needs known. Review of R2's hospital medical record, dated 4/7/23, notes R2 presented to the emergency room with complaints of headache after an assault. R3 assaulted R2. R2 was being punched with R3's fists. R2 is normally alert and oriented x 4 at baseline but currently disoriented. Complaining of diffuse headache. Assessment noted multiple lacerations to face with associated swelling and bruising. Nose swollen and bruised. Eyes with conjunctival bleeding. Left eyebrow laceration is 9cm (centimeters) and was sutured. Right eyebrow laceration is 4cm and was sutured. Left cheek laceration is 1cm and was sutured. CT (computed tomography) of R2's head and face noted displaced fractures of the left orbital floor, left lateral orbital wall and left lamina papyracea (medial orbital wall) with extraconal soft tissue gas and bleeding in the inferior left orbit. Associated bleeding is also seen in the left maxillary sinus. Mildly displaced bilateral nasal bone fractures are seen. R2 was admitted to the hospital for further evaluation. R3: Review of R3's medical record notes R3 was admitted to this facility on 3/14/23 with diagnoses including schizoaffective disorder-bipolar type, schizophrenia, psychosis, and alcohol abuse. R3 was hospitalized ,d+[DATE]-[DATE] for psychiatric evaluation. Review of R3's medical record notes: On 3/15/23, R3 walked around facility during most of the shift. R3 had to be redirected repeatedly. On 3/21/23, R3 displayed behaviors of yelling/ screaming, hallucinations, delusions, verbally threatening, responding to internal stimuli, and rejection of care. Interventions attempted: R3 was re-directed, assisted to office, and removed from situation. R3's behaviors continued and rejected redirection. R3 then attempted to kill himself - tied a linen around his neck with a knot standing behind the door thereby attempting to commit suicide. On assessment, R3 states that he is fine and wasn't planning on harming himself. R3 was placed on 1:1 until he was transported to the hospital for psychiatrist evaluation. EMS (emergency medical services) reported R3 became highly suicidal during transport and needed to be re-routed to the closest hospital due to R3's acuity. On 4/4, nurse noted R3 needs to be continuously redirected before R3 follows directions. On 4/7 at 6:15am, V10 (nurse) was called by the CNA into R2's room while passing medication. Nurse noted R3 standing very close to R2 holding the room curtain and pacing. V10 asked R3 what happened, no verbal response. R2 was noted bleeding from the face; no initial explanation was received from either R2 or R3. Review of this facility's abuse policy, dated 04/2020, notes this facility affirms the right of our residents to be free from physical abuse. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.

Based on interview and record review, the facility failed to protect a resident's right from being sexually abused by other residents and failed to have interventions in place to prevent a resident from being manipulated/coerced into having sex with other residents. R1 remains at risk for sexual assault due to an inappropriate behavior of trading sexual activities for cigarettes and/or money. This failure affected one resident (R1) who was assessed as being at risk for abuse, and who was sexually assaulted by other residents (R2 and R3). R1 was found unresponsive in a bathroom located in the male residential area of the facility. R1 was transported to the hospital where she reported the sexual assault incident to hospital staff and the police. This was identified as immediate jeopardy situation that began on 10/15/2022 when R1 was sexually assaulted after requesting R2 to stop based on R1 report; she was forced by R2 to have sex, R1 told him to stop but he did not, he held her down, made her perform oral sex on him and penetrated her for 10 to 15 minutes. who was holding her hand down, she told him to stop and pleaded with him not to discharge inside her. V1 (administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on 10/25/22 at 4:00 PM. Findings include: 1. According to an initial abuse report dated 10/15/2022, the local police department came to the facility requesting to take the bed sheets of resident R1 and face sheets information of four residents (which included: R2, R3, R4). Initially the police officer stated that it was a confidential investigation and would not disclose why he was requesting items from the facility. A few minutes later a sergeant from the local Police Department called this writer explaining that there was an allegation of sexual assault and that the police would need the items for an investigation. Shortly after, a nurse from local community hospital called the facility informing the nurse that resident R1 made an allegation at the hospital. The facility started an investigation. Resident R2 was placed on increased monitoring. According to the final abuse report received by the state agency on 10/24/2022 undated included but not limited to the following: the determination of investigative findings indicate that both residents stated during interview that they consented to an exchange of a sexual favor for cigarettes. The allegation of sexual assault is unfounded. R1 went to the room of R2 on her own free will, was not forced. When she went into the room, accepted a deal with co-resident R2. Both residents have intact cognition based on their BIMs score for cognitive evaluation. All assessments have been reviewed and care plans have been updated for both. Groups and individual counseling will be offered to both residents for support and education. 2. R1 is a [AGE] year-old female who have resided at the facility since March of 2022. R1's medical history includes, but not limited to [CONDITION(S)] disorder [CONDITION(S)] type, unspecified [CONDITION(S)] not due to substance or known physiological condition, drug induced subacute dyskinesia, [CONDITION(S)] [CONDITION(S)], major depressive disorder, and generalized anxiety disorder. During the investigation on 10/17/2022 at 11:20AM, R1 was observed in her room, awake and alert and on a one-to-one monitoring by staff who was outside her door. R1 did not want to answer any questions but told surveyor to come back after lunch and smoke break. At 2:30PM, R1 was interviewed, and she said that she went to R2's room to look for her friend (R4) who always hangs out there, R4 was not there but R2 told R1 that he will tell R4 not to give anything to R1 anymore unless she had sex with him. R2 also offered R1 some cigarettes in exchange. R1 admitted to having sex with R2 who was holding her hand down, she told him to stop and pleaded with him not to discharge inside her. R1 said it happened for a while and she did not tell the staff but reported it at the hospital. R1 asked the surveyor not to tell anyone about it. Police report dated 10/15/2022 states in part: R1 was forced by R2 to have sex, R1 told him to stop but he did not, he held her down, made her perform oral sex on him and penetrated her for 10 to 15 minutes. R1's Minimum Data Set (MDS) assessment dated [DATE], section C (Cognitive) coded R1 with a BIMS score of 15. The same assessment section G coded R1 as requiring staff supervision for all ADLs including locomotion on and off unit. MDS assessment dated [DATE] section C1000 (Cognitive skills for daily decision making) coded R1 as 2, indicating moderately impaired, decisions poor, cues/supervision required. Hospital record dated 10/24/2022 stated the chief complaint as hyperventilation and sexual assault of adult. Care plan initiated 3/05/2022 states that R1 is at risk for abuse and neglect based on the comprehensive assessment as evidenced by a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goals include Resident will be treated with respect, dignity and free from mistreatment while residing in the facility. Resident will remain safe and will be free of abuse/neglect through next review. The resident will identify and practice coping strategies that will prevent mistreatment from peers through the next review. Interventions include the following: Assure the resident that he/she is in safe and secure environment with caring professionals. Explain psychosocial adjustment is often facilitated by developing a trusting relationship with another person and verbalizing thoughts, provide supervision during visits, as necessary, etc. R1 was also listed as one of the residents to be monitored hourly by the C.N.As and the PRSAs/security. R2 is a [AGE] year-old male who has resided at the facility since 1/23/2022, with past medical history including, but not limited to [CONDITION(S)] disorder, major depressive disorder, psychotic disorder with delusions due to known physiological condition, cocaine abuse, pain in the right foot, etc. R2's MDS assessment dated [DATE] section C (cognitive status) coded R2 with a BIMs score of 15, section G of the same assessment coded R2 as requiring supervision for all ADLs, including bed mobility and ambulation on and off unit. 10/17/2022 at 11:35AM, R2 was interviewed, and he said that R1 came into his room and wanted to have sex, he asked her if she want to do something in exchange for a cigarette and she said yes, they had sex and he gave her some cigarettes, this is not the first time, last time he gave her $3.00 in exchange for sex. Surveyor asked R2 if he used any type of protection and he said no. R2 added that R1 also had sex with R3 who was sharing a room with R2. R3 is a [AGE] year-old-male who has resided at the facility since 8/12/2021, with the following past medical history: Paranoid [CONDITION(S)], [CONDITION(S)] disorder current episode hypomanic, major depressive disorder, unspecified [CONDITION(S)] not due to a substance or known physiological condition, other psychoactive substance abuse uncomplicated, tremor, etc. R3 MDS assessment dated [DATE] scored R3 with a BIMs score of 15, section G (Functional status) coded R3 as requiring supervision for ass ADLs, including locomotion on and off unit. Care plan dated 5/16/2022 states: R3 has demonstrated deficiency in grooming and basic self-maintenance skills due to the following: Cognitive deficit Lack of hygiene awareness. 10/17/2022 at 11:40AM, R3 said that he is familiar with R1 and admitted to having sex with R1 before she had sex with R2. R3 said that this is not the first time, he has had sex with R1 before and he gave her $5:00, this time he did not give her anything. 3. 10/17/2022 at 2:50PM, V5 (C.N.A) said that she worked morning shift on the E wing and was the one who found R1 in a bathroom in the male section of the facility, she called the nurse who came and assessed resident, she was then sent to the hospital for evaluation. V5 said that she did not see R1 entering any room in the E wing, she went on a break and after that she was in the dining room charting, she then went to make rounds after charting that's when she found R1 unresponsive. V5 said that no one covers or monitors the hallway when the assigned staff take a break, she did not check the rooms after lunch so she cannot say how long the resident has been in the male section. R1's nurse's progress note dated 10/15/2022 at 15:00 states: Resident noted on the floor in room #E7 bathroom floor hyperventilating with her tongue sticking out and not responsive to verbal stimuli at this time. Vital signs done, B/P 138/88, P 115, Room air saturation 99%, resident remain warm to touch and dry. Dr called and informed of resident's change in condition. Respond with order to monitor 1:1 and if condition worsen transfer out as needed. order noted and carried out. All necessary administrative personnel notified. 10/15/2022 at 15:15, nurse's progress note reads: Upon continued monitoring, resident's condition noted to be deteriorating, resident's pulse continued to elevate at an alarming rate. 911 called and resident was transferred out of the facility via stretcher with 911 crew members. Dr notified, ADON and administrator notified. 10/2/2022 at 19:48, nurse's progress notes states: Resident was found in the bathroom breathing heavily and not responding. Resident was noted with change in status. Resident was assisted to a nearby chair where the vitals were taken. Vital sign was BP 159/116. pulse 137. Dr was contacted and 911 emergency assistance were contacted. Resident was also found smoking in another resident's room on 10/5/2022 as documented in social service note and care plan. 10/18/2022 at 10:24AM, V9 (LPN) said that she was the assigned nurse to R1 the day she was sent to the hospital, it was close to 3PM, C.N.A reported that resident was found in the bathroom in room #E7, the two residents who occupy the room were present and said that they did not know what happened to her. V9 assessed the resident who was hyperventilating, but her oxygen level was 99% on room air, resident was transported to her room with staff assistance. V9 said they were monitoring resident, but her heart rate was increasing, she already has an order to send resident out if her condition worsens, the ambulance was called, and resident was sent to the hospital. 10/17/2022 at 1:27PM, V1 (Administrator) said that a nurse from the hospital called the facility stating that a resident alleged sexual assault and V1 later found out that it was R1. The facility nurse reported that R1 was sent to the hospital because she was having difficulty breathing and abnormal vitals. V1 said that she initiated investigation and sent out the initial report to IDPH (Illinois Department of Public Health) the following day. V1 said she spoke R1 when she returned from the hospital and she said that nothing happened, she admitted going to R2's room but was there looking for her friend (R4), she was not there and R1 said she went back to her room. R1 was asked if she had sex with R2 and she said no. V1 said that she spoke to R2 and he admitted knowing R1, she comes to his room all the time to ask for money, coffee, and cigarette, R1 was in his room yesterday, asked for a cigarette, took off her clothes and laid on his bed and they had sex, R1 did not say no. V1 said that they do not have any resident under the age of 18, so they are all adults and can intermingle. She is aware that R2 and R4 are boyfriend and girlfriend, but she is not aware that R1 had any sexual relationship with R2. V1 added that residents are supposed to be monitored but they also have a right to privacy. The male residents can visit the females so long as the female comes out and walks with them to their room. The females are always monitored by staff, those who have boyfriends and girlfriends are offered condoms. V1 said that residents are screened for abuse and background check is done upon admission, those found to be at risk for abuse are placed under increased monitoring by staff using facility monitoring tool. Surveyor told V1 that the sexual assault of R1 is a concern and she said, Even when she consented? 10/18/2022 at 4:20PM, V1 said that she spoke to R3 who also admitted to having sex with R1, but according to what he said, it was about a week ago and it happened one time. 10/19/2022 at 5:00PM, V11 (Psychiatrist) said that he is familiar with R1, he is not aware of the sexual assault allegation. V11 said that R1 has had a mental history and has been unstable, she has made such allegation in the past but if another resident is saying that it happened, then it is the truth and R1 is not being delusional. V11 said that at this time, R1 is not capable of making such decision of consenting to a sexual relation based on her diagnosis. 10/24/2022 at 1:22PM V14 (Psychiatrist for R3) said that he had a thorough initial assessment on R3, and he does not have the capacity to make decisions, based on his last evaluation, he cannot operate normally, his judgement is impaired, and he does not have the capacity to consent to sexual activity. Per State operational manual at 42-CFR S483.5, sexual abuse section states in part that a resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion, or fear, whether it is expressed by the resident or suspected by staff. The facility provided an acceptable plan of correction on 10/26/22 at 3:15PM. On 10/26/2022 confirms the implementation of the facility's remove plan. The Immediate Jeopardy was removed on 10/26/2022, but noncompliance remains at Level Two until the facility can evaluate the effectiveness of the in-service training. On 10/26/2022 the surveyor confirmed per interview and record review the following removal plan was initiated: R1 has been placed on 1:1 monitoring beginning on 10/16/2022 upon return from the hospital, and continues to be on 1:1 monitoring. (Specific staff assigned to 1:1 only each shift). R1 was provided with emotional counseling for possible emotional harm or physical harm. (PRSD) Counseling continued for 72 hours with Social Services. R1 was assured of safety and free from retaliation from other residents. Daily check-ins continue with Social Services. (10/25/2022) R1 was counseled on appropriate sexual relationships and at-risk behaviors on 10/26/2022 R2 was placed on a 1:1 supervision since 10/15/2022 until discharge on [DATE]. R3 has been placed on a 1:1 on 10/25/2022 Any resident assessed to be at risk for abuse have a potential to be affected. Measures the facility will take or systems to ensure the problems will be corrected and will not recur. -All the residents assessed to be at risk for abuse have been placed on hourly monitoring to prevent alleged sexual coercion. -The facility has developed a tracking sheet for residents that are at risk for abuse to be monitored hourly by their location to prevent alleged sexual coercion. -Facility staff were educated on the tracking sheet for residents that are at risk for abuse to be monitored hourly by their location to prevent alleged sexual coercion. Staff In-services initiated 10/26/22. -The facility conducted a resident meeting conducted by Social Services to educate residents regarding intimacy, safe sex, sexual harassment, sexual coercion etc. 10/25/2022. The PRSD (psychiatric rehabilitation service director) or designees will monitor continued compliance via the following Quality Improvement Programs.

Based on interview and record review, the facility failed to have an effective monitoring or supervision system in place for those resident identified as needing supervising, to alert staff when residents are engaging in appropriate sexual behavior to prevent possible sexual abuse.This failure affected three of four residents (R1, R2 and R3) reviewed for supervision. As a result, R1, R2, and R3 engaged in sexual favors for money and cigarettes, which lead to R1 being sexually assaulted by another resident (R2). Facility staff members were unable to identify when R1 entered R2's room, despite R1 being on hourly monitoring. This was identified as immediate jeopardy situation that began on 10/15/2022 when R1 was sexually assaulted after requesting R2 to stop based on R1 report; she was forced by R2 to have sex, R1 told him to stop but he did not, he held her down, made her perform oral sex on him and penetrated her for 10 to 15 minutes. who was holding her hand down, she told him to stop and pleaded with him not to discharge inside her. V1 (administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on 10/25/22 at 4:00 PM. Findings include: 1. R1 is a [AGE] year-old female who has resided at the facility since March of 2022. R1's medical history includes, but not limited to [CONDITION(S)] disorder [CONDITION(S)] type, unspecified [CONDITION(S)] not due to substance or known physiological condition, drug induced subacute dyskinesia, [CONDITION(S)] [CONDITION(S)], major depressive disorder, and generalized anxiety disorder. Facility Minimum Data Set (MDS) assessment dated [DATE] section G (functional status) coded R1 as requiring supervision for all Activities of Daily Living (ADL), including walking in room, walking in corridor, and locomotion on and off unit. During the investigation on 10/17/2022 at 2:30PM, R1 was interviewed, and she said that she went to R2's room to look for her friend (R4) who always hangs out there, R4 was not there but R2 told R1 that he will tell R4 not to give anything to R1 anymore unless she had sex with him. R2 also offered R1 cigarettes in exchange for sex. R1 admitted to having sex with R2 who was holding her hand down, she pleaded with him to stop and not to discharge inside her. R1 said it happened for a while and she did not tell the staff but reported it at the hospital. R1 asked the surveyor not to tell anyone about it. R1 was also listed as one of the residents to be monitored hourly by the C.N.As and the PRSAs/security. Care plan initiated 3/05/2022 states that resident is at risk for abuse and neglect based on the comprehensive assessment as evidenced by a diagnosis of dementia or mental illness, history/current behavior of physical abuse or threatening physical aggression towards others. Goals include Resident will be treated with respect, dignity and free from mistreatment while residing in the facility. Resident will remain safe and will be free of abuse/neglect through next review. R2 is a [AGE] year-old male who has resided at the facility since 1/23/2022, with past medical history including, but not limited to [CONDITION(S)] disorder, major depressive disorder, psychotic disorder with delusions due to known physiological condition, cocaine abuse, pain in the right foot, etc. R2's MDS assessment dated [DATE] section C (cognitive status) coded R2 with a BIMs score of 15, section G of the same assessment coded R2 as requiring supervision for all ADLs, including bed mobility and ambulation on and off unit. 10/17/2022 at 11:35AM, R2 stated that he had sex with R1, he gave her some cigarettes, this is not the first time, last time he gave her $3.00 in exchange for sex. R3 is a [AGE] year-old-male who have resided at the facility since 8/12/2021, with the following past medical history: Paranoid [CONDITION(S)], [CONDITION(S)] disorder current episode hypomanic, major depressive disorder, unspecified [CONDITION(S)] not due to a substance or known physiological condition, other psychoactive substance abuse uncomplicated, tremor, etc. R3's MDS assessment dated [DATE] scored R3 with a BIMs score of 15, section G (Functional status) coded R3 as requiring supervision for ass ADLs, including locomotion on and off unit. 10/17/2022 at 11:40AM, R3 said that he is familiar with R1 and admitted to having sex with R1 before she had sex with R2. R3 said that this is not the first time, he has had sex with R1 before and he gave her $5.00, this time he did not give her anything. R1's nurse's progress note dated 10/15/2022 at 15:00 states: Resident noted on the floor in room #E7 bathroom floor hyperventilating with her tongue sticking out and not responsive to verbal stimuli at this time. Vital signs done, B/P 138/88, P 115, Room air saturation 99%, resident remain warm to touch and dry. Dr called and informed of resident's change in condition. Respond with order to monitor 1:1 and if condition worsen transfer out as needed. order noted and carried out. All necessary administrative personnel notified. 10/15/2022 at 15:15, nurse's progress note reads: Upon continued monitoring, resident's condition noted to be deteriorating, resident's pulse continued to elevate at an alarming rate. 911 called and resident was transferred out of the facility via stretcher with 911 crew members. Dr notified, ADON and administrator notified. 10/2/2022 at 19:48, nurse's progress notes states: Resident was found in the bathroom breathing heavily and not responding. Resident was noted with change in status. Resident was assisted to a nearby chair where the vitals were taken. Vital sign was BP 159/116. pulse 137. Dr was contacted and Crestwood 911 emergency assistance were contacted. Resident was also found smoking in another resident's room on 10/5/2022 as documented in social service note and care plan. 2. 10/17/2022 at 3:11PM, V3 (PRSD) said that he works with 3 PRSC and three PRSA/security staff. The PRSA are supposed to monitor residents, help with smoking times, and help get residents ready for groups. Residents are also monitored by Certified Nurse Assistants (C.N.As) who are stationed in the hallways. The facility assesses residents for abuse risk upon admission and every three months, those identified to be at risk are monitored using the security sheet every hour. 10/17/2022 at 2:50PM, V5 (C.N.A) said that she worked morning shift on the E wing and was the one who found R1 in a bathroom in the male section of the facility, she called the nurse who came and assessed resident, she was then sent to the hospital for evaluation. V5 said that she did not see R1 entering any room in the E wing, she went on a break and after that she was in the dining room charting, she then went to make round after charting that's when she found R1 unresponsive. V5 said that no one covers or monitors the hallway when the assigned staff take a break, she did not check the rooms after lunch so she cannot say how long the resident has been in the male section. 10/17/2022 at 3:45PM, V7 (Security) said that he was the one monitoring R1 the day of the incident, resident is always walking back and forth, this is the third time R1 was being sent out for similar episode. V7 said that when she was found in the bathroom on the men's side of the building, he helped the nurses transfer resident to the nursing station and was told that she was having an allergic reaction, no one knows how long she was in there. V7 said he was not sure the last time he saw R1, he marks her in the dining room if he does not see her anywhere, resident is always going to the men's wing by herself, she is always looking for her only friend R4 who gives her coffee all the time. 10/18/2022 at 10:00AM, V8 (C.N.A) said that she worked on Saturday 10/15/2022 on the A hall but left about 1:30PM after lunch for an appointment. V8 said that R1 was in the dining room for breakfast, was in her room after breakfast when she made the beds, but she did not see her again between 9:30AM and 12:PM when she was in the dining room charting. V8 said she saw R1 again around 12PM, she left shortly after lunch and told the nurse that she was leaving for the day. V8 said that when they take a break, the C.N.A on the opposite hallway was supposed to cover but no one covers when they are charting in the dining room. 10/18/2022 at 10:24AM, V9 (LPN) aid that she was the assigned nurse to R1 the day she was sent to the hospital, it was close to 3PM, C.N.A reported that resident was found in the bathroom in room E7, the two residents who occupy the room were present and said that they did not know what happened to her. V9 said that the C.N.As on the B wing was supposed to take over when the A wing C.N.A went home, but she added that R1 was probably visiting between the time the C.N.A left which is about 1:30PM and she was found around 3:00PM. V9 said that there are C.N.As on the men's side too who are supposed to be monitoring the residents. 10/17/2022 at 1:27PM, V1 (Administrator) said that all the residents are over [AGE] years, they can visit each other if there is no conflict, they are not supposed to spend a night, they must go back to their rooms. Residents are supposed to be monitored but they also have a right to privacy. 11/19/2022 at 2:00PM, V1 said that she spoke to the clinical team this morning, nurses are to create a care plan for the residents that express the desire to have sex, they are planning on a relationship group and increase monitoring by adding more staff. 10/24/2022 at 3:25PM, V10 (Medical director) said that he is the medical director and a member of the QUAPI team, the facility has residents who are young, they provide them with birth control injection that is given every three months, he is not in control of how that is being maintained. V10 will not answer any questions regarding monitoring residents who are sexually active, stated that the issue has never come up in QUAPI and should be addressed with management or nursing, he is only at the facility 2 days a week, does not know about training or any rules, and regulations, the question should be directed to administration. V10 stated that it is going to be hard and difficult to monitor the residents, they move around, are young and active, there are no locks on the doors. V10 was asked for his advice or recommendation, and he said that he does not know what to advise or recommend. The facility does not have any policy on supervision per V1 (Administrator). A document provided by V1 (Administrator) titled behavior management with an effective date of 3/2021states in the guidelines that mental and psychosocial adjustment difficulties may be experienced by a resident, due to problems adapting to changes in life's circumstances. A resident may have trouble adjusting and therefore demonstrate signs and symptoms of mood distress or behavioral disturbance. Under standards, the document states in part: residents who display mental or psychosocial adjustment difficulty should receive appropriate services, to minimize risks. The facility provided an acceptable plan of correction on 10/26/22 at 3:15PM. On 10/26/2022 confirms the implementation of the facility's remove plan. The Immediate Jeopardy was removed on 10/26/2022, but noncompliance remains at Level Two until the facility can evaluate the effectiveness of the in-service training. On 10/26/2022 the surveyor confirmed per interview and record review the following removal plan was initiated: R1 has been placed on 1:1 monitoring beginning on 10/16/2022 upon return from the hospital, and continues to be on 1:1 monitoring. (Specific staff assigned to 1:1 only each shift). R1 was provided with emotional counseling for possible emotional harm or physical harm. (PRSD) Counseling continued for 72 hours with Social Services. R1 was assured of safety and free from retaliation from other residents. Daily check-ins continue with Social Services. (10/25/2022) R1 was counseled on appropriate sexual relationships and at-risk behaviors on 10/26/2022 R2 was placed on a 1:1 supervision since 10/15/2022 until discharge on [DATE]. R3 has been placed on a 1:1 on 10/25/2022 Any resident assessed to be at risk for abuse have a potential to be affected. Measures the facility will take or systems to ensure the problems will be corrected and will not recur. -All the residents assessed to be at risk for abuse have been placed on hourly monitoring to prevent alleged sexual coercion. -The facility has developed a tracking sheet for residents that are at risk for abuse to be monitored hourly by their location to prevent alleged sexual coercion. -Facility staff were educated on the tracking sheet for residents that are at risk for abuse to be monitored hourly by their location to prevent alleged sexual coercion. Staff In-services initiated 10/26/22. -The facility conducted a resident meeting conducted by Social Services to educate residents regarding intimacy, safe sex, sexual harassment, sexual coercion etc. 10/25/2022. The PRSD (psychiatric rehabilitation service director) or designees will monitor continued compliance via the following Quality Improvement Programs.

Based on interviews and record reviews, the facility failed to follow their Abuse Policy, to affirm the right of their resident to be free from physical abuse. This failure affect one resident (R1) of 3 residents reviewed for Abuse. This failure resulted in R1 getting hit on the head and going to local hospital for skin laceration in forehead with steri-strips. Findings Include: Facility Reported Incident dated 12/13/21 reads in part: Both residents were in involved in physical altercation. R1 attempted to take R2's belongings and when R2 asked R1 to leave, R1 became verbally aggressive resulted in physical engagement. R1 has a laceration (small cut on the head). Conclusion of Investigation: Based on investigation conducted, review of medical records and interview with staff and residents involved, it could be concluded that both residents were involved in the altercation. R1 did go into R2's room. Upon being asked to leave R1 began to argue with R2 and the two ended up in a tugging match both pulling the clothing item at the same time. R1 would not let go, so R2 did take off her (R2) shoe and hit R1. R1 reported that R2 hit R1. R2 admitted that R2 hit R1 with her (R2)shoe because R1 would not let go of R2's shirt and would not leave when asked. R1 remains on increased monitoring. R2 will be placed on increased monitoring upon return from the hospital and will be counseled regarding seeking assistance from staff. R1's record reviewed. R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has a BIMS (Brief Interview for Mental Status) score of 12 (Moderately Impaired). R1's care plan for wandering behavior, and it reads in part: 1.) R1 has a current behavior of going into peers room and staff offices uninvited. With interventions of but not limited to: R1 will be monitored as needed. R1 will participate in structured activities of interest and scheduled groups. R1 will receive 1:1 to discourage current behavior. 2.) R1 has a history of wandering, aggressive, inappropriate, attention-seeking behavior. R1 displayed inappropriate behavior towards staff on 4/22/21. On 6/13/21, R1 was socially inappropriate towards staff and was counseled. With intervention of: Intervene when any inappropriate behavior is observed. Communicate assertively that the R1 must exercise control over impulses and behavior. R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has a BIMS (Brief Interview for Mental Status) score of 12 (Moderately Impaired). Progress note on 12/13/21 at 15:30, reads in part: R1 had a physical altercation with a peer where he received a superficial cut to the right forehead. Order received to transfer resident out via 911. Progress note on 12/14/2021 at 09:19, reads in part: R1 returned with laceration to right side of forehead. R1 had 3 steri-strips (thin adhesive strips used to close small incisions or wounds) applied to site. Order given and for treatment carried out. R2's record reviewed. R2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 has a BIMS score of 15 (Cognitively intact). R2's progress note on 12/13/21 at 17:55, reads in part: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress note on 12/14/2021 at 07:45, reads: Follow up call to hospital, spoke with ER nurse, R2 admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 is care plan for aggressive behavior, reads in part: 1.) R2 displays behavioral symptoms related to severe mental illness. R2 is diagnosed with [CONDITION(S)] disorder and major depression recurrent. The behavioral symptoms are manifested by physical aggression. 2.) R2 displays behavioral symptoms related to severe mental illness. These behavior symptoms are manifested by R2 displaying physical abuse/aggression towards others. 3.) R2 displays socially inappropriate and maladaptive behavior related to: A mental illness diagnosis. R2 has the potential to be aggressive towards peer. 4.) R2 has a history of aggressive behavior and displayed physical aggression towards another peer on 6/9/2021. On 12/28/21 at 11am, interviewed R2 and reported that R2 was sleeping in R2's room and R2 heard a noise. R2 woke up and saw R1 rummaging at R2's cabinet drawers. R2 asked R1 to stop and leave R2's room. Per R2, R1 refused to leave the room and continued to touch R2's belongings. R2 stated R1 always come to my room and other residents' room. I got tired of him going through my stuff and taking my belongings. So I started hiding my shoes close to my bed. I told R1 to leave and R1 refused, so I hit him R1 with my shoe. R1 ran out of my room, bleeding. On 12/28/21 at 1pm, R4 (President of Resident Council) reported that R1 wanders in the facility and at times will take another resident's food off their meal trays. R4 also reported that R1 wanders to other residents' room. R4 is concern that R1's behaviors might end up in physical altercation with other residents. On 12/29/21 at 10:15am, V6 (PRSD) stated R2 has a history of physical aggression towards other residents in the facility. R2 is care plan for those behaviors. On 12/29/21 at 12:30pm, V1 (Administrator) stated R1 goes around the facility sometimes, R1 wanders occasionally. I don't think it is the first time, to my knowledge R1 has done it before. We have CNA on each halls. Somebody should be there watching the unit unless they are assisting other resident. R1 is pretty quick, R1 is ambulatory. V1 also stated that V1 investigated the incident on 12/13/21. Per V1, R2 admitted in hitting R1 with R2's shoe. R1 had a laceration on R1's forehead, and was hospitalized and returned in the facility the next day. R2 remained agitated and was sent out also for evaluation, per doctor's order. R2 was admitted in the local hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated that a CNA may have stepped away for a minute during that particular time, the incident happened in the afternoon during shift change, someone may have stepped out at the time. When it is shift change, it is hard to have someone stationed in the dining room to watch R1 and other residents. Per V1, R2 admitted that R2 hit R1. I did it, I hit R1. R2 has a history of verbal aggression but I can't remember if any physical. R2 was yelling and screaming and acting out verbally, she did not hit anybody else after R1 incident, however the doctor was called and the doctor gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Was in the hospital for a couple of days. R2 returned to the facility much calmer. Abuse Policy reads in part with an effective date of 4/2020: This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation or property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means, Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to monitor a resident after a fall incident, complaints of dizziness and abnormal vital signs for 1 of 3 (R1) residents reviewed for monitoring a change in condition. This failure resulted in R1 having another un-witnessed fall incident and being found unresponsive requiring CPR and subsequently expiring at the facility. Findings include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's fall report dated [DATE] at 13:43 documents under incident description: It was reported to V3 (nurse) that R1 fell in A wing hallway. R1 stated she fell after feeling dizzy. Under immediate action documents: Upon arrival writer noted resident seating on the floor alert and oriented x3. Denies any complaints of pain at this time. Assessment done from head to toe all extremities are equal. R1 assisted up from the floor and back to her room. No injuries. V9 (Nurse), V5 (nurse) and V13 (unit manager) all said on [DATE] around 11pm, they were made aware that R1 was not feeling well. On [DATE] at 4:14PM, V9 (nurse) said he was unable to get R1's blood pressure due to machine malfunctioning. V9 said R1 reported she did not want to blood pressure checked again. On [DATE] at 223PM, V13 (unit manager) said around 11pm she assisted staff with assessing R1. R1's hands were cold and staff took all vitals within normal limits and no further concerns. On [DATE] at V5 (nurse) said she saw R1 shaking like she was cold. V9 was trying to get blood pressure but it was not working. V5 (nurse) reported R1 said she was fine and went back to her room. R1's medical record did not have documentation of event on [DATE] at 1100pm. R1's progress notes dated [DATE] at 300AM document: Nurse was informed that R1 had complaints of shortness of breath, writer (V4 (nurse)) immediately assessed R1. Vital signs Respirations 22, Temperature 96, Heart rate 135 beats per minute, blood pressure ,[DATE], oxygen saturation was 92 % on room air. V4 gave breathing treatment, oxygen 2liters/minutes via nasal cannula. Resident was stabilized. R1 progress note dated [DATE] at 315 document: Staff continue to monitor R1. Oxygen saturation 94% with oxygen treatment. Doctor notified of R1's change in condition order to send R1 to the hospital for evaluation. Writer (V4) called elite ambulance for pick up within 20 minutes. Nurse notified R1 about her status going to the hospital. On [DATE] at 203PM, V4 (nurse) said V6 (CNA) reported R1 was complaining of shortness of breath. R1 was in the dining room. R1's respirations were elevated and oxygen saturations were in the low 90's. R1 was given [MEDICATION NAME] inhaler and oxygen. R1 did not want to use oxygen. R1 said she was feeling better. V4 (nurse) said she left R1 with V6(CNA) and went to call doctor and send to hospital. V4 said CNA's are supposed to stay with residents but unsure if staff took the R1 to her room to rest. V4 (Nurse) said she called private ambulance who stated a 20 minute estimated time of arrival. V4 said she went to R1's room and notified R1 that ambulance would at the facility in 20 minutes to transfer her to hospital. On [DATE] at 419PM, V15 (MD) said normal blood pressure is ,[DATE], normal pulse would be less than 100 and respirations ,[DATE]. R1's documented vital signs (Respirations 22, Temperature 96, Heart rate 135 beats per minute, blood pressure ,[DATE]) would indicate a change in condition requiring immediate intervention and 911 would be the best option unless private ambulance would there within same time frame. R1 should have been monitored by staff while waiting for ambulance due to possibility of experiencing a further change in condition. R1 would be at higher risk for falls due to low blood pressure. On [DATE] at 937AM, V2 (DON) said normal vital signs for blood pressure would be ,[DATE]. Systolic below 100 and diastolic under 60 would be considered low. Normal pulse ,[DATE]. V2 said R1 should have been sent out 911 with documented vital signs because 911 is faster and able to deliver care faster for resident. R1 would be at higher risk for falls or further change in condition and should have been monitored by staff while waiting for ambulance. On [DATE] at 301pm, V6 (CNA) said no one instructed her to stay with R1. V6 said she went on her break after informing nurses about R1's concern around 300AM. R1's Medication Administration Record [REDACTED]. R1 progress note dated [DATE] at 325AM by V4 (nurse) document: While Nurse and CNA was on the way to R1's room, saw roommate in the hallway and stated R1 was in the floor in the bathroom. Nurse immediately ran into R1's room noted R1 was unresponsive CPR was initiated immediately. Code was called. 911 was called. On [DATE] at 1130am, R2 (R1's roommate) said around 1030 pm she heard R1 breathing funny and told her to go to the nurse but was unsure if she did. R2 does not recall hearing or seeing anything until around 340am she heard staff tell R1 the ambulance would be here in 20 minutes. R1 was in her bed sleeping at that time. She heard R1 get up and go to the bathroom turn on the water. Shortly after she heard a loud noise and saw R1 on the ground in the bathroom. R2 said she went to get the nurse and saw staff in dining room and reported R1 was on the floor and staff came to assist R1. Private ambulance run sheet documents received call on [DATE] at 3:22AM, enroute 3:27AM at patient at 352AM. Call was received by dispatch while 10 minutes away from scene reporting the facility called sounding frantic and wondering how much longer until crew arrived. Crew notified dispatch it would be 10 minutes till arrival and dispatch notified facility. The facility acknowledged the ETA. When crew arrived to the scene local police department was on the scene, but no local fire department. Ems went to the back of the ambulance to get stretcher, a staff member from the facility came to the door and tried to rush crew into the facility stating this is an emergency. When crew asked why local police on scene, they responded the patient is not doing well. Upon arrival to patient room, staff observed in hallway and when the nurse saw crew coming went into the crash cart, got ambu bag and went into the patient's room. When crew entered room, local police officer was performing CPR on the patient in bathroom. Crew asked the police officer how long he had been performing CPR and he stated 10- 15 minutes. The nurse was getting the ambu bag and started ventilations for the patient. Patient downtime unknown per the nurse because they did not find the patient themselves but the roommate found the patient. Local police report documents dated [DATE] at 342AM dispatched to facility for unresponsive female. Police officer documented he took over CPR and local Emergency service arrived but unable to revive R1 and pronounced deceased at 411AM. Report documents report given by V4 (nurse) to local police as follows: R1 was not feeling well around 130AM and 200AM on [DATE]. V4 said she took her vital and they were low. V4 contacted local ambulance to transport to hospital. After speaking to Ambulance Company she told R1 to get a bag ready to go to the hospital. V4 then left R1 in her room to gather her belongings. V4 said a short time later R2 told the nursing staff at front desk that R1 had fallen in the bathroom. R1 progress note dated [DATE] at 411 document: staff continued CPR on R1 while paramedics arrived and took over the compression from the nurses. R1 was pronounced dead at 411 AM. Doctor and family notified. On [DATE] at 430 PM, V1 (Administrator) said there was no incident report for R1 for [DATE]. Facility fall policy dated ,[DATE] documents if 911 emergency intervention is indicated: call ambulance, notify family, have staff member stay with resident and continue to monitor condition; complete transfer documents. Facility change of condition policy dated ,[DATE] documents under guideline to keep the physician who is in charge of medical care, responsible party, responsible for health care decisions, informed of the residents medical condition so they may direct the plan of care as needed. Under procedure documents determining when to call, evaluate situation and determine it is an emergency, medical situation or non-emergency situation. If death or emergency is a trigger event; send resident to the hospital, then contact the physician.

Based on interview and record review, the facility failed to follow their abuse policy by not preventing the physical assault of one of four residents (R1) reviewed for physical abuse. This failure resulted in R1 being physically assaulted by R2. R1 was transferred to the local hospital and treated for [REDACTED]. Findings include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility final investigation dated 9/25/20 documents a resident to resident altercation on 9/17/20 at 1200am in dining room. R1 reported she was pushed by R2. R1 sustained a cut to back of her head and sent to local hospital. R2 was taken by local police. Based on the investigation conducted review of medical records and interview of staff and residents involved, it can be concluded that R2 pushed R1. R1 fell as a result of the push. It can be concluded that R2 did not have any willful intent of causing harm or physical abuse to R1. R2 appeared to be exhibiting behaviors related to his diagnosis. V12 (CNA) statement documents she saw R2 go straight to R1 in the dining room and started beating her and pushed her on the floor and hit her head on the floor then there was blood all over the floor. V5 (social service aide/security) statement documents R1 was on the floor and said R2 pushed her. R2 was coming out of (A) wing and said he didn't know what happened. Then he came back and kicked R1 and he kept kicking and punching R1. V8 (nurse) statement documents R1 was attacked, beaten and pushed down by another pacing /agitated Resident. R1 sustained an injury to back of her head and blood was noted gushing out from injured area. R1's care plan dated 1/13/07 documents R1 is at risk for abuse and neglect based on comprehensive assessment. R1 has behavior or using racial slurs, verbally aggressive, making demeaning and offensive comments. Interventions in place initiated 1/13/07 are as followed assure R1 that she is in safe and secure environment with caring professionals. Explain psychosocial adjustment is often facilitated by developing a trusting relationship with another person and verbalizing thoughts, needs and feeling. Counsel R1 on the importance of appropriate behaviors and encourage to utilize appropriate coping techniques; establish guidelines regarding visiting if persons interested in visiting have a history of inappropriate and maladaptive behavior towards R1. Provide supervision during visits, as necessary. Local police incident report dated 9/17/20 documents call related to a battery complaint. R2 said he kicked R1. R2 related he did not know R1 and R1 did nothing to upset him. R2 was detained. V12 (CNA) reported she was in the C wing when she heard a man screaming. V12 said she exited the room and observed R2 running and screaming down the hallway. V12 said she followed behind R2 and observed him enter the dayroom at which time he ran up to R1 pushed her to the ground and began kicking and punching her while she was on the ground. V5 (social service aide/security) said he entered the day room and observed R2 kicking R1. V5 was able to get R2 to walk away from R1 and then R2 spun away from him and ran back to R1 and began kicking R1 again. Unable to speak to R1 due to hysterical condition. On 9/25/20 at 9:47AM, R1 said she was going to get something from vending machine that night and said that R2 just attacked her. R1 said R2 threw her to the ground and she had to get stitches to back of her head, five or six broken ribs and one punctured her lungs. R1 reports being in pain a lot. R1 said she was scared and afraid of getting hit again. R1 said she was afraid for her life if she went back to nursing home. R1's local hospital records dated 9/17/20 document R1 from local nursing home after being pushed by another resident. R1 fell and hit her head and has laceration to the back of her head. Laceration length of 3 cm with depth of 6mm that required 6 staples. CT of chest on 9/17/20 documents acute fractures involving the right third rib, right posterolateral fourth, fifth and sixth rib. Acute right posterior tenth and eleventh rib fracture. Right sided pneumothorax. Facility abuse prevention program policy dated 2/7/2017 documents, the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behaviors.

Based on interview and record review the facility failed to develop a plan of care with effective interventions to monitor/supervise a resident with a history of aggressive behaviors to reduce the risk of peer to peer physical assault affecting 2 of 5 residents (R2/R1) reviewed for supervising aggressive behavior. This failure resulted in R2 physically assaulting R1 causing R1 a right sided pneumothorax, broken ribs and a laceration requiring (6) staples at the local hospital. The facility also failed to develop a plan with interventions to prevent or reduce the risk of fire setting for a resident with known history of setting fire for 1 of 3 residents (R3) reviewed for supervision. This failure resulted in R3 setting a pile of clothing in R3's room on fire. Based on interview and record review the facility failed to develop a plan to prevent a resident with history of poly substance abuse from obtaining unknown prescription medication from outside of the facility. This failure affected 1 of 3 residents (R5) reviewed for supervison. Findings include: R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's progress notes document on 2/7/20 R2 was throwing chairs in common dining room. R2 started throwing punches and hit one staff to left side of her head. R2's progress notes document on 2/23/20 R2 hit another resident in the arm and sent to local hospital. R2's progress note dated 3/13/20 document R2 becoming aggressive with another peer (R11) and sent to local hospital. Facility abuse reportable dated 3/20/20 document R11 said R2 pushed her. Staff reported R2 becoming agitated and standing up out of his chair and pushing R11. R2's progress note dated 6/15/20 document R2 was physically aggressive toward staff and damaging facility property. R2's progress note dated 9/17/20 document R2 was running in dining room and agitated. R1 was on the floor attacked, pushed down and beaten. R2's care plan focus documents: The resident has history of aggressive behavior and has exhibited verbally/physically abusive behavior related/manifested by: Being challenged by mental illness, ineffective coping mechanisms, physically abusive behavior when agitated, poor verbal skills and inability to express self in more appropriate language. Resident was physically aggressive towards staff and peers on 2/10/2020. R2 attempted physical aggression towards staff on 02/19/2020. Resident was physically aggressive towards a peer on 2/23/2020. Resident was physically aggressive to female peer on 9/18/20. The following intervention all initiated 1/27/20 document the following: Assist in identifying coping skills for anger control; Avoid getting in power struggle with resident; Encourage verbalization of concern and make clarifications if needed; Explain the rules of Conduct to the resident and importance to treat others with respect; Intervene by speaking in a calm and professional soft tone of voice; Utilize the use of behavior contract if needed; Utilize the use of Non Violent Crisis Intervention as a last resort. On 9/25/20 at 1:15 PM, V4 (social service director) said R2 care plans should be updated after each behavioral incident. R2 required monitoring but unable to locate interventions related to monitoring in plan of care. V4 unable to locate any updates to R2's care plan or able to explain how interventions listed were effective. Facility final investigation dated 9/25/20 documents a resident to resident altercation on 9/17/20 at 1200 am in dining room. R1 reported she was pushed by R2. R1 sustained a cut to back of her head and sent to local hospital. R2 was taken by local police. Based on the investigation conducted review of medical records and interview of staff and residents involved, it can be concluded that R2 pushed R1. R1 fell as a result of the push. It can be concluded that R2 did not have any willful intent of causing harm or physical abuse to R1. R2 appeared to be exhibiting behaviors related to his diagnosis. V12 (CNA) statement documents she saw R2 go straight to R1 in the dining room and started beating her and pushed her on the floor and hit her head on the floor then there was blood all over the floor. V5 (social service aide/security) statement documents R1 was on the floor and said R2 pushed her. R2 was coming out of A wing and said he didn't know what happened. Then he came back and kicked R1 and he kept kicking and punching R1. V8 (nurse) statement documents R1 was attacked, beaten and pushed down by another pacing /agitated Resident. R1 sustained an injury to back of her head and blood was noted gushing out from injured area. R3 was admitted to facility on 6/3/2020 with a [DIAGNOSES REDACTED]. R3's Preadmission screening and Resident review Passar dated 6/15/20 documents under behavior type fire setting and arson; behavior level- high; 6/2019 burned bible under a porch. R3's Pre admission paperwork dated 5/28/20 documents, In regards to one to one constant supervision: patient stated I don't need anyone to watch me all day. If I am about to hurt myself or anyone, I'll let the nurse know right away. Monitor patient closely every 15 minutes. Facility reportable dated 8/14/20 documents R3 was upset with co-peer because she would not let her use her phone, so she reportedly took a lighter during smoking time, then went into the room and set some clothes on fire. Resident reported that her roommate was not in the room at that time. Code initiated. Resident was placed on one to one monitoring until ambulance arrived. R3 was given an emergency discharge upon leaving the facility. On 9/25/20 at 1:15 PM, V4 (social service director) said he was not aware of R3's history with fire and there should have been a plan of care in place to ensure we are able to meet the needs and ensure they are monitored. V4 said he was not made aware of R3's PASARR was in medical record. V4 said residents rooms are searched weekly if not daily by staff. If resident has history of unsafe smoking or behaviors we would do more room searches. On 9/25/20 at 3:53Pm, V1 (administrator) said she was not aware of R3's PASARR or preadmission paper work prior to admission. R3's plan of care does not document any interventions related to fire/smoking safety. R3's smoking safety risk assessment signed 6/5/20 documents a score of one indicating may be independent with smoking. Facility smoking safety policy revised 12-2018 documents, it is against facility policy to carry a lighter. Facility is match free facility. staff are available to light cigarettes for residents during designated smoking times. R5 was admitted with the [DIAGNOSES REDACTED]. R5's brief interview for mental status dated 7/2/2020 document a fifteen which indicates cognitive intact. On 9/23/2020 at 1:50pm, R5 said, I went to an outside substance abuse group. My drug of choice is opioids. I asked V35 (Housekeeper) to get my medication from an outside pharmacy. I gave him my information and it was free to pick up. On 9/24/2020 at 12:21pm, V1 (Administrator) said, V34 (Activity Director) found a bag of medication in the activity room. She brought the bag to me. The medication was inside of a burger king bag. The V35 (Housekeeper) had the bag. V35 went to lunch an sat the bag down in the activity room. It was a clear bag, with a burger king bag and inside of the burger king bag were prescription bags with medication inside. V1 reported that V35 said, R5 asked him to pick up the medication as a favor. V1 said, V35 said, I thought it was ok to help the resident. I went to the pharmacy, gave them the residents name, got the medication and then got my lunch. I put the medication in my food bag. V35 left the building before I could complete the investigation. V35 was terminated for failing to return to work. On 9/24/2020 at 1:19pm, V4 (Social Service Director) said, staff was bringing R5 medication from an outside pharmacy. Staff brought the medication in the building inside a burger king bag. The facility doctors did not prescribe the medication. We did a room search and found some pills in R5's room. We discharged R5 to the hospital for a psychiatric evaluation. On 9/24/2020 at 2:22pm, V2 (Director of Nursing) said, we do not prescribe medication to treat opioid drug addiction. We don't have a license. The nurse practitioner at an outside group prescribed R5 the medication to treat opioid addiction. R5 should have not had the script. On 9/25/2020 at 3:03pm, V31 (Restorative Adie) said, we did a room search for R5. We found white loose pills in a bag in a sandwich bag. The bag was half full. On 9/25/2020 at 3:30pm, V32 (Psychiatrist) said, the facility was concerned that R5 was getting a medication to treat opioid drug addiction from an outside source. R5 had a prescription from a doctor that did not work with the facility. R5 had three or four brown bags full of different medication. The medication to treat opioid drug addiction was included in those bags, it was a controlled substance. The medication was confiscated. On 9/28/2020 at 10:31am, V33 (Medical Doctor) said, R5 has a psychiatrist. R5 was discharged to the hospital for a drug overdose. R5 had medication that was old. I don't know where she got the medication from. I did not prescribe the medication for opioid addiction nor was I aware of it. R5's Petition for Involuntary/Judicial admitted d 9/10/2020 documents: R5 has a lot of medication in room while a room sweep was being performed. Facility Inventory for Control Drugs date 9/11/2020 documents: R5 had one hundred and ten pills of medication for depression.

Based on observation, interview and record review, the facility failed to ensure adequate supervision for one resident (R1) in a total sample of 6 residents (R3-R7) during a facility outing to the local convenience store. This failure led to R1 purchasing an uncased razor blade and inflicting self harm upon returning to the facility. Findings include: R1's initial psychiatric evaluation denotes: R1 is a [AGE] year old female admitted to the facility on [DATE] with a history of; suicidal ideation, self harm, depression, bipolar disorder, hallucinations, and insomnia. On 2/9/2015, at approximately 3:00 pm, E5 (Activity Director) and E6 (Activity aide) drove R1, R3, R4, R5, R6, and R7, to the local convenience store to pick up personal belongings. During this facility outing, R1 purchased an uncased razor blade, returned to the facility, and inflicted self harm. R1s inflicted self-harm resulted in an approximate six inch laceration to the left wrist that required six sutures. In addition, R1 was admitted to the local hospital for a psychiatric evaluation and was readmitted to the facility on [DATE]. On 2/20/2015 at 10:00 AM, a dry and intact dressing was observed to R1's left wrist. R1 voiced feelings of suicidal ideation and feeling down on 2/9/2015. When R1 was asked where she got a razor blade, R1 replied that she purchased razor blades during a facility outing. R1 stated that while in the convenience store, E5 and E6 remained in the facility's van while R1 and R3-R6 shopped for personal items. R1 stated that the facility failed to search her bags upon re-entering the facility. R1 further stated that upon returning to her assigned room, the voices told her to kill herself. R1 stated she then took the razor blade and cut her left wrist. R1 further stated that she remained in her bed for four hours. R1 stated that the staff did not make rounds, so she walked up to the nurses' station to tell E9 (License Practical Nurse) about the self inflicted laceration to the left wrist. R1 was transported to the local hospital where she received six sutures to the left wrist and was admitted for a psychiatric evaluation. On 2/20/2015 at 10:13 AM, E4 (Psychiatric Rehabilitation Service Counselor) stated that R1 had a history of [REDACTED]. E4 stated that on 2/4/2015, during the quarterly resident assessment, R1 was feeling unhappy and was thinking about the past, but did not voice thoughts of self harm. E4 further stated, based on R1's admission packet, R1 should be monitored every thirty minutes. When E4 was asked if R1 was reassessed for suicidal ideation and thoughts of self harm prior to the facility outing on 2/9/2015, E4 replied, no we did not assess her that day. E4 was also asked what steps the staff should take when accompanying a resident to a convenience store. E4 replied that the staff should go to each aisle with the residents to ensure their safety and to observe what the resident is planning to buy. E4 stated that R1 should have been closely supervised during the outing. On 2/20/2015 at 11:01 AM, E5 (Activity Director) was asked about the facility's policy when accompanying residents on facility outings. E5 stated, "we don't have a policy but we know we have to monitor what the residents purchase...I stand at the register to watch what is being scanned to monitor what is being purchased by each resident." E5 stated that R1 purchased snacks and must have stolen the razors. E5 was asked if each resident was accompanied to each aisle, E5 replied no. E5 was also asked if the activity staff was aware that R1 had a history of [REDACTED]. E5 replied, "I was not aware that the resident had a history of [REDACTED]. On 2/20/2015 at 11:20 AM, E6 (Activity Aide) stated while the residents are shopping, "we stand by the door, then we go up to the register to see what they buy...I did not see any razors...I don't know exactly what the resident had but I didn't see a razor." E6 further stated that the activity staff was not aware of R1's suicidal ideation or past self harm. E5 stated if the activity staff had been aware of the R1's history, the staff would have paid closer attention to R1 during the facility's outing. On 2/9/2015 at 12:19 pm, E2 (Director of Nursing) stated, "Before residents are allowed to go on a facility outing, the list of residents is reviewed by the social services department, to determine if anyone on the list has had any negative behaviors." When E2 was asked who notifies the activity staff about the resident's past and current behaviors, E2 replied, "There is no way for us to let all the staff know all the [DIAGNOSES REDACTED]." E4 further stated that the facility did not have a resident outing policy in place. In addition, E4 stated that all bags are checked by social services upon the resident's return to the facility. On 2/20/2015, 12:45 PM, E3 (Psychiatric Rehabilitation Service Director), was asked if there was a facility policy regarding resident outings. E3 stated that the facility did not have a policy in place related to resident outings. E3 stated that before a resident is allowed to go out on pass, or on a facility outing, the resident must display stable behavior. E3 states that stable behavior means the resident must display positive behavior such as no altercations with peers or staff, and no signs of depression. When E3 was asked if it was the facility's policy to check resident's bags upon returning from an outing, E3 replied yes. E3 further stated that all bags are checked when a resident returns from a community outing to ensure safety of the staff and other residents. E3 also stated that R1 should have been closely monitored by the activity staff. On 2/20/2015 at 3:24 PM, E9 (License Practical Nurse) stated that while standing at the nurses' station, R1 approached the nurses' station and stated, " I cut myself." E9 stated, "I saw a big cut, it was not bleeding at the time, but then it started to bleed a lot." E9 was also asked about the facility policy in regards to the monitoring of residents with a history of suicidal ideation and self harm. E9 stated that all residents are monitored every two hours. When E4 was asked did the two hour monitoring policy pertain to residents with a history of suicidal ideation and self harm, E9 stated yes. E9 also stated that the staff was not aware that R1 had a history of [REDACTED]. On 2/20/2015, at 3:30 PM, E1 (Administrator) stated that the facility did not have a resident outing policy in place. E1 also stated, "We go with safety before a resident is allowed to go out; we make sure there are no negative behaviors within the past few days. The employees are supposed to go aisle to aisle with each resident. The employees have to stay with the residents the entire time. This is a part of monitoring the residents. We also check bags when the residents return from the outing." On 2/24/2015, at approximately 12: 05 PM, R4 stated that on 2/9/2015, E5 stayed in the car while some of the residents went into the local convenience store. R4 also stated that E6 went in the convenience store but stayed at the front door. R4 further stated that the facility does not always check bags when the residents return from a facility outing. R1's initial suicidal self-harm assessment dated , 11/1/2014 denotes: Mood: Related signs triggered as feelings of hopelessness, sad expressions, and sad voice and tearful. Behavioral: Disturbance History of suicide attempts and or ideations, demonstrates agitation and or restlessness. Physical signs: Self-destructive behaviors, lack of energy; fatigues easily, Ideal disturbances: Poor self-esteem, self-blame, fatigues easily. The recommendation and outcome for this assessment denotes, please explain any signs and symptoms of suicidal ideation that may need to be addressed in the plan of care and explain any recommendations to be made for the interdisciplinary team to assist in determining an appropriate level of monitoring based on assessment. Resident states pass attempt. Resident is at risk for suicide. This assessment was completed by E4. R1's suicidal self harm assessment dated [DATE] denotes: Mood: The resident has sad expressions, feelings of hopelessness; Behavioral: History of social attempts and or ideations. The recommendations and outcome for this assessment denotes: please explain any signs and symptoms of suicidal ideation that may need to be addressed in the plan of care and explain any recommendations to be made for the Interdisciplinary team to assist in determining appropriate level of monitoring based on assessment. Staff will check resident every 30 minutes for 72 hours. E4 completed this assessment. The Criminal Analysis report dated 11/7/2014 denotes: Moderate Risk - The resident has mental illness and substance abuse. The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that assessments should ascertain whether the level of supervision is sufficient. The document was signed by two clinical psychologists. R1 has displayed suicidal ideation since returning from the facility. On 2/22/2015, the resident voiced feelings of self-harm. The resident was transported to a local hospital. However, the resident was not admitted . There is still no order to closely monitor the resident. R1's initial care plan dated 11/6/2014 was reviewed. R1's care plan did not document the need for close supervision. R1's care plan documents daily supervision. The facility did not provide adequate evidence to show that R1 is being closely monitored every 15minutes, every 30 minutes, or every hour as stated by E3 and E4. R1's updated care plan dated 2/14/2015, denotes, R1 is to be monitored every 30 minutes for 72 hours. R1's care plan did not specify supervision past the 72 hours. The facility's undated policy titled "Searching of Residents/Visitors Belongings" denotes: searches of the residents and their belongings may take place upon admission as well as in resident rooms, of resident belongings, of items resident may bring into the facility after admission, or items on the person of the resident (e.g. pockets, cuffs of clothing, etc.). The facility failed to provide a policy related to the supervising of residents that have a history of suicidal ideation or self harm. In addition, there is no policy in place specifying the role of staff when accompanying residents on facility outings.

Based on observations, interview and record review the facility neglected to develop and implement a bathing policy to protect at risk residents of [MEDICAL CONDITION] 1 of 11 residents (R4) reviewed for bathing assistance. This failure resulted in R4 receiving first and second [MEDICAL CONDITION] her lower extremities that required admission to the hospital for treament. Findings Include: R4 is a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R4 was observed on 2-7-14 in the hospital in bed, non-verbal and had multiple dressing covering multiple wound sites. R4 is non-verbal, moaning and unable to move her lower extremities. R4 has a gastric tube feeding infusing with many large blisters on the entire back side of her body. These are fluid filled blisters on top of reddened excoriated areas on her skin. The large fluids filled blisters vary in size on her lower back, both hips, both posterior thighs, ankles and both feet. Some of the fluid filled blisters were draining and others were intact with fluid that was visual with thick clear skin holding the fluid inside of the capsulated blisters. R4 was connected to a pain medication pump which delivered her pain medication to control the pain from the burns. R4 was lying in bed with disposable dressing which has copious amount of drainage ranging from clear to red in color. R4's hospital history and physical dated 2-4-14 notes R4 is a [AGE] year old white female, very confused, disoriented, demented, and unable to give any adequate or satisfactory medical information. Admitting [DIAGNOSES REDACTED]. There are 22 to 24% [MEDICAL CONDITION] lower extremities, lower back and buttock. On 2-7-13 at 9:48AM an interview with Z1 (Physician) indicates R4 is a [AGE] year old female admitted to the emergency room and after examination from the emergency room physician the [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] on 20 to 24 percent of lower extremities. The degrees [MEDICAL CONDITION] 16 percent first degree and 8 percent second degree burns. This incident happen in the tub. R4 was in the tub for care and the water was not hot to immediately burn, but for the elderly if left in the water any period of time unsupervised could cause harm. R4 was left in water for an extended period of time which is consisted with the [DIAGNOSES REDACTED]. R4 is an elderly person who has less/decrease adipose tissue (which is the norm for the elderly), is up in age at 92, skin is very thin and the length of time in the water caused [MEDICAL CONDITION] different degrees. The facility's camera video shows the following: on 2-4-14 at 2:38PM E3 (certified nurse aide) leaving R4's room after placing R4 in the tub. The video displayed E3 working in other rooms in the hallway with linen. At 2:56pm the video displayed E3 returning to R4's room where R4 was still in the tub of water where E3 left her since 2:38pm. E6 (Social Service Director) confirmed on 2-7-14 no one was supervising R4 while in the tub for 18 minutes. Review of the facility's policy "Bathtub or Shower" dated 01-2013 notes the procedures for using hydrotherapy type tubs and manufacturer's instructions, not for regular tubs in the bathroom. Review of the facility's "Abuse Prevention Program" dated December, 2013 notes: Resident Assessment: As part of the resident social history evaluation of the Minimum Data Set (MDS) assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, mistreatment or misappropriation or resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. R4's Minimum Data Set ((MDS) dated [DATE] notes the following assessments: R4's ability is limited to making concrete request responds adequately to simple, direct communications only. R4 is significant risk for physical illness or injury. R4 is at a level 8, unable to ambulate, extensive assistance with eating, transferring, personal hygiene and dressing and toileting is total assistance is required. R4's care plan dated 12-21-13 assessments notes the following: R4 has cognitive deficits and poor decision making skills while leads to her having memory issues, R4 is at risk of abuse, due to her mental illness that make her vulnerable , R4 is noted to have limitation in range of motions related to generalized weakness, R4 requires assistance from staff in areas of personal grooming related to impaired cognitions, R4 is minimally involved in the life of the facility and demonstrates limited social interactions related to mental illness, disorientation, memory deficits and compromised decision-making. E1 (Director of Nursing) and E5 (Administrator) on 2-19-14 had no comments but to say they can in-service there staff about the assessment done to manage and care for the residents to prevent harm.

Based on observations, record reviews and interview the facility failed to monitor and provide supervision for 1 of 5 resident (R4) all reviewed for bathing assistance. R4 required supervision and assistance with bathing was left in a tub of water that the temperature was uncontrolled for 18 minutes without supervision, this failure resulted in R4 recieving first and second degree burns on her lower extremities and being admitted to hospital for treatment. Findings Include: R4 is a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R4 was observed on 2-7-14 in the hospital in bed, non-verbal and had multiple dressing covering multiple wound sites. R4 is non-verbal, moaning and unable to move her lower extremities. R4 has a gastric tube feeding infusing with many large blisters on the entire back side of her body. These are fluid filled blisters on top of reddened excoriated areas on her skin. The large fluids filled blisters vary in size on her lower back, both hips, both posterior thighs, ankles and both feet. Some of the fluids fill blisters were draining and others were intact with fluid that is visual with thick clear skin holding the fluids inside of the capsulated blisters. R4 was connected to a pain medication pump which delivered her pain medication to control the pain from the burns. R4 was lying in bed with disposable dressing which has copious amount of drainage ranging from clear to red in color. R4's hospital history and physical dated 2-4-14 notes R4 is a [AGE] year old whit female, very confused, disoriented, demented, unable to give any adequate or satisfactory medical information. Admitting [DIAGNOSES REDACTED]. Z1 (Attending Physician) confirmed on 2-7-13 at 9:48AM, R4 is a [AGE] year old female admitted to the emergency room and after examination from the emergency room physician the [DIAGNOSES REDACTED]. The thermo burns are on 20 to 24 percent of lower extremities. The degrees of burns are 16 percent first degree and 8 percent second degree burns. This incident happen in the tub. R4 was in the tub for care and the water was not hot to immediately burn, but for the elderly if left in the water any period of time unsupervised could cause harm. R4 was left in water for an extended period of time which is consisted with the [DIAGNOSES REDACTED]. The facility's camera video shows the following: on 2-4-14 at 2:38PM E3 (certified nurse aide) leaving R4's room after placing R4 in the tub. The video displayed E3 working in other rooms in the hallway with linen. At 2:56pm the video displayed E3 returning to R4's room where R4 was still in the tub of water where E3 left her since 2:38pm. E6 (Social Service Director) confirms that at 2:31PM E8 (nurse) doing rounds and informed E3 (nurse aide) that R4 is soiled. At 2:38PM E3 went room and E3 was observed in and out of room changing linen. At 2:56PM E3 and E8 entered the room. E6 stated that R4 was in the room in the tub 18 to 25 minutes unsupervised. E8 confirmed on 2-7-14 at 10:30AM in the conference room, that once E3 came to her help her get R4 out of the tub she went immediately, without delay. R4's Minimum (MDS) data set [DATE] notes the following assessments: R4's ability is limited to making concrete request responds adequately to simple, direct communications only. R4 is significant risk for physical illness or injury. R4 is at a level 8, unable to ambulate, extensive assistance with eating, transferring, personal hygiene and dressing and toileting is total assistance is required. R4's care plan dated 12-21-13 assessments notes the following: R4 has cognitive deficits and poor decision making skill while leads to her having memory issues, R4 is at risk of abuse, due to her mental illness that make her vulnerable , R4 is noted to have limitation in range of motions related to generalized weakness, R4 requires assistance from staff in areas of personal grooming related to impaired cognitions, R4 is minimally involved in the life of the facility and demonstrates limited social interactions related to mental illness, disorientation, memory deficits and compromised decision-making. E1 (Director of Nursing) identified and documented 11 residents that are [AGE] years and older who are totally dependent with all activities of daily living. E1 has no comments about any working policies implemented related to supervision to residents who are unable to speak and or ambulate or move to remove them from the tub. E1 gave no comments that R4 was assessed as requiring assistance with activities of daily living and the nursing and medical assessments were not followed. E1 had no comments the facility ' s camera showed that R4 was left unattended and unsupervised for 18 minutes in a tub of water with no known temperatures.

Based on interview and record review, the facility failed to follow their policies on wound care and injury prevention for 2 residents (R1 and R3) in a sample of 11. This neglect resulted in surgical debridement of R1's pressure ulcer for necrosis with infection including [MEDICAL CONDITION] and neglected to provide adequate supervision for falls and self-injurious behaviors (head banging) for R3. The facility failed to have a system in place to assess/implement/intervene and monitor for effective interventions for self injurious behaviors and falls for R3. The facility also failed to seek an evaluation of injuries from falls (hitting head) and head banging. This neglect resulted in R3 being hospitalized for [REDACTED]. Findings include: 1. According to the Admission Record, R1 was admitted to the facility on [DATE] with diagnoses, in part, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. The only wound reported on admission to the facility was an open area on her right ankle. Wound Reports dated 11/7/12 identify R1 as developing a left buttock wound on 10/28/13 that was first identified as a boil. Laboratory results reviewed dated 2/21/13 document a Low [MEDICATION NAME] of 3.0 (Normal 3.4-4.8) and a low Total Protein of 2.8 (Normal 5.6-8.3) on 3/22/13. R1's physician's orders [REDACTED]. The Care Plan dated 1/16/13 identifies R1's left buttock wound as a boil with interventions including Provide wound care, Document wound care, status, healing process in accordance with facility protocol, and assess/review nutritional needs among others. According to weekly documentation entitled Other Skin Condition Weekly Status Report/Pressure Ulcer Reports and/or Other Skin Condition Report, documentation of R1's left buttock wound from 3/6/13 thru 5/1/13 were incomplete, not thorough, in conflict with one another and/or were inaccurate as to staging. This failure resulted in decline in R1's coccyx pressure ulcer that resulted in surgical debridement on 5/11/13 when the facility failed to accurately identify infection including [MEDICAL CONDITION] and necrosis , and neglecting to take action until R1 required surgery. The Other Skin Condition Weekly Status Report dated 4/17/13 documents R1's left buttock wound measurements as 1.8 x 1.6 treated with [MEDICATION NAME] but includes no other documentation as to the status/characteristics of the wound and/or status of the wound bed. The next week, 4/24/13 report documents R1's left buttock wound as twice the size being 2 1/2 x 3, again with no other assessment information being documented. On 5/1/13, R1's left buttock wound is documented as being as "degenerated" with measurements 2.5 x 3cm and "E" for depth on the weekly skin notes. The nurse assessing R1's left buttock wound neglected to include characteristics, odor, exudate, signs and symptops (s/s) of infection and or pain symptoms if present. The treatment of [REDACTED]. On 5/3/13, the POS documents the treatment being changed to cleansing the wound with Sea Clens then applying Santyl (a debridement ointment) daily. The Treatment Administration Record (TAR) for May 2013 documents no initials for treatment being done on 5/5/13 or 5/6/13. The TAR also documents that both the old treatment and the new treatment is initialed as being done on 5/7/13 and 5/8/13. On 5/8/13, the left buttocks is documented on a Pressure Ulcer Report sheet as a facility acquired, stage III, wound type "P" (pressure ulcer), measuring 2.5 x 5cm with 1/4 cm depth, slough and eschar noted with deterioration of the wound identified. There is no reference to infection including odor and/or peri-wound status including pain. Z1, Physician, documented as being notified on the Weekly note and an order to send to the hospital for evaluation and possible debridement is obtained. There is no Physician's note regarding this order and no entry into the nurses notes further explaining why R1's wound needed to be evaluated for debridement. The nurses notes dated 5/1/13 through 5/9/13 reflect only three entries regarding R1's pressure ulcers. The first is written by the Registered Dietician dated 5/6/13 in which the dietician refers to the wound as a pressure ulcer. The other two nurses notes reflecting the pressure ulcers are dated 5/9/13: 7:19am - documents "resident is to be transferred today" to area hospital for "possible debridement of left buttocks. Daughter notified" and at 14:47 (2:47pm), "resident is schedule to go to" hospital for "evaluation on 5/10/13." There is no further documentation on wound status, pain and/or signs/symptoms of infection. The Hospital History and Physical dated 5/11/13 obtained on 6/13/13 document that R1 was "admitted to the hospital through the emergency room because of signs and symptoms and findings consistent with the [DIAGNOSES REDACTED]. The patient has swelling and redness and obvious infection on the left side with development of pressure sore which needed to be debrided surgically." The Emergency Department note dated 5/10/13 at 11:12am documents patient with c/o (complaints of) fever now resolved. "Per EMS, pt had temp (temperature) at NH (Nursing home). NH stated they did not take temp but rather pt felt hot to touch. Pt was given Tylenol po (by mouth), afebrile now." and "C/O pain to left buttock due to stage III pressure ulcer." The Physician's Documentation describes the area "The buttocks and sacral area reveals a 3.5 to 4cm round ulcer, stage III, with necrotic tissue at the base and margins." Admitting exam describes the wound as "pressure ulcer - unstageable" length 3 cm x 3cm with 1 cm depth. The Physician Note dated 5/10/13 at 11:15am documents that R1 presented with known pressure ulcer left buttock and fever. There is no documentation in the clinical record as to when R1 was transfered out and in what condition R1 was in. There is no evidence that R1 exhibited a fever at any time and there is no indication she had complaints of pain as described in the hospital notes. Review of the Medication Administration Records (MAR) for the month of May documents no Tylenol being administered for pain and/or fever at any time. The nurses notes neglect to record R1 being transferred to the emergency room and her feeling "Hot to touch" that was reported to the EMT's on transfer. On 6/12/13 at 2:35pm, E13, Corporate Personnel and Previous Administrator identified E18, former Director of Nurses, (DON), as the nurse responsible for R1's wound assessments stating that she was employed from 11/5/12 thru 5/10/13 when she was terminated in part for failing to ensure that scheduled assessments were completed. According to E13, on 5/8/13 when E16, Nurse Consultant/Registered Nurse (RN), was informed R1 was being transferred to the hospital on [DATE] for debridement of a boil, a full assessment was done and E16 determined R1's wound was an unstageable pressure ulcer with E18's assessment being incorrect. On 6/12/13 at 2:50pm, E16 stated she questioned the assessments of R1's left buttock when informed that she was going for a debridement. E16 stated she immediately went to assess R1's area and found it to be blackish in color with slough present, no odor noted, "no drainage really" and not quite as big as a golf ball but bigger than a quarter. E16 stated she knew right away it was a pressure ulcer and not a "boil" as E18 had referred to it at times. E16 stated E18 should have known it was a pressure ulcer. E16 acknowledged that incomplete assessments were done and that the area was infected. E16 also confirmed E18 had been counseled numerous times before R1's incident in regards to completing thorough, accurate and consistent assessments. Review of R18's personnel file documents she was counseled 12 times between 1/10/13 and 5/2/13 before being terminated on 5/10/13. Interview with Z2, R1's family member, on 6/12/13 at 9am indicate that her siblings called her the week before R1 went to the ER and said they could smell R1's left buttock ulcer and R1 repeatedly complained of pain when they were visiting. Z2 stated she called the facility at that time and reported the wound odor to a nurse but was told that it was normal and that the wound was getting better. Z2 could not identify who she spoke with but stated it was a male nurse with a foriegn accent. Z2 stated her mother had also complained to her on the phone in the weeks prior to the debridement that her "butt hurt really bad" and when reported to the nurse, was told that it was probably the sore on her bottom. Z2 stated she originally noted the left buttock wound at Christmas time and described it as small and scabbed over at that time. Z2 said she talked with R1 daily during her last week at the facility and her mother would complain repeatedly that her "butt hurts her really bad." The MAR's for March, April and May 2013 documents that R1 had only Tylenol 325mg tabs two ordered by mouth every 4 hours as needed (PRN) for pain/fever which was never documented as being given during those 3 months. In addition, there is no evidence that pain management was considered in the wound therapy and/or included in the plan of care for pressure ulcer treatment. On 6/12/13 at 2:05pm, Z1, Medical Director/R1's Physician, was interviewed and stated he was "very familiar" with R1 and knows his residents very well. When asked if he was aware of R1's pressure ulcer on left buttocks, stated "yes, it was a stage I" and told the facility to use a padded dressing. Z1 stated there was no break in the skin at all when he last saw it. When questioned whether he was thinking of another resident since R1 had been admitted to the hospital for evaluation which resulted in surgical debridement on 5/10/13 based on facility and hospital records, Z1 insisted that he had sent R1 to the emergency room because she had been complaining of coccyx pain and they (ER) were not happy with him for doing so. Z1 advised to get the hospital records from the emergency room , that he was "a surgeon and very familiar with pressure ulcer treatment." Z1's progress notes from March 2013 thru 4/19/13 periodically refers to the ulcer but fails to include any characteristics of the wound or the status of it other than "stable." There are no progress notes written after 4/26/13. Z1 is identified on the Hospital History and Physical dated 5/11/13 as the dictating Physician and includes information on R1's pressure sore which "needed to be debrided." The facility's Policy and Procedure for the Treatment and Prevention of Skin Breakdown dated 5/13 documents the policy is to "properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for ulcer according to industry standards of care. The Purpose of the procedure is to "provide guidelines for the treatment of [REDACTED]., pain, warmth, and/or maceration) and pain. The policy indicates that documentation of pressure ulcers will include at a minimum of weekly and when an ulcer is present, daily monitoring should include an evaluation of the ulcer, status of the area surrounding the ulcer, presence of possible complications such as signs of infections, whether pain is present, and when change is identified. The facility neglected to provide accurate, and complete assessments according to their policy on at least a weekly basis which identified decline on an in-house acquired pressure ulcer on R1's left buttock when it showed signs of infections and resulted in her have surgical debridement. 2. R3's Admission Sheet documents R3 was admitted to the facility on [DATE] with a diagnoses, in part; [MEDICAL CONDITION]'s Chorea, [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. Facility Fall Risk Assessment's of 11/24/11 through 1/2/13 document R3 scored above 10 which is a high risk for falls. Nurses Notes from 11/11/11 thru 1/2/13 document R3 fell 12 times during his stay at the facility. Nurses Notes of 11/15/11, 3/14/12, 8/29/12, 9/19/12 and 1/2/13 document R3 fell and hit his head. Nurses Note of 1/2/13 document R3 fell 3 times. The Incident/Accident Report of 1/2/13 documents R11, another resident, witnessed the first two fall and no staff were in the area when R3 fell . After the second fall, Z1 R3's Physician, was called, and Z3, R3's POA (Power of Attorney). The facility neglected to supervise R3 after the second fall with a head injury and R3 fell for the third time and again hit his head. Nurses Notes of 1/2/13 at 7AM documents - R3 fell in the main dining room on his hands and knees. This was around 4:55AM. No injury sustained. At 6:55AM, R3 fell again. Noted injury to left eye brow and left side of face. Gait very unsteady. Z3, Brother, and Z1 notified. R3 had a third fall while awaiting a call back from Z1...R3 will be transferred to Hospital for evaluation. Nurses Notes reviewed from 11/11/11 thru 1/2/12 documents only two notes addressing R3 using a helmet. Documentation on 3/31/12, "R3 refuses to wear helmet and family does not want him to either. Wants to make R3 feel he is in control of his balance. R3 is resistant of care @ interval. Has to be redirect & consel on why he needs assistance." Restorative Nursing Notes of 3/30/12 document R3 has been noted consistently banging head back of occipital lobe against the dining room wall near the patio exit..Received orders to try a soft helmet to protect R3's head from injury. Note of 3/31/12 documents R3's, POA (Power of Attorney) was at the facility and angry with staff stating he did not want helmet on R3. Staff attempted to explain and reason with POA. Still he refused to allow R3 to wear helmet. Refused to accept reason for safety precaution. Soft helmet removed. Received MD (Medical Doctor) order to discontinue soft helmet. The facility neglected to provide supervision and care to prevent R3 from injury due to head banging. The second Nurses Note addressing the use of a helmet documents on 10/27/12, "R3 was also hitting his head on the wall, However he has head gear on." There is nothing in the note addressing interventions used to stop R3 from banging his head. Review of Nursing Restorative Notes and Social Service Notes from 10/9/12 to 11/14/12 document R3 was banging his head against the wall 5 times. The facility neglected to do a comprehensive assessment of R3's head banging and refusal to wear the helmet. During meeting on 6/14/13 at 10AM, E13 (Corporate Administrator), who was the facility Administrator while R3 was at the facility, and E16 (Corporate Nurse) both stated the facility did not do a comprehensive evaluation for the use of the helmet. R3's Annual Minimum Data Set (MDS) of 12/26/12 documents that R3 is independent in transfers, walking in room, walking corridor, Locomotion on and off unit and toilet use. The MDS documents R3 is always continent of bowel and bladder. Under Section J for falls, there is documentation that R3 had two or more falls since admission/entry or reentry or since prior assessment. Injury or major injury is marked "none." Yet Monthly Summary Nurses Notes for November and December 2012 document R3 has unsteady gait and is incontinent of bowel and bladder. Report of November documents R3 wears incontinent pads and briefs. The facility neglected to do a significant change MDS for R3 and the previous MDS was done on 8/24/12. This is more than 4 months in between MDS's. During interview with E14, MDS Coordinator at 6/14/13hen asked why there was not an MDS done between 8/24/12 and 12/26/12, E14 stated, "It was missed." Physician Document Report/Operative Report of 1/4/13 documents date of procedure as 1/3/13. Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure Performed: Right frontal temporoparietal craniotomy and evacuation of subdural hematoma with extensive membrane removal and the bone was left out due to cerebral [MEDICAL CONDITION]. Comment: The patient is a [AGE] year old right-handed white male, who has had numerous falls most likely contributed to by his [MEDICAL CONDITION] chorea's constant falls and some self mutilation with banging of his head against the wall. He now comes with progressive lethargy...There is also an abrasion on his scalp with blood extruding from the abrasion...Computerized tomographic scanning of the brain reveals a large right sided subdural hematoma with significant mass effect and chronic and subacute appearance with isodense component also. ...It was necessary to dissect membranes because this clearly was a chronic condition with loculated fluid collections needing evacuation...Due to the patient's young age, it was felt the bone should be left out in order to accommodate any possible swelling. During interview with Z1 on 6/12/13 at 2PM, Z1 stated he was aware that R3 was banging his head on the wall. R3 was refusing to wear the helmet. Probably because it was uncomfortable and due to his medical condition. Z1 stated he never saw R3 wearing the helmet when he visited the facility. Z1 didn't know if he had the helmet, if there was an ordering problem or if staff couldn't find it. Z1 stated, "yes, very likely indeed that banging head could contributed to subdural hematoma. Most definitely." Z1 stated he was aware of the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Z1 stated, "Probably looking back he probably didn't belong at the facility." ....He would make himself fall and he would bang his head and make himself fall. Part of his diagnosis." Record review of Z1's PROGRESS NOTES from 11/11/11 thru 12/28/12 documents there is no documentation by Z1 addressing R3's head banging or use of the helmet. On 6/14/13 at 10AM, E13 stated R3's head banging was a behavior and not [MEDICAL CONDITION]'s. R3 maybe wanted a cigarette, or thought he didn't take medication he had already taken. The facility neglected to implement Behavior Tracking and assess and monitor effectiveness of the interventions. The facility neglected to obtain a Psychiatric Evaluation for the head banging. On 6/14/13 at 8AM, E6, Nurse for E5, (R3's Neurosurgeon), called and stated E5 stated it was reasonable to think R3 should have had a Neuro evaluation for brain trauma after the head banging on the wall began. The facility neglected to obtain a Neurological evaluation. During interview with E10 Social Service Director on 6/13/13, E10 stated he is in charge of Behavior Tracking. E10 stated he implemented a Behavior Tracking System about 5 months ago. E10 stated the facility did not have a system in place for staff to documents behavior of R3 hitting his head and if interventions used were effective. E10 stated R3's Behaviors were documented in the Nurses Notes and Social Service Notes. E10 stated staff would go to the Social Worker and report behaviors. They determined that staff were unable to report night behaviors because no one was there to report the behaviors to. E10 stated he personally observed R3 banging his head on the wall and refuse to wear the helmet. He had aggressive behaviors. At the patio door he would stand and bang his head. He did it quite often. R3 was confused about smoking time. During interview with E13 on 6/13/13 at 9:15AM, E13 stated the Policy and Procedure for Behavior Tracking was new for about 3 months. Prior to that behaviors were documented in the social service notes. There were no tracking forms. There was no assessment of interventions other than what was recorded in the Social Service Notes and what was on the Care Plan.

Based on interview, observation, and record review, the facility neglected to have a system in place to accurately assess pressure sores, monitor for decline including infection/pain and change of treatment according to their policy for 2 of 2 (R1 and R10) reviewed for pressure sores in a sample of 11. This failure resulted in R1's left buttock pressure ulcer developing an infection/[MEDICAL CONDITION] and necrosis that requirement surgical debridement. Findings include: 1. According to the Admission Record, R1 was admitted to the facility on [DATE] with diagnoses, in part, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. The only wound reported on admission to the facility was an open area on her right ankle. Wound Reports dated 11/7/12 identify R1 as developing a left buttock wound on 10/28/13 that was first identified as a boil. Laboratory tests reviewed dated 2/21/13 document a Low [MEDICATION NAME] of 3.0 (Normal 3.4-4.8) and a low Total Protein of 2.8 (Normal 5.6-8.3) on 3/22/13. R1's physician's orders [REDACTED]. The Care Plan dated 1/16/13 identifies R1's left buttock wound as a boil with interventions including Provide wound care, Document wound care, status, healing process in accordance with facility protocol, and assess/review nutritional needs among others but fails to reflect any specifics to the wound on R1's ankle and/or left buttocks and/or pain management associated with the left buttocks wound. The weekly documentation for the week ending 3/6/13 documents R1's left buttock open area measured 2.0 cm (Centimeter) x 2.4 with no depth but having eschar. There is no staging identified and no further information recorded. A another skin condition report for week ending 3/7/13, (one day later), documents the wound measures 2cm x 3cm and is improving but neglects to include documentation or even identify the eschar present the day before. There is no explanation as to why there are two wound reports. For the week ending 3/13/13 (skin condition report), again, two reports documenting the same wound reflect different measurements: On the skin condition report - stage II 2.3 x .3cm treated with silvadeen and 1.2cm x 1.6, with 0.4 x 0.4 cm eschar and granulation - improving. None of the assessments are signed or indicate who did them. The facility nurses neglected to correctly document wound status that included not only measurements and location, but other essential wound information including stage, other characteristics of the wound such as color, odor, drainage, treatment, signs/symptoms of infections and pain if present on a consistent basis. According to the "Other skin condition weekly Status Report" dated 3/20/13, R1's left buttock wound was again identified as a stage II measuring 1.4 x 1.5cm treated with [MEDICATION NAME] and facility acquired. An "Other Skin Condition Weekly Status Report" dated 3/27/13 documents the left buttock as facility acquired, 1.4cm x 1.5c, treated with Xendaerm. A day later, for the week ending 3/28/13, an "Other Skin Condition Report" documents R1's left buttock wound as 1.8cm x 1.5cm with no depth, "S" (Slough) and granulation present and documented as "Stable." There is no stage recorded even though it has slough. On the skin report dated 4/3/13, R1's left buttocks again measured 1.4 x 1.5 (same as 3/20/13) treated with Silvadeen. On 4/9/13, the Other skin condition weekly status report documents R1's left buttock as being present on admission, measuring 1.8cm x 1.6cm (same as 3/28/13) except with eschar present treated with [MEDICATION NAME]. Status is documented as "regenerated" but a report dated the next day, 4/10/13, document the measurements as 3 x 2 1/2 "[MEDICATION NAME] > eschar sloughing off" indicating a major increase in size. There is no staging documented. The nurses neglected to fully assess and document any other characteristics of the wound that included color, odor, exudate, signs/symptoms (s/s) of infections including peri-wound and/or pain if any. The wound sheets also conflict with whether it was in-house acquired or present on admission. This last evaluation identified R1's left buttock wound as facility acquired, not present on admission as the day before. The Physician is documented as being notified but no family. The Other Skin Condition Weekly Status Report dated 4/17/13 again measures R1's left buttock as 1.8 x 1.6 treated with [MEDICATION NAME] but includes no other documentation as to the status/characteristics of the wound. The next week, 4/24/13 report documents R1's left buttock wound as twice the size being 2 1/2 x 3, again with no other assessment information being documented. There is no evidence the nurses evaluated R1's wound response to the current treatment for [REDACTED]. The Treatment Administration Record (TAR) documents changes in orders: a new treatment was ordered on 3/6/13 for Hydrogel after cleansing the wound, cover with dry dressing once daily. On 3/8/13, this order was changed to apply Silver Sulfate after cleansing with normal saline(NS)/cover with a dry dressing until 3/15/13 when it was again changed to "cleanse lt (left) buttocks c (with) NS , apply thin film [MEDICATION NAME], apply skin prep to wound edges, apply [MEDICATION NAME] every Mon (Monday) & Thurs (Thursday.) The nurses documented that the [MEDICATION NAME]/[MEDICATION NAME] dressing was done daily from 3/16 thru 3/25 then documented every Monday and Thursday except from 3/28/13 thru 4/1/13 when there is nothing documented except a "O" on 5/1/13 with no explanation. Again, from 4/8/13 thru 4/12/13, the treatment is documented daily. This treatment continued despite the decline in the wound status until 5/3/13. On 5/1/13, R1's left buttock is identified as "degenerated" with measurements 2.5 x 3cm and "E" for depth. The nurse assessing R1's left buttock wound again neglects to include characteristics, odor, exudate, s/s of infection and or pain symptoms if present. physician's orders [REDACTED]. The TAR documents both the old treatment of [REDACTED]. On 5/8/13, the left buttocks is documented on a Pressure Ulcer Report sheet as a facility acquired, stage III, wound type "P" (pressure ulcer), measuring 2.5 x 5cm with 1/4 cm depth, slough and eschar noted with deterioration of the wound identified. There is no reference to infection and/or peri-wound status including pain. Z1, Physician, is documented as being notified and an order to send to the hospital for evaluation and possible debridement is obtained. There is no Physician's note regarding this order and no entry into the nurses notes explaining why R1's wound needed to be evaluated for debridement. The nurses notes dated 5/1/13 through 5/9/13 reflect only three entries regarding R1's pressure ulcers. The first is written by the Registered Dietician dated 5/6/13 in which the dietician's refers to the wound as a pressure ulcer. The other two nurses notes reflecting the pressure ulcers are dated 5/9/13: 7:19am - documents "resident is to be transferred today" to area hospital for "possible debridement of left buttocks. Daughter notified" and at 14:47 (2:47pm), "resident is schedule to go to" hospital for "evaluation on 5/10/13." There is no further documentation on wound status, pain and/or signs/symptoms of infection and no note as to when she actually was transferred from the facility. The Hospital History and Physical dated 5/11/13 obtained on 6/13/13 documents that R1 was "admitted to the hospital through the emergency room because of signs and symptoms and findings consistent with the [DIAGNOSES REDACTED]. The patient has swelling and redness and obvious infection on the left side with development of pressure sore which needed to be debrided surgically." The Emergency Department note dated 5/10/13 at 11:12am documents patient with c/o (complaints of) fever now resolved. "Per EMS, pt had temp (temperature) at NH (Nursing home). NH stated they did not take temp but rather pt felt hot to touch. Pt was given Tylenol po (by mouth), afebrile now." and "C/O pain to left buttock due to stage III pressure ulcer." The Physician's Documentation describes the area "The buttocks and sacral area reveals a 3.5 to 4cm round ulcer, stage III, with necrotic tissue at the base and margins." Admitting exam describes the wound as "pressure ulcer - unstageable" length 3 cm x 3cm with 1 cm depth. The Physician Note dated 5/10/13 at 11:15am documents that R1 presented with known pressure ulcer left buttock and fever. There is no documentation in the nurses notes or pressure ulcer assessments that includes R1 exhibited a fever at any time and there is no indication she had complaints of pain as described in the hospital notes. Review of the Medication Administration Records (MAR) for the month of May 2013 documents no Tylenol being administered. The nurses notes neglect to record R1 being transferred to the emergency room and her feeling "Hot to touch" that was reported to the EMT's on transfer. On 6/12/13 at 2:35pm, E13, Corporate Personnel and Previous Administrator identified the E18, former Director of Nurses (DON), as the nurses responsible for R1's wound assessments stating that she was employed from 11/5/12 thru 5/10/13 when she was terminated in part for failing to ensure that scheduled assessments were completed. According to E13, on 5/8/13 when E16, Nurse Consultant/Registered Nurse (RN), was informed R1 was being transferred to the hospital on [DATE] for debridement of a boil, a full assessment was done and E16 determined R1's wound was an unstageable pressure ulcer with E18's assessment being incorrect. On 6/13/13 at 9:10am, E13 agreed that the documentation for pressure ulcers was "horrible." On 6/14/13 at 10am, E1, Administrator stated that Z1, R1's physician/Medical Director, never voiced concern about R1's pressure ulcer care or steps would have been taken to transfer her to another facility. E1 also confirmed that Z1 was aware of her pressure sore. E18 employee file was reviewed and she was found to have been counseled 12 times from 1/10/13 to when she was terminated on 5/10/13 for failing "to ensure scheduled assessments are completed, which can harm the operation of the facility." On 6/12/13 at 2:50pm, E16 stated she questioned the assessments of R1's left buttock when informed that she was going for a debridement. E16 stated she immediately went to assess R1's area and found it to be blackish in color with slough present, no odor noted, "no drainage really" and not quite as big as a golf ball but bigger than a quarter. E16 stated she knew right away it was a pressure ucler and not a "boil" as E18 had referred to it at times. E16 stated E18 should have known it was a pressure ulcer. E16 acknowledged that incomplete assessments were done and that the area was infected. E16 also confirmed R18 had been counseled multiple times before R1's incident in regards to completing thorough, accurate and consistent assessments. Interview with Z2, R1's family member, on 6/12/13 at 9am indicated that she was not notified that the pressure ulcer was bad until she was notified that she was going to the emergency room for evaluation on 5/9/13. Z2 stated that her siblings called her the week before going to the ER and said they could smell R1's left buttock ulcer and R1 repeatedly complained of pain when they were visiting. Z2 stated she called the facility at that time and reported the wound odor to a nurse but was told that it was normal and that the wound was getting better. Z2 could not identify who she spoke with but stated it was a male with a Jamaican accent. Z2 stated her mother had also complained to her on the phone in the weeks prior to the debridement that her "butt hurt really bad" and when reported to the nurse, was told that it was probably the sore on her bottom. Z2 stated she originally noted the left buttock wound at Christmas time and described it as small and scabbed over. Z2 said she talked with R1 daily and in the last week or so, her mother would complain that her "butt hurts her really bad." Z2 also stated that she was told when her mother was readmitted by facility staff that the "nurses here are not trained to treat severe bedsores" and that given it's an Intermediate Facility, R1 would have to be transferred to a skilled facility. Records document R1 as being transferred to another facility on 5/14/13. The MAR's for March, April and May 2013 documents R1 had only Tylenol 325mg tabs two ordered by mouth every 4 hours as needed (PRN) for pain/fever and was never documented as being given during those 3 months. In addition, there is no evidence that pain management was considered in the wound therapy and is not included in the Care Plan. On 6/12/13 at 2:05pm, Z1 was interviewed and stated he was "very familiar" with R1 and knows his residents very well. When asked if he was aware of R1's pressure ulcer on left buttocks, stated "yes, it was a stage I" and told the facility to use a padded dressing. Z1 stated there was no break in the skin at all when he last saw it. When questioned whether he was thinking of another resident since R1 had been admitted to the hospital for evaluation which resulted in surgical debridement on 5/10/13 based on facility and hospital records, Z1 insisted that he had sent R1 to the emergency room because she had been complaining of coccyx pain and they were not happy with him for doing so. Z1 advised to get the hospital records from the emergency room , that he was "a surgeon and very familiar with pressure ulcer treatment." Z1's progress notes from March 2013 thru 4/19/13 periodically refers to the ulcer but fails to include any characteristics of the wound or the status of it. There are no progress notes written after 4/26/13. Z1 is identified on the Hospital History and Physical dated 5/11/13 as the dictating physician and includes information on R1's pressure sore which "needed to be debrided." The Facility's Policy and Procedure for the Treatment and Prevention of Skin Breakdown dated 5/13 documents the policy is to "properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for ulcer according to industry standards of care. The Purpose of the procedure is to "provide guidelines for the treatment of [REDACTED]., pain, earmth, and/or maceration) and pain. The policy indicates that documentation of pressure ulcers will include at a minimum of weekly and when an ulcer is present, daily monitoring should include an evaluation of the ulcer, status of the area surrounding the ulcer, presence of possible complications such as signs of infections, whether pain is present, and when change is identified. A stage II ulcer, according to the policy, is partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. The policy describes an "Unstageable" ulcer (page 8 dated 5/13) as "full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown.) and/or eschar (tan, brown, or black) in the wound bed. The facility neglected to provide accurate, complete assessments as to stage (unstageable) prior to her hospitalization and neglected to act when it showed signs of infections resulting in R 1 being hospitalized for [REDACTED]. On 6/14/13 at 10 am, E1, E2 and E16 stated all nurses had been inserviced on pressure ulcers including assessment/documentation and monitoring and identified E3, Assistant Director of Nurses/License Practical Nurse, as being the wound nurse now. All three stated R1 was transferred out to a skilled facility due to her pressure ulcer on 5/14/13 as this facility is an ICF. 2. The facility failed to correctly identify, thoroughly assess, evaluate treatments and monitor R1's ankle pressure ulcer. According to admission records, R1 was admitted with an ankle ulcer on 8/7/12 which was identified as a stage I at the time. According to current wound sheets dated 5/8/13, it was determined to be a pressure ulcer stage II measuring 2 x 3cm pink/red "E" for Escar 80% with 20% granulation. On 6/12/13 at 2:50pm, E16 stated she questioned the assessments of R1's ankle on 5/8/13 and reevaluated it herself determining at that point that it was a pressure ulcer. E16 stated that E18 was responsible for the wound assessments and E16 found them to be inaccurate. Interview with Z2, R1's family member, on 6/12/13 at 9am indicated she saw R1's ankle ulcer on a home visit in December 2012 and described the wound as circular, with yellow around the inside of the edge and a "mucousy" plug in the center. Wound reports dated 12/25/12 identify the area as an acquired stasis ulcer on right ankle measuring 1.5cm x 1.5cm "stable" with no additional documentation. The assessment fails to identify who completed it. On 3/6/13, the wound sheet documents R1's right ankle area as 1.4cm x 1.2cm with no depth and improving. On 3/13/13, the weekly wound sheet documents it as measuring 1.2cm x 1.4 with eschar but improving. One week later on 3/20/13, the wound record identifies it as a stage I measuring 1.8cm x 1.5cm with [MEDICATION NAME] as the treatment. The treatment remains the same and on 4/24/13, according to the weekly wound sheet, R1's right ankle measures 2cm x 3cm with no other documentation present. On the 5/1/13 weekly wound sheet, R1's ankle documents another decline measuring 2.5cm x 3cm with Eschar (no othe documentation on the characteristics of the wound). The treatment remained the same from 1/11/13 and read "Silver Sulfate Cream 1%" apply to rt (right) ankle ulcer & apple drsg (dressing) once daily until R1 was transferred out to the emergency roiagnom on [DATE]. The May 2013 TAR documents no initials as treatments done on R1's ankle from 5/5/13 through 5/10/13 when R1 left the facility. The facility failed to adequately assess R1's ankle wound to include all characteristics of the wound and failed to re-evaluate the course of treatment when the wound didn't improve but declined with eschar present. On 5/14/13, a change in treatment was done and Santyl, a [MEDICATION NAME] agent was ordered.. The Weekly Wound sheet dated 5/14/13 identifies the wound as a ulcer measuring 2cm x 2cm. but no other wound characteristics even though E16 indicated that all nurse were inserviced on pressure ulcer/wound documentation. According to the Pressure Ulcer Policy/Procedure, a stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. (Page 7 dated 5/13) An Unstageable ulcer is described (page 8 dated 5/13) as "full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown.) and/or eschar (tan, brown, or black) in the wound bed. 3. According to the MDS dated [DATE], R10 is dependent on staff for all activities of daily living and is a double [MEDICAL CONDITION]. Laboratory tests reviewed dated 9/24/12 identify a normal [MEDICATION NAME] and total protein. The Skin Condition Weekly status report dated 6/12/13 identify a coccyx wound with no measurements but identified as "stable." The wound type is identified as "other." The report is unsigned and has no further wound characteristics identified. A Progress note dated 6/12/13 was provided during refutation on 6/14/13 and identified the wound location on the coccyx, unmeasureable, slightly raised bed, with no drainage, odor, stage or comments. The documentation does not reflect the pinpoint area nor the redness of the peri-wound. On 6/13/13 at 9:36am, R10's coccyx area was observed with E2, Director of Nursing (DON) in attendance. R10's coccyx was reddened/shiny (circular) with some scarring and a small pinpoint open area in the middle. No drainage or odor was noted. The wound documentation/report failed to reflect the pinpoint open area and the redness/size. According to E16 all nurses were inserviced on accurate, complete assessments after 5/10/13.

Based on record review and interview, the facility failed to provide adequate supervision for falls and self injurious behavior (head banging); failed to have a system in place to assess causal factors for self injurious behaviors; failed to implement and monitor the effectiveness of interventions for self injurious behaviors; failed to have a system in place to ensure interventions are implemented correctly and consistently; failed to seek an evaluation for injuries caused by self injurious behavior for 2 of 2 residents (R3 and R1) reviewed for falls and self injurious injuries in the sample of 11. This failure resulted in R3 being hospitalized for [REDACTED]. Findings include: 1. R3's Admission Sheet documents R3 was admitted to the facility on [DATE] with a diagnoses, in part; Huntington's Chorea, Epilepsy and recurrent seizures and Schizoaffective Disorder. Skull Series Exam of 11/07/11, that was done before R3's admission to the facility documents, "Examination reveals no evidence of fracture." Physician Document Report/Operative Report of 1/4/13 documents date of procedure as 1/3/13. Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure Performed: Right frontal temporoparietal craniotomy and evacuation of subdural hematoma with extensive membrane removal and the bone was left out due to cerebral edema. Comment: The patient is a [AGE] year old right-handed white male, who has had numerous falls most likely contributed to by his Huntington chorea's constant falls and some self mutilation with banging of his head against the wall. He now comes with progressive lethargy...There is also an abrasion on his scalp with blood extruding from the abrasion...Computerized tomographic scanning of the brain reveals a large right sided subdural hematoma with significant mass effect and chronic and subacute appearance with isodense component also. At this time due to the significant shift and history of deterioration, although difficult to ascertain due to the progressive advanced Huntington's chorea clinical picture, surgical intervention was offered as an option...It was necessary to dissect membranes because this clearly was a chronic condition with loculated fluid collections needing evacuation...Due to the patient's young age, it was felt the bone should be left out in order to accommodate any possible swelling. Facility Fall Risk Assessment's of 11/24/11 through 1/2/13 document R3 scored above 10 which is a high risk for falls. Nurses Notes from 11/11/11 thru 1/2/13 document R3 fell 12 times during his stay at the facility. On the afternoon of 6/12/13, E13, Corporate Administrator, provided copies of R3's Incident/Accident investigations stating that these were the investigations for R3 from admission to discharge. There were no incident investigation for the fall of 3/14/12. R3's Nurses Notes document on 11/15/11 - R3 was observed standing up from the wheel chair and falling to the floor and hitting the left side of his head. Pressure dressing applied. R3 was sent to the ER (emergency room ) and received 7 staples to the left side of his head. R3's Nurses Notes document on 3/14/12 - R3 seen on patio by CNA (Certified Nurse Aide), R3 states he lost his footing - put his hands down and bumped his lips. Has small slit to upper and lower lip. Slight redness. Few drops of blood. Note of 3/17/12 documents X ray was ordered per brother's request to bilateral upper extremities. X-ray results showed no signs of fractures. R3's Nurses Notes document on 8/29/12 - R3 was noted ambulating with an unsteady gait toward patio door ambulating thru the dining room for a cigarette. R3 bump and tripped over his feet and hit forehead on right side of facial orbital on patio door. Incident/Accident Report/Fall Investigation Report of 8/29/12 documents that facility will, "Anctipate needs, offer assistance with ambulation." Care Plan approach attached to the incident report documents fall on 8/29/12, R3 refuses to accept assistance and should be encouraged to accept assistance with ambulation. "Anticipate needs - offers assistance with ambulation." Nurses Notes of 9/16/12 document - R3 on patio and went to sit down in a chair and missed the chair and fell on buttocks sustain abrasion on his left elbow. Portable X-ray done. (There is no further follow up in the Nurses Notes documenting the result of the X-ray.) Incident/Accident Report/Fall Investigation Report of 9/16/12 documents that facility will "Anticipate needs - R3 encouraged about safe sitting." The Care Plan approach attached to the incident report documents, "CNA will be inserviced to ensure R3 is well sitted in patio during smoking time. Anticipate needs. Encouraged about safe sitting practice." The Care Plan for R3, that was provided from the facility as R3's Care Plan from admission to discharge has the statement, "CNA will be inserviced to ensure R3 is well sitted in patio during smoking time" appears to have been altered/whited out (removed from the Care Plan). R3's Nurses Notes of 9/19/12 document- R3 tripped and fell on his way from the smoking patio to the Dining Hall according to him. He sustained a laceration to his chin. Some bleeding noted from the laceration. Ice pac applied to stop the bleeding. Neuro checks. Sent to ER. Returned with 11 stitches to his chin. Incident/Accident Report/Fall Investigation Report of 9/19/12 documents, "Facility will place small ramp between door way and flat flore surfaces. Will continue to monitor and offer assistance with ambulatory and transfer." Care Plan attached to the Incident Report documents, "Continue to attempt to educate fall risk and safety. Facility will place small ramp space between Patio & dining entry on floor surface." The attached Care Plan also documents under potential for fall due to "Ambulation unstable" and Diagnosis: [REDACTED]." This is not on the Care Plan that was provided to Surveyor as R3's Care Plan from admission to discharge. R3's Nurses Notes of 10/14/12 document - Social service observed R3 entering the Dining Room walking quickly and unsteady. Before social service could approach R3, R3 lost his balance and dropped to his hands. R3 immediately got back up and after several more steps dropped again to his hands. Incident/Accident Report/Fall Investigation Report of 10-14-12 documents that the facility will review labs and medication per MD (Medical Doctor). Care Plan attached to report documents, "R3 had a fall r/t (related to) the use of psychotropic medication. hh/x of fall and he has a d/x (diagnosis) of [DIAGNOSES REDACTED], SEIZURE." Care Plan Goal is, "R3 will have no major injury related to fall." Interventions are, "Educate resident to slow down during ambulation. Date initiated 10/14/12. Order for helmet. Date initiated 10/14/12. Refer to social service. Date initiated:10/14/12." R3's Nurses Notes of 12/13/12 document - Social Service states she was in the Dining Room and she saw R3 unsteady and dropped to the floor on his hands and knees. R3 got up by himself and went to his room. The Nurse went to the room and assessed R3. Incident/Accident Report/ Fall Investigation Report of 12/13/12 documents, "R3 referred to social services for behavior intervention. R3 noted with this behavior in the past." Care Plan attached to the Investigation Report documents, "R3 may intentionally fall due to misconception and confusion." Care Plan Goal documents, "R3 will not exhibit such behavior." Care Plan interventions are, "Encourage R3 to clarify misconception with Staff. Staff will educate R3 on danger of such behaviour. When R3 is observed confused during meds Pass, Staff will immediately clarify any confusion per medicine." R3's Nurses Notes of 12/22/12 at 11:55PM, documents - R3 was standing in the Hallway and became combative and lost his balance and fell on buttocks. No apparent injury. Incident/Accident Report/Fall Investigation Report dated 12/21/12 for the above fall shows no documentation for additional comments/interventions but does document that shoes appear to be too big. Care Plan approach was added, "Evaluation for appropriateness of footwear." Nurses Notes of 12/30/12 document - CNA told nurse she saw R3 fall back in the smoking patio hitting his left elbow on the ground. Vital signs were taken and R3 stated he had no pain during assessment. Incident/Accident Report/Fall Investigation Report of 12/30/12 documents R3 stated he tripped on peer. The report documents no additional comments/interventions. The Care Plan approach was added to encourage R3 to sit during smoking times. Nurses Notes of 1/2/13 at 7AM documents - R3 fell in the main dining room fell on his hands and knees. This was around 4:55AM. No injury sustained. At 6:55AM, R3 fell again. Noted injury to left eye brow and left side of face. Gait very unsteady. Z3, Brother and Z1, R3's Doctor, notified. R3 had a 3rd fall while awaiting a call back from Z1...R3 will be transferred to Hospital for evaluation. Neuro check in progress. Incident/Accident Report/Fall Investigation Report of 1/2/13 documents under comments, "While waiting to be transferred to hospital pt (R3) fell . Typed note added to the report on a separate sheet of paper dated 1/3/13 documents, "Administrator and ADON (Assistant Director of Nursing) watched video of dining room on 1/2/13 at 6:18am. R3 tripped over dining room chair and hit the right side of his head twice on the floor. Witnessed by R11, another resident." Nurses Notes reviewed from 11/11/11 thru 1/2/12 document two notes addressing R3 using a helmet. Documentation on 3/31/12, "R3 refuses to wear helmet and family does not want him to either. Wants to make R3 feel he is in control of his balance. R3 is resistant of care @ interval. Has to be redirect & consel on why he needs assistance." Note of 10/27/12 documents, "R3 was also hitting his head on the wall, However he has head gear on." During meeting on 6/14/13 At 10AM, E13 (Corporate Administrator), who was the facility Administrator while R3 was at the facility, and E16 (Corporate Nurse) both stated the facility did not do a comprehensive evaluation for the use of the helmet. MONTHLY SUMMARY Nurses Notes for March 2012 through September, November and December 2012 found in R3's medical record do not identify and address behavior of R3 banging his head on the wall. There was no MONTHLY SUMMARY for October 2012. Notes for August 2012 and September 2012 document R3 uses a wheel chair intermittently. Notes for November and December document unsteady gait. Restorative Nursing Notes of 3/30/12 document R3 has been noted consistently banging head back of occipital lobe against the dining room wall near the patio exit. Resident becomes very agitated and combative during this time period. Wants staff to open door to smoke during meal time. R3 refuses to eat if he does not get his way and bangs his head on the wall...Received orders to try a soft helmet to protect R3's head from injury. Note of 3/31/12 documents R3's POA (Power of Attorney) was at the facility and angry with staff stating he did not want helmet on R3. Staff attempted to explain and reason with POA. Still he refused to allow R3 to wear helmet. Refused to accept reason for safety precaution. Soft helmet removed. Received MD (Medical Doctor) order to discontinue soft helmet. There is nothing in the Restorative Nurses Notes as to what other interventions the facility would take to keep R3 safe from injury due to head banging. Restorative Nurses Notes of 10/9/12 documents R3 is in the dining area and noted R3 attempting to bang head on wall, staff assist R3 to the table. Called POA explain once again to POA the importance of the soft helmet to be worn by R3. Explain R3 will only wear it when awake and remove it at bed time. POA decided he would allow it to be worn. Received orders for R3 to wear soft helmet when awake. Record review of R3's Physician order [REDACTED]. On 6/12/13 at 11:55AM, E13 stated she was not able to find an order for [REDACTED]. Review of the Invoice for the helmet ordered in October 2012 documents a Purchase Date of 10/9/13, a request ship date of 10/10/12, and an invoice date of 10/23/13. Interview with Z4, supply company representative on 6/18/13 at 10:05AM, Z4 stated the facility ordered the helmet on 10/9/12. There were none in the warehouse so the company had to order the helmet from the vendor, which is the 10/10/12 ship request date. Z4 stated the invoice date of 10/23/12 is when the helmet was shipped to the facility with overnight delivery. The Social Service Notes document R3 was banging his head against the wall on 10/15/12. He was redirected by staff and given his helmet to wear. R3 refused to wear his helmet. He was offered a cigarette and finely complied. (The review of the invoice for the helmet documents it was shipped out on 10/23/12.) The Social Service Note of 10/25/12 documents that R3 was banging his head on the wall. Staff attempted to redirect R3. R3 became loud and aggressive. R3 was given a cigarette to calm him down. Staff will continue to monitor and document all progress. The Social Service Note of 10/30/12 documents R3 was observed in the dining room banging his head on the wall. R3 was redirected, but he refused to oblige. Incentives were offered and R3 obliged to wear his soft helmet and desist from banging his head on the wall. The Social Service Note of 11/5/12 documents R3 was observed in the dining room banging his head on the wall without his soft helmet. A cigarette was offered, R3 complied, and then took off the helmet after the cigarette and threw it on the floor. The Social Service Note of 11/14/12 documents staff reported that R3 was hitting his head against the wall in the dining room. Notes of 11/14/12 document a contract was implemented with R3 to reduce/ will not hit his head on the wall and will receive additional goodie bag/ can of pop per day and cigarette every day behavior is not exhibited. R3's Annual Minimum Data Set (MDS) of 12/26/12 documents that R3 is independent in transfers, walking in room, walking corridor, Locomotion on and off unit and toilet use. The MDS documents R3 is always continent of bowel and bladder. Under Section J for falls, there is documentation that R3 had two or more falls since admission/entry or reentry or since prior assessment. Injury or major injury is marked "none." Yet Monthly Summary Nurses Notes for November and December 2012 document R3 has unsteady gait and is incontinent of bowel and bladder. Report of November documents R3 wears incontinent pads and briefs. The facility failed to do a significant change MDS for R3 and the previous MDS was done on 8/24/12. This is more than 4 months in between MDS's. During interview with E14, MDS Coordinator on 6/13/13, when asked why there was not an MDS done between 8/24/12 and 12/26/12, E14 stated, "It was missed." R3's Comprehensive Care Plan that is dated 11/24/11, 2/24/12 and 5/24/12 documents R3 has [DIAGNOSES REDACTED] and Seizure Disorder. R3 has history of falls; impaired sense of balance and unsteady gait and generalized weakness. Care Plan Goal dated 8/12/12 documents R3 will wear protective safe soft helmet when up and about. With approach to wear protect safe soft helmet when up and about the facility. Check shoes for proper fit. When awake keep in common area and monitor. This conflicts with Restorative Note that the helmet was discontinued on 3/31/12. The next note addressing the use of the helmet is in Nursing Restorative Notes of 10/9/12 that documents R3 was banging his head and Z3 gave permission for the helmet and R3's helmet was ordered. The Care Plan of 10/1/12 documents R3 exhibits physical abusive behavior towards self manifested by: bang of head on the wall related to the [DIAGNOSES REDACTED]." (Yet Social Service Notes document the contract was not implemented until 11/14/12.) "Intervene by speaking in a calm and professional soft tone of voice. Staff should avoid raising own voice. Offer resident cookies to distract behaviour. Staff will attempt to redirect resident from such behavior." Intervention added on 12/26/12 documents, "Staff will continue to redirect resident upon any exhibition of physical abusive behavior towards self." The first incident of head banging documented after March 2012 was documented in the Restorative Nurses Notes of 10/9/12. There is no other documentation in the medical record of head banging before this date, yet the Care Plan for R3's head banging is documented as 10/1/12 with interventions implemented on 10/1/12. The Care Plan of 10/13/12 documents R3 had a fall related to the use of psychotropic medication and he has a [DIAGNOSES REDACTED]. The Care Plan documents on 12/30/12 to prompt R3 constantly to keep helmet on. The Care Plan of 10/25/12 documents R3 exhibits the symptom of resisting care by refusing to put on head helmet which is related to SAD (Schizoaffective Disorder) and Huntington. The Care Plan approach is, Emphasize soothing kind, slow and compassionate speech and Try different staff members to provide care if on staff member cannot, "connect" with resident." R3's RESIDENT CAREPLAN CONFERENCE SIGN IN SHEET of 12/28/12 document R3 was in attendance but did not have his signature. Note on the sheet documents, "R3 was reminded about the health risk of banging his head against the wall." On 6/12/13 at 3PM, E19, Certified Nurse Aide (CNA) stated R3 wore a blue like foot ball helmet that was cushioned to protect his head when he would fall or bang his head on the wall. Sometimes R3 would take his helmet off and at times could be redirected. He would bang his head against the wall while he was in his room. On 6/12/13 at 10:30AM, E12, CNA, stated she saw R3 banging his head in the Dining Room. He would bang his head if he was upset. He would take his helmet off. He didn't like to wear it. During interview with E10, Social Service Director, on 6/13/13, E10 stated he is in charge of Behavior Tracking. E10 stated he implemented a Behavior Tracking System about 5 months ago. E10 stated the facility did not have a system in place for staff to documents behavior of R3 hitting his head and if interventions used were effective. E10 stated R3's Behaviors were documented in the Nurses Notes and Social Service Notes. E10 stated staff would go to the Social Worker and report behaviors. They determined that staff were unable to report night behaviors because no one was there to report the behaviors to. E10 stated he personally observed R3 banging his head on the wall and refuse to wear the helmet. He had aggressive behaviors. At the patio door he would stand and his his head. He did it quite often. R3 was confused about smoking time. During interview with E13 on 6/13/13 at 9:15AM, E13, Corporate Administrator, stated the Policy and Procedure for Behavior Tracking was new for about 3 months. Prior to that behaviors were documented in the social service notes. There were no tracking forms. There was no assessment of interventions other than what was recorded in the Social Service Notes and what was on the Care Plan. During interview with Z1, R3's Physician/Facility Medical Director on 6/12/13 at 2PM, Z1 stated he was aware that R3 was banging his head on the wall. R3 was refusing to wear the helmet. Probably because it was uncomfortable and due to his medical condition. Z1 stated he never saw R3 wearing the helmet when he visited the facility. Z1 didn't know if he had the helmet, if there was on ordering problem or if staff couldn't find it. Z1 stated, "yes, very likely indeed that banging head could contributed to subdural hematoma. Most definitely." Z1 stated he was aware of the Huntington [DIAGNOSES REDACTED]. Z1 stated, "Probably looking back he probably didn't belong at the facility. If you are there you can see what type of patients they have. It's not 1 on 1 person watching." "Those people have sex all over the place. All sorts of behaviors and fighting. We can't tie them up or chemically restrain them....He would make himself fall and he would bang his head and make himself fall. Part of his diagnosis." On 6/14/13 at 10AM, E13 stated R3's head banging was a behavior and not Huntington's. R3 maybe wanted a cigarette, thought he didn't take medication he had already taken. The facility failed to implement Behavior Tracking and assess and monitor effectiveness of the interventions. On 6/14/13 at 8AM, E6, Nurse for E5, (R3's Neurosurgeon), called and stated E5 stated it was reasonable to think R3 should have had a Neuro evaluation for brain trauma after the head banging on the wall began. 2. The Facility's Policy for falls/accidents dated 5/2013 documents residents will be assessed for falls on admission, readmission, any significant change, and quarterly using the falls risk assessment. For residents who have been identified as risk for falls upon admission, the plan of care shall include initial interventions to prevent injuries and accidents from falls. The Facility failed to develop a falls prevention plan that has resident oriented interventions to assist in reducing falls. R1's MDS dated [DATE] identifies her to require minimal assist of one staff for transfers and all ambulation with balance deficits requiring staff assistance. R1's clinical record included three different Care Plans reflecting falls and additional plans for a lap buddy and ambulation. The Care Plan dated 10/21/12 identifies her as a fall risk due to unsteady gait with a goal to not sustain a fall related injury through the next review date of 7/15/13 but fails to reflect a goal to prevent falls. Review of the falls log documents that R1 is documented fell at least eight times from 11/19/12 to 5/6/13, however, the log is incomplete as it does not include falls recorded on 5/6/13, 11/21/12 and 10/21/12. The Care Plan on admitted d 8/1/12 identifies that R1 uses a lap buddy, self release while awake and up in wheelchair. The only other interventions checked are assessing to determine the most enabling treatment, provide skin checks and care, and offer sensory and social stimulation throughout the day. The current Care Plan goal is originally dated 10/21/12, reviewed on 2/21/13 with a goal date of 7/15/14 includes only interventions that coincide with falls, the first identified on 10/21/12. The Care Plan (10/21/12) interventions do not fall in order as they were added. There is an intervention for a low bed dated 8/12/12 with no explanation as to reason why on the Care Plan. The only intervention dated 10/21/12 when the unsteady gait is identified is to educate staff to toilet R1 every two hours and as needed when she had a fall reported. The Fall Report indicates R1 was transferred to the emergency room for treatment to a laceration above her left eyebrow. A physical therapy evaluation was ordered. On 11/19/12, R1 is documented again as falling to the floor when the CNA stated she "slid out of chair." The intervention dated 11/19/12 simply documents "Staff education" but nothing resident specific on preventing further falls. On 11/21/12, R1 was again found on the floor according to a report reviewed but again, the only intervention included again is staff education. On 12/10/12, an intervention is added to the Care Plan to "Implement fall precaution procedure" and instruct resident to ask for assistance prior to attempting to transfer or walk, place call light within easy reach and encourage use. The incident report dated 12/10/12 indicates that R1 fell into the bathtub. On 2/11/13, the incident report/log documents that R1 attempted to get out of chair by herself and fell to the floor. Care Plan interventions indicate a lab buddy was placed on R1 along with reminding resident to call for assistance. R1 was again reported to fall on 2/15/13 according to incident reports. The Care plan intervention dated 2/15/13 document "Staff, CNA to be inserviced" only. The Report documents that the CNA assisted the resident to the toilet and turned away from her giving the resident the opportunity to fall into the tub sustaining redness and a small abrasion on her back. E21, CNA, was inserviced on 2/18/13 to gather supplies before taking resident to the toilet. On 4/3/13, a report indicates a housekeeper witnessed R1 falling to the floor on her buttocks but getting up herself. The only intervention added was to "encourage resident to relax during care" however, there no indication as to how this intervention is appropriate to the fall witnessed by the housekeeper. On 4/15/13, a report documents R1 was "walking down hallway and fell on her back." The fall was unwitnessed. The facility report documents R1 noted on the "facility camera coming out of her room initially holding on to the handrail then lost her balance and fell to the floor." An intervention to place R1 on the "falling star" program was implemented. The facility provided no explanation as to why R1 wouldn't have already been placed on the falling star program given her repeated falls prior to this date. A report dated 4/25/13 documents R1 falling after taking off her lap buddy. Training was provided to two staff, E12, CNA, and E22, Security staff, as they observed R1 taking it off and sliding to the floor with no intervention provided to prevent her from hitting the floor. On 6/12/13 at 9am, Z2, family member of R1, stated R1 has had a lot of falls lately and has declined in ambulation to where R1 in now using a wheelchair. There is no evidence that adequate supervision was provided when R1 attempted to ambulate by herself or get up by herself.