Every finding on record at El Paso Rehabilitation and Health Care Center

Based on observation, interview, and record review the facility failed to maintain a resident's room and to ensure the room was free from food, trash, soiled clothing and dirty floor surfaces for one of four residents (R1) reviewed in a sample of four.Findings include:R1's current Care Plan documents: exhibits mood instability related to disorganized schizophrenia, obsessive compulsive personality disorder, and borderline personality disorder as evidenced by agitation, irritability, verbal outbursts, resistance to care, intrusive behaviors, and difficulty accepting redirection. R1 requires one-to-one supervision due to increased behavioral symptoms that may place the resident or others at risk; activities of daily living self-care performance deficit related to degenerative disease of nervous system, Obsessive Compulsive Disorder, Schizophrenia and Insomnia; communication problem with slurred, weak or absent voice; one-on-one staff support, and demonstrates behaviors that may require staff intervention; and impaired cognitive function, thought processes and difficulty making decisions.On 7/28/26 at 9:45 am, R1 was lying in R1's bed and upon entrance into the room, R1 stood up and was walking in R1's room. R1's room had an extensive amount of clothing in piles on the floor, including a pair of brown soiled under garments (underwear) with flies, food debris, dried brown liquid substance and soiled folded up band aids. On R1's dresser and tabletops there were stacks of personal items including food debris, dried brown liquids, and four plates of food plates (with dried chicken, dried carrots, dried sausage crumbles and syrup) and multiple empty, dried coffee cups with brown substance (coffee/hot chocolate) and Styrofoam and plastic cups of liquids with flies. A plate of scrambled eggs, one piece of toast and a bowl of oranges was also on a bedside table with flies. R1 could not identify how long the food had been sitting on the bedside table. R1 proceeded to eat two oranges and a bite of toast.On 7/28/26 at 9:45 am, R1 was non-sensical and mumbling, with erratic movement.On 7/28/26 at 9:59 am, V3 (Assistant Administrator) entered R1's room, and V3 stated, (R1) will not let us clean (R1's) room or let us take anything out of the room. We are working on getting (R1) a guardian. V3 removed one of the plates (dried chicken and dried carrots) and exited R1's room. V3 did not attempt to remove the plate of food with scrambled eggs, toast and oranges. V3 stated, Breakfast was served about 2 hours ago, that may be (R1's) breakfast.On 7/28/26 at 11:25 am, V6 (Ombudsman) entered R1's room. R1's room had an extensive amount of clothing in piles on the floor, including a pair of brown soiled under garments (underwear) with flies, food debris, dried brown liquid substance and soiled folded up band aids. On R1's dresser and tabletops there were stacks of personal items including food debris, dried brown liquids, and three plates of food plates (dried sausage crumbles and syrup) and multiple empty, dried coffee cups with brown substance (hot chocolate) and Styrofoam and plastic cups of liquids with flies. A plate of scrambled eggs, one piece of partially eaten toast and a partially eaten bowl of oranges was also on a bedside table with flies. V6 stated, This is unacceptable, this room needs cleaned.On 7/29/26 at 9:07 am, R1 was walking down the hall and entered R1's room. R1 had multiple stains on R1's orange top and grey pants. R1's white socks were entirely black debris on the soles of the socks. R1 was not wearing shoes.On 7/29/26 at 9:07 am, V7 (Certified Nursing Assistant) stated, (R1) does not always like to shower. I am not sure what (R1's) scheduled shower days are or the last time that (R1) showered. V7 verified that R1 had stains on R1's shirt and black debris on socks. V7 did not attempt to help R1 change clothing.On 7/29/26 at 9:09 am, upon entrance to R1's room, the surveyor's shoes exhibited a heavy tactile resistance, causing the soles of the surveyor's shoes to stick and adhere to the floor of R1's room.On 7/29/26 at 9:22 am, V8 (Housekeeper) was cleaning the floors in the Main Dining Room. V8 stated, I am the only full-time housekeeper right now. I think they are working on hiring another person, so V9 (Housekeeping Supervisor) is helping today. We just do the best we can. I am assigned to B Wing and D Wing. When I clean a resident's room, it depends on what a resident will let us do, but I always sweep and mop it the floor. Some residents have a lot of clutter, and it is hard to clean around that.On 7/29/26 at 9:37 am, V9 (Housekeeping/Laundry Supervisor) stated, We currently only have one full-time housekeeper and have just hired a new housekeeper but are waiting on the background paperwork to be completed, then they will start. I have to help out on the weekends or pull my floor technician and laundry workers to help with housekeeping, until we get more housekeepers hired.On 7/29/26 at 9:00 am, V3 (Assistant Administrator) stated, We contract our Housekeeping Department out and I think we are in the process of hiring a new housekeeper, so that will help. (R1) did let us clean (R1's) room this morning.The Facility admission Agreement, undated, documents the following items are not permitted: excessive clutter.V1's (Administrator) Interim Administrator Job Description, dated 4/1/25, documents: oversees the day to day operations of the Facility to meet State and Federal regulations and supervises all department managers to ensure the Facility is in compliance; ensures compliance with Federal, State regulations; ensures the highest standard of care for services provided; directs location of staff to provide high quality in daily care for environment; organizes the functions of the nursing home through delegation of duties; and follow.The Facility Light Housekeeper Job Description, undated, documents: responsible for satisfactory and timely completion of assigned cleaning area according to schedule; duties including dust and damp mopping floors; cleans and sanitizes patient room floors and furniture; removes and disposes of trash; cleans horizontal surfaces and vertical surfaces; ensures that established sanitation and safety standards are maintained; and must work with a wide variety of people with differing functions, personalities and abilities.The Facility Certified Nursing Assistant Job Description, undated, documents: responsible for delivering and assisting Resident with daily needs, including personal care needs, routine activities in accordance with accepted standards of practice, state and federal regulations and licensing requirements; provides basic nursing care to residents within the scope of the nursing assistant responsibilities and performs basic nursing procedures; provides personal hygiene by helping with showers/baths; assists with meal service including serving, clearing and cleaning the dining room; knowledge of proper procedures to provide personal care services; checks on residents regularly; and maintains cleanliness of resident units.

Based on interview and record review, the facility failed to follow the facility's established bathing/shower schedule and assist a resident with showering for one resident (R2) of four residents reviewed for bathing/showering in a sample of four.Findings include:R2's Face Sheet, documents R2's diagnoses including: Schizoaffective Disorder, Dysphagia, Weakness, Chronic Obstructive Pulmonary Disease, Encephalopathy, Dysphagia, Muscle Weakness, Abnormal Gait, Unsteadiness on Feet, Difficulty Walking and Extrapyramidal Movement Disorder.The Facility Shower Days Report, undated, documents R2's showers on Wednesday and Saturday evening shift.R2's electronic Activity of Daily Living Bathing Report, dated 7/1/26 through 7/28/26, documents that R2 requires assistance of one staff member for showers/bathing.R2's electronic Shower Schedule/Activity of Daily Living Bathing, dated 7/1/26 through 7/29/26, documents completed showers on Saturday (7/4/26), Tuesday (7/7/26), Wednesday (7/8/26), Wednesday (7/15/26) and Saturday (7/18/26).On 7/28/26 at 9:09 am, R2 stated, I did not get my shower last Wednesday (7/22/26) or last Saturday (7/25/26).On 7/29/26 at 9:07 am, V7 (Certified Nursing Assistant) stated, The Residents are scheduled for two showers a week.On 7/29/26 at 9:00 am, V3 (Assistant Administrator) stated, I cannot find any documentation that R2 received a shower for those missed days.The Facility Certified Nursing Assistant Job Description, undated, documents: responsible for delivering and assisting Resident with daily needs, including personal care needs, routine activities in accordance with accepted standards of practice, state and federal regulations and licensing requirements; provides personal hygiene by helping with showers/baths; and knowledge of proper procedures to provide personal care services.

Based on observation, interview, and record review, the facility failed to protect residents from misappropriation of property for two of four residents (R1 and R7) reviewed for misappropriation of property in a sample of seven. Finding include: The facility's Abuse, Prevention and Prohibition Policy, dated February 2026, documents that each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident consultants or volunteers, staff of other agencies serving the resident family members or legal guardians, friends, or other individuals. This form documents that the resident has the right to be free from verbal, mental, sexual exploitation, or physical abuse: corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property The Facility Resident Trust Fund Best Practices policy, revised 1/26/26, documents that all Resident Trust withdrawals must have the resident's signature on a receipt or ledger page. If a resident has asked a facility staff member to purchase items outside of the facility for their use, the receipt must be signed by the resident prior to a withdrawal entry posting into the resident ledger. If the resident is unable to sign the receipt or manual ledger, it is acceptable for the resident to make a mark on the receipt while witnessed and signed by two staff members, with at least one being a supervisor. This form documents that withdrawal disbursements of cash or by check shall be recorded to reflect purpose, payee, amount, date, and signature-the signature may be either on the manual ledger or a separate source document. The facility shall maintain Resident Trust support documentation for deposits and disbursements to be attached to the Computer Resident Trust posting reports and maintained with the AR Closing each month. R1's Trust Transaction History, dated 11/14/25, documents that $5809.00 were taken out of his account for a shopping spenddown. The facility was unable to provide receipts to account for this withdrawal. R1's Trust Transaction History, dated 12/3/25, documents that $4,000.00 was taken out of R1's account for shopping. The facility was unable to provide receipts to account for the withdrawal. R1's Trust Transaction History, dated 12/24/25, documents that $4,000.00 was taken out of R1's account at R1's Financial Power of Attorney's request. R1's Trust Transaction History, dated 1/2/26, documents that $2800.00 was taken out for a wheelchair for R1. The facility provided a wheelchair receipt in the amount of $301.99. The facility could not provide a receipt for the remainder of the $2800.00 taken out of R1's account. R1's Trust Transaction History, dated 1/5/26, documents that $2835.00 was taken out of R1's account. The facility could not provide receipts for any purchase for the amount taken out of R1's account. R1's Trust Transaction History, dated 1/30/26, documents that $2337.00 was taken out of R'1 trust account. The facility was unable to provide receipts for this withdrawal. R1's Trust Transaction History, dated 2/17/26, documents that $2175.00 dollars was taken out of R1's account per the request of V4. The facility was unable to provide any receipts for this transaction. R1's Trust Transaction History, dated 3/30/26, documents that R1 withdrew $3175.00 from his account. There were no receipts provided for this transaction. R1's Trust Transaction History, dated 4/14/26, documents that $10,000 was taken out of R1's account for shopping. There were no receipts to account for the amount of $10,000. R1's Trust Transaction History, dated 5/18/26, documents a cash withdrawal from R1's account of $8000.00. The facility was unable to provide receipts totaling $8,000. R1's Trust Transaction History, dated 6/4/26, documents a cash withdrawal of $6250.00 from R1's account. The facility was unable to provide receipts that add up to $6250.00. The facility provided receipts dated from December 2025 through 6/30/26, totaling under $10,000. R1 had a receipt, dated 12/29/25, in his file for a 32 television for the amount of $98.00 and an electric shaver for the amount of 79.96. There was a receipt in R1's file for a 100.00 Visa Hex Box card, dated 2/27/26. Another receipt for an Improving Life the Gears Clock for the amount of $2174.98. V3's Social Service Director's statement dated 7/7/26 documents that social services has not received money to shop for R1 since November because V5, Business Office Manager (previous), took over his personal shopping. On 7/15/26 at 10:30am, R1 was on his way to vending. R1 was unable to keep focused on one subject. At 1:00pm, R1 was in his room and able to answer simple questions. R1 stated that he has asked several times for a new television and has not gotten one yet. R1 stated that he was told that it was ordered. R1 also stated that he does not have an electric razor. R1 was unable to give specific details concerning his spending or his bank account. R1 verified that he did give permission for a desk, a bed, and a couple of dressers to be ordered on his behalf. R1 had his own personal desk, dresser, nightstand, tray table, recliner, and clothing in his room. R1 had one wheelchair. There was a broken wall clock sitting on the top of his dresser. R1 stated that he does not know what a Visa Hex Gift Card is and has never had one. R1 also stated that he has never had a twenty-one-hundred-dollar clock. On 7/16/26 at 8:40am, V4, R1's Trust Attorney, stated that she would never ever ask to withdraw any money from R1's account. V4 stated that she handles R1's trust fund money and pays his bills at the facility, such as his monthly room and board, pharmacy, and personal item bills. V4 stated that she deposits the money into his account at the facility, and then they take it back out for his monthly bills. V4 verified that she is not R1's financial power of attorney. On 7/16/26 at 9:45am, V1 Administrator stated that he sent in a reportable concerning V5, Business Office Manager (previous), taking money from R1's trust. V1 stated that she told him that she purchased furniture and other items that R1 requested, but was unable to provide receipts. V1 stated that V5 had already talked to her about not keeping receipts and following the facility trust policy, so she was terminated. V1 stated that an inventory was conducted of R1's belongings. V1 stated that $17,000 was deposited back into R1's account. V1 stated that only he and V18, Assistant Director of Nursing, were able to sign checks. V1 verified that it was his signature on several of the checks written for withdrawals for R1's account. V1 stated that he did not question the amounts requested because R1 would bring up catalogs or magazines and request items to be ordered. V1 verified that he signed several of the checks authorized for R1 trust withdrawals. V1 stated that the money for R1's shopping was given to social services so they could shop for R1, but stated that he does not have all of the receipts. V1 stated that the entire banking system had been changed since this was discovered. V1 agreed that R1 needs a financial guardian even though his Brief Mini-Mental Status score was high. V1 verified that over $17,000 was deposited into R1's account. V1 also stated that some funds were deposited into R7's account. 2. R7 stated that he is a tightwad and has never asked for money from his bank account. R7's Trust Transaction History documents that R7 withdrew $350.00 on 2/17/26 for personal shopping. R7's Trust Transaction History documents that R7 withdrew $275.00 on 3/4/26. R7's Trust Transaction History documents that R7 withdrew $2230.50 on 5/11/26. The facility was unable to provide purchase receipts for the items purchased for R7. The facility was unable to provide receipts for the amount equal to the amount that was withdrawn from R7's account. On 7/17/26 at 1:00pm, V17, Regional Reimbursement Specialist, stated that an outside company is auditing the facility's trust funds. V17 also stated that deposits were made into R1 and R7's accounts.

Based on interview and record review the facility failed to ensure a resident's right by insisting residents provide a two week notice prior to a home visit, for two of five residents (R28 and R90), reviewed for resident rights, in a sample of 36. Findings include:The facility form, Acknowledgement of Resident Responsibilities, provided and signed by each resident upon admission documents, Resident Planned Absences from the Facility: Competent residents may leave the facility at any time for outings after signing out. The facility must be provided information on the time leaving, estimated return and location of the outing. A friend or family member must accompany residents who are not competent. Those residents leaving for overnight outings must have a current physician order. Medications will be provided for the overnight stay. The facility may notify the resident or authorized representative that the payment program that the resident is currently approved for may prohibit an overnight stay. No requirement for residents to provide a two weeks' notice is present. On 6/08/2026 at 9:43 A.M., during the facility Resident Council Meeting, R28 stated that facility staff told him that when he wanted to go on an overnight outing, he was required to give them a two week notice so they could get his medications set up, for him to take with. At that time, V90 also confirmed he and his family were also informed they had to give the facility a two week notice prior to leaving for an overnight visit, to prepare his medications. On 6/08/2026 at 10:18 A.M., V6/Social Services Director (SSD) stated when residents request to go on a home visit, the resident tells social services or the family calls social services and lets them know what dates the resident will be out of the facility. V6/SSD states the facility requests a two week notice due to notifying the pharmacy to get medications. When asked who instituted the two weeks' notice policy, V6/SSD stated, facility management. On 6/08/2026 at 10:22 A.M., V8/Licensed Practical Nurse (LPN) stated when a resident goes on a home visit, social services let the nurse know and the nurse places the required medications into pill packets, along with instructions for use, for the resident to take home. States one resident (R90) requires a special pre-filled card that comes from the pharmacy, due to his pain control arrangement. States pharmacy staff deliver to the facility daily in the evening, but will deliver at noon also, if needed. States no medications take two weeks to obtain from the pharmacy. On 6/08/2026 at 1:32 P.M., V2/Director of Nurses (DON) confirmed that nurses were instructed to inform residents that requested an overnight outing, provide the facility nurses with a two weeks' notice, so medications could be obtained from the pharmacy. At that time, V2/DON confirmed the facility received medications regularly from the pharmacy, up to two times daily and she was uncertain why the two weeks' notice was required.

Based on interview and record review, the facility failed to distribute mail on Saturdays for three of five residents reviewed (R15, R28 and R90) for mail delivery, in a sample of 36. Findings include:The facility Resident Rights booklet, provided to all residents upon admission to the facility documents, Your rights to privacy and confidentiality: Your facility must deliver and send your mail promptly. On 6/08/2026 at 9:43 A.M., during the facility Resident Council Meeting, R15, R28 and R90 all voiced concerns that facility residents only receive packages on Saturday, but they do not receive any mail. At that time, R15 stated he had important personal mail that he had been waiting for and had to wait until Monday mornings, when business office staff were present in the facility, to receive his mail. On 6/08/2026 at 10:26 A.M., V7/Activity Assistant (AA) stated resident mail comes to the facility and is delivered to the business office staff. The business office staff sort through the mail, and then give it to the Activity staff, for resident distribution. V7/AA stated activity staff are present each weekend, but business office staff were not. Therefore residents get packages on Saturday, but only get mail delivery on Monday through Friday. On 6/08/2026 at 10:35 A.M., V5/Administrative Assistant (AA) stated the facility business office manager is off on medical leave at this time. V5/AA stated that facility mail is delivered to the business office, business office staff go through the mail and take out all facility mail and then give the mail to Activity staff for resident distribution. States business office staff are not in the facility on weekends, typically. At that time, V5/AA confirmed that facility residents do not receive mail on Saturdays.

Based on interview and record review, the facility failed to ensure a resident was free from verbal and physical abuse for one of two residents (R14) reviewed for abuse in a sample of 36. Findings include: The facility's Abuse, Prevention and Prohibition Policy, dated 01/24, documents Statement of Intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy: This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. This same policy documents, Definitions: Abuse- means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology.R14 and R53's Initial Reported Incident to Illinois Department of Public Health, dated 5/24/26, documents It was reported to the abuse coordinator (V1/Administrator) at approximately 6:10 PM that (R53) made unwanted physical contact with (R14) during the evening mealtime. R14 and R53's Final Five-Day Reported Incident to Illinois Department of Public Health, dated 5/29/26, documents Original Complaint: It was reported to the Abuse Coordinator (V1/Administrator) at approximately 6:10 PM that (R53) made unwanted physical contact with (R14) during evening mealtimes. This same Report documents, Determination; Following completion of the investigation, the allegation was substantiated, as evidence confirmed that (R53) struck (R14) in the face during the altercation. An Occurrence Interview Form dated 5/24/26 and signed by V18/CNA (Certified Nursing Assistant), documents (R53) began yelling at (R14) as (R53) exited the dining room calling (R14) Gay, fat, ugly without being provoked. (R53) kept getting closer to (R14) as a dietary employee was attempting to keep them separated, I approached to de-escalate the situation. (R53) hit (R14) in the face and (R14) tried to get near (R53) but could not be due to myself and other staff members blocking her way. (R14) sat back down [NAME] other staff members removed (R53) who was still attempting to attack (R14).An Occurrence Interview Form dated 5/24/26 and signed by V17/CNA, documents (R53) walked out of the dining room into the from room yelling and calling (R14) names. (R53) stopped and continued to call (R14) names and was provoking (R14) to fight. When (R14) stood up and walked up to (R53), I (V17) was physically in the middle trying to keep distance in between them when (R53) started to fight (R14), then (R14) tripped trying to get to (R53).R14's admission Record documents R14 is a [AGE] year-old female who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, and Pervasive Developmental Disorder.R14's MDS (Minimum Data Set Assessment), dated 5/1/26, documents R14 is cognitively intact.R14's Progress Note, dated 5/24/26 and signed by V23/LPN (Licensed Practical Nurse) documents The change in condition (R14) is currently experiencing is (R14) was hit in her face in nose area by another resident (identified as R53).R53's admission Record documents R53 is a [AGE] year-old female who admitted to the facility on [DATE], with the following, but not limited to, diagnoses: Bipolar Disorder, Major Depressive Disorder, and Pseudobulbar Affect.R53's MDS Assessment, dated 5/1/26, documents R53 is cognitively intact.R53's Progress Note, dated 5/24/26 and signed by V19/LPN, documents (V19) did not witness this incident. It was reported by staff that (R53) had a physical altercation with another resident (identified as R14).On 6/9/26 at 2:26 PM V18/CNA stated During the evening meal, (R53) began yelling at (R14) as (R53) was leaving the dining room. (R53) started calling (R14) fat, ugly, a b***h, you name it. (R53) was walking closer to (R14) so (R14) stood up. I then got between (R53) and (R14). (R53) started swinging her arms and was able to get one hit on (R14, smacking (R14) on the left side of (R14)'s face. (R14) and (R53) were finally able to be separated. (R14) was upset from getting hit.On 6/10/26 at 9:35 AM R14 stated, I was sitting by the dining room. (R53) got up out of nowhere and started walking towards me calling me a fat cow, fat b***h, and a c**t. I got up and told (R53) to leave me alone. After I said that (R53) smacked me in my nose. It hurt me and upset me because (R53) knows better.On 6/10/26 at 10:10 AM V17/CNA stated, after dinner I was walking with (R53) to walk (R53) back to her room. As we are walking, (R53) turns to (R14) and starts yelling at (R14) stating (R14) was the reason no one likes (R53). (R53) called (R14) a b***h, called her big, and a pig. (R14) then started yelling at (R53) stating she is always crying and to leave (R14) alone. (R53) started walking towards (R14), (R14) then stood up, and I got in between both (R14) and (R53). I have my right arm back trying to hold (R14) back because I am facing (R53). (R53) shoved me, then started swinging at (R53). (R53) ended up slapping (R14) in the face once as I was trying to intervene.I was walking with (R53) after dinner to assist them back to their room. During the walk, (R53) turned to (R14) and began yelling, claiming that (R14) was the reason nobody liked them. (R53) called (R14) a 'b***h,' 'big,' and a 'pig.' (R14) then yelled back, telling (R53) that they were always crying and to leave them alone. When (R53) started coming toward (R14), (R14) stood up. I immediately stepped between them, facing (R53) while extending my right arm backward to hold (R14) back. (R53) shoved me, began swinging wildly, and managed to slap (R14) once in the face while I was actively trying to intervene.On 6/10/26 at 11:13 AM (R53) stated, (R14) has made a few remarks about my daughter in the past. My daughter has cancer and (R14) thinks it's funny so I don't like her. I don't want to talk about what happened in the dining room.

Based on interview and record review the Facility failed to issue written notification for hospital transfers/discharges to Resident/Resident's Representatives for three of 19 Residents (R5, R14 and R45) reviewed for hospital transfer/discharge in a sample of 36.Findings include:The Facility Bed Hold Policy, dated 4/2026, documents: before the Facility transfers a Resident to a hospital or the Resident goes on therapeutic leave, the Facility will provide written information to the Resident and/or Resident Representative that specifies the duration of the state bed-hold policy, reserve payment policy in the state plan and the bed-hold period; all information provided to a Resident and/or Representative requires a signature of receipt of the policy by the Resident and/or Representative including bed hold information; and documentation could include a copy of the notice, progress notes or transfer list.1. R5's Census Record, undated, documents R5's Hospital Paid Leave dates of 1/4/26 and 1/26/26. R5's Nursing Progress Notes, dated 1/4/26 and 1/26/26, document that R5 had a change of condition and was transferred to the local hospital for evaluation and treatment. Written notification to R5 and/or V21 (R5's Responsible Party) was not documented.2. R14's Census Record, undated, documents R14's Hospital Paid Leave dates of 1/20/26 and 3/20/26. R14's Nursing Progress Notes, dated 1/20/26 and 3/20/26, document R14 had a change of condition and was transferred to the local Hospital for evaluation and treatment. Written notification to R14 and/or V20 (R14's Responsible Party) was not documented.3. R45's Census Record, undated, documents R45's Hospital Paid Leave dates of 1/29/26, 2/9/26 and 5/14/26. R45's Nursing Progress Notes, dated 1/28/26, 1/29/26, 2/9/26 and 5/14/26, document R45 had a change in condition and was transferred to the local Hospital for evaluation. Written notification to R45 (R45's Responsible Party) was not documented.On 6/10/26 at 9:10 am, V2 (Director of Nursing) stated, I cannot find any written notifications to responsible party or Residents when they are transferred to the hospital.On 6/10/26 at 10:02 am, V6 (Social Service Director) stated, I am responsible for providing the written notification of discharges to the responsible party's or Residents upon discharge and I have not provided any written notification of discharges.

Based on interview, observation and record review, the facility failed to ensure a resident who developed a new open skin area received immediate clinical assessment, timely physician notification, and necessary medical orders per facility policy for one of two residents (R4) reviewed for wounds in a sample of 36.Findings include:The facility's Skin Identification, Evaluation, and Monitoring Policy, dated 2/2026, documents Purpose: The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity. Communities will implement preventive measures, and an individualized care plan will be formulated upon completion of findings. Procedure: A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified. The nursing assistant will observe the resident's skin when assisting with activities of daily living and report changes to the nurse. Licensed Nurses will evaluate the resident's risk for skin breakdown using the Braden Risk Assessment tool upon admission, weekly for three consecutive weeks (totaling 4), quarterly, and when a significate change is identified. The Certified Nursing Assistant: D. Report skin integrity changes to nurse. Licensed Nurse Weekly: b. If new wound is identified: i. Initiate protective dressing, ii. notify health care provider for further treatment orders. c. Document evaluation in the medical record.R4's admission Record documents R4 is a [AGE] year-old male who admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Type Two Diabetes Mellitus, Chronic Kidney Disease (stage 3), Peripheral Vascular Disease, Acquired Absence of Right Leg Above Knee, and Lymphedema.R4's MDS (Minimum Data Set) Assessment, dated 3/13/26, documents R4 is cognitively intact and requires substantial/maximal assistance with rolling left to right.R4's Skin Check Assessment, dated 5/30/26, documents, R4 had no skin issues to R4's coccyx.R4's Skin Check Assessment, dated 6/9/26 with an effective date of 6/8/26, documents R4 has an open lesion to R4's coccyx.On 6/9/26 at 10:00 AM R4's Physician Order Sheets, Progress Notes, or Skin Assessments does not document any skin assessment, orders, or physician notification of R4's open lesion identified on 6/8/26.On 6/8/26 at 1:35 PM V14/CNA (Certified Nursing Assistant) and V15 (CNA) prepared to provide R4 incontinent care. During R4's incontinent care, R4 complained of pain while being cleaned up on R4's coccyx. R4 had a pea size red open area observed to R4's coccyx area. V14 and V15 both verified at this time that the area was open.On 6/9/26 at 11:22 AM V14 stated she reported to R4's open area to R4's coccyx to V16/LPN (Licensed Practical Nurse) on 6/8/26 right after cares were provided and the open area was identified. V14 stated she never witnessed V16 come down and assess R4's open to R4's coccyx.On 6/9/26 at 11:34 AM V16/LPN (Licensed Practical Nurse) V16 confirmed that V14/CNA reported a coccyx wound on R4 the previous day. V16 noted that while her initial visual check on 6/8/26 revealed no open areas, V14 reported the issue again the following morning. During R4's shower on June 9, V16 reassessed the resident and identified the open wound on the coccyx. V16 admitted that she had not yet measured the wound, documented a skin assessment or progress note, or notified the physician. Additionally, V16 acknowledged that she failed to have V14 or V15 point out the exact location of the wound on June 8 after her own initial assessment came up negative or type a progress note of her assessment on 6/8/26. On 6/9/26 at 10:45 AM V2/Director of Nursing stated that R4's open area should have been investigated the previous day (6/8/26). V2 noted that staff should have located the wound, completed a comprehensive wound assessment with measurements, and obtained a treatment order. Furthermore, V2 verified that no wound assessment or progress notes had been completed or entered into the system for R4 as of that time.On 6/9/26 at 11:00 AM V3/Wound Nurse verified that V16 was responsible for measuring R4's wound and initiating immediate treatment. V3 noted that V16 should have investigated why they did not observe an open area, especially since V14 and V15 (both CNA's) identified the wound that same day. Furthermore, V3 clarified that V16 was required to enter a progress note regarding the assessment, regardless of whether a wound was visible.

Based on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter drainage bag remained below the level of the bladder during transfers and routine care for one of one resident (R4) reviewed for urinary indwelling catheters in a sample of 36.Findings include:The facilities Urinary Catheter Care Policy, dated 12/2024, documents The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow: 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.R4's current Care Plan documents R4 has the following, but not limited to, diagnoses: Type Two Diabetes Mellitus, Chronic Kidney Disease (stage 3), and Neuromuscular Dysfunction of Bladder. This same Care Plan documents R4 has an indwelling urinary catheter.On 6/8/26 at 1:25 PM two Certified Nursing Assistants (V14 and V15) prepared to transfer R4 from a wheelchair to the bed using a mechanical lift to perform catheter care. During the transfer preparation, V14 placed R4's indwelling urinary catheter drainage bag onto the R4's lap. While setting up the mechanical lift, V15 took the drainage bag from R4's lap and secured it to one of the lift's loops. V14 and V15 then proceeded to transfer R4 into the bed. After the transfer, V14 removed the urinary catheter drainage bag from the lift sling and set it directly on R4's bed. The drainage bag remained on the bed throughout the duration of R4's urinary catheter and incontinence care.On 6/9/26 at 11:22 AM V14/CNA verified R4's indwelling catheter bag was placed on R4's lap, then attached to R4's mechanical lift sling during R4's transfer on 6/8/26. R4 verified the indwelling catheter bag was then placed on the bed during R4's catheter care and incontinence care.On 6/9/26 at 11:34 AM V2/Director of Nursing stated R4's urinary catheter drainage bag should have been maintained below R4's bladder and should not have been placed on R4's lap or on R4's bed.

Based on observation, interview and record review, the facility failed to provide the posted diet for three of three residents (R15, R28 and R90), in a sample of 36. The undated facility policy, Menu Substitutions or Changes and Approval directs staff that menu changes are made for instances such as food delivery problems, food quality issues, planned special events or in disaster situations. The facility Spring/Summer Master Menu 2026- week 3 includes the following noon meal for Monday, June 8th: Wheat Roll, Turkey Cutlet and Gravy, Baked Potato, [NAME] Roasted Vegetables and Homemade Frosted Banana Cupcake. The noon meal for Tuesday, June 9th includes: Pork Carnitas and Cheese Quesadilla, Ranchero Beans, Cilantro Coleslaw and Yellow Cake/Chocolate Icing. On 6/08/2026 at 9:43 A.M., during the facility Resident Council Meeting, R15, R28 and R90 all voiced concerns that they only receive plain cake with no frosting or icing. 0n 6/08/2026 at 12:26 P.M., during an observation of the facility noon meal, R15, R28 and R90 's meal consisted of turkey cutlet, mashed potatoes and gravy, vegetables and a banana cupcake with no frosting. On 6/08/2026 at 12:45 P.M., V24/Dietary Manager (DM) confirmed R15, R28 and R90's banana cupcake had no frosting. At that time, V23/DM stated she would ask the cook why the cupcakes were plain and not frosted. On 6/09/2026 at 12:32 P.M., during an observation of the facility noon meal, R15, R28 and R90's meal consisted of a chicken taco, beans, coleslaw and a piece of plain yellow cake with no frosting or icing. On 6/09/2026 at 12:51 P.M., V24/Dietary Manager (DM) confirmed R15, R28 and R90's yellow cake did not have any chocolate frosting. At that time, V24/DM stated she would talk with the kitchen staff. On 6/10/2026 at 9:43 A.M., V1/Administrator stated the facility kitchen staff should always follow the established facility menu, including frosting or icing all cakes, cupcakes, brownies, as ordered.

Based on interview and record review, the facility failed to notify the State Guardian of an elopement of a cognitively impaired resident for one of three residents (R1) reviewed for notification in a sample of three. Findings include: The facility's Significant Condition Change and Notification policy, approved 12/2014, documents to ensure that the resident's family and or representative and medical practitioner are notified of resident changes, such as those listed below: an accident or incident, with or without injury that has the potential for needed medical practitioner interventions. A significant change in the resident's physical, mental, or psychosocial status. This form documents an incident of wandering or elopement. The facility's Past Noncompliance Statement, dated 5/10/26, documents that staff became aware that R1 had exited the building, without signing out or staff directly observing his departure through a secured exit. The staff were unsure as to how this had occurred, as the doors to the facility are magnetically locked and require a code to disengage the system to exit the facility. R1's Progress Notes does not contain documentation that V18, State Guardian, was notified of R1's elopement from the facility on 5/10/26. On On 5/18/26 at 8:40am, V18, State Guardian, stated that she was not notified of R1 leaving the facility unsupervised. On 5/20/26 at 10:30am, V1, Administrator, stated that V18 was not notified of R1's leaving the facility until he did on 5/20/26.

Based on interview and record review, the facility failed to accurately assess a cognitively impaired resident with known exit-seeking behaviors as an elopement risk for one of three residents (R1) reviewed for accuracy of assessments in a sample of three. Findings include:The facility's Elopement Policy, approved 09/2025, documents that all residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. The facility's Care Planning policy, approved 12/2024, documents that every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. R1's current care plan or MDS does not address R1's exit-seeking behaviors.R1's Elopement Risk Assessment, dated 3/5/26, documents a. Is the resident cognitively impaired and independently mobile (with or without a device)? Yes is checked. History of elopement. b1. Does the resident have a history of elopement, 2. a desire to leave the building? 3. exit seeking with a purpose. 4. wandering activity. ba. If any of the above are checked, the resident is at risk for elopement. Proceed with elopement interventions and elopement risk care plan.On 5/19/26 at 10:55am, V17, Social Service Aide, stated that she does the elopement risk assessments. V17 stated that R1 has a diagnosis of Alzheimer's and Psychosis. V17 also stated that R1 has a history of delusions, hallucinations, and fixates on the family farm from the past. V17 also stated that R1 states that his family is coming to pick him up to take him to the farm. V17 and V4, Licensed Practical Nurse/Care Plan Coordinator, both verified that after reviewing the elopement risk assessment, R1 should have been triggered as an elopement risk, and interventions should have been put into place, but were not.

Based on observation, interview, and record review, the facility failed to implement elopement interventions to prevent an elopement of a cognitively impaired resident for one of three residents (R1) reviewed for care plans in a sample of three. Findings include:The facility's Care Planning policy, approved 12/2024, documents every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. This form documents that the purpose is to assess each resident's strengths weaknesses, and care needs. To use this assessment data to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and well-being as possible. R1's Care Plan, dated 5/15/26, does not contain goals or interventions for exit-seeking or elopement risk behaviors. On 5/15/16 at 3:30pm, R1 sat up on the side of his bed and stated that he was waiting for his mom, dad, and brother to come pick him up to take him to the farm. R1 was unable to give any specific information concerning leaving the day he left the building. On 5/16/26 at 11:45am, R1 was sitting on the side of his bed, stated that he is waiting for his mom and dad to come pick him up, to go to the farm. At 1:30pm, R1 was sitting in a chair at the front door, stating he was waiting for the tractors to go by.On 5/18/26 at 12:35, R1 stated that he just got a loan for 4 million dollars so he and four of his neighbors can start a dairy farm. R1 stated that it wall make 1,4 million dollars a year. At 12:55pm, R1 was sitting in a chair at the front door and stated that he was waiting for his family to come pick him up. At pm, 1:55pm, R1 remained in the same chair, waiting for his family. On 5/19/26 at 1:45pm-3:00pm, R1 sat in a chair by the front door. R1 stated that his family is coming to pick him up. On 5/16/26 at 11:00am, V4, Licensed Practical Nurse/Care Plan Coordinator, stated that R1 has a long history of sitting by the front doors waiting for his family to pick him up to take him to the farm. V4 also stated R1's behaviors of sitting at the door on a daily basis and talking about visiting his friends in the neighborhood should have been care planned.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and implement effective interventions to prevent the elopement of a cognitively impaired resident with known exit-seeking behaviors for one of three residents (R1) reviewed for elopement in a sample of three. Findings include: The facility's Elopement Policy, dated 9/2025, documents that it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. This form documents that an elopement is generally characterized as any unplanned departure from a designated safe environment. For the purpose of this policy, Missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. This form also documents that Wandering is defined as traveling with or without a known purpose. Residents who are at risk for elopement shall be provided with at least one of the following safety precautions by the facility: Door alarms on facility exits and or a personal safety device that will alert facility staff when the resident has left the building without supervision and staff supervision. This form documents that, using the MDS (Minimum Data Set) resident assessment schedule, all residents shall be reviewed for safety concerns and precautions. Residents at risk for elopement shall be identified and documented in the individual plan of care. Unless otherwise identified in a plan of care, residents who are at risk for possible elopement shall be accompanied when leaving the facility grounds. The resident representative shall sign the resident out of the facility on the resident sign-out sheet. This form also documents that procedures for missing residents and or elopements or attempted elopement include a designated someone to record the sequence of events as they occur and the specific time of notifications of each person/agency in this procedure. Contact the residents' representative. R1's electronic medical record documents the following diagnosis: Schizophrenia, Hypercholesterolemia, unsteadiness on feet, Sepsis, Weakness, other abnormalities of gait, Atrial Fibrillation, Asthma, Type 2 Diabetes, abnormal findings in cerebrospinal fluid, anticoagulant use, Orthostatic Hypotension, Hypothyroidism, Supraventricular Tachycardia, Retention of Urine, Benign Prostatic Hyperplasia, Alzheimer's disease, Gastro-Esophageal Reflux Disease, Psychotic disorder, Hyperlipemia. R1's Order for Guardianship, dated 10/12/21, documents in the matter of the guardianship of (R1), a high-risk adult. This form documents that the Office of State Guardian is hereby appointed as guardian for (R1) for his person. R1's Elopement Risk Assessment, dated 3/5/26, documents a. Is the resident cognitively impaired and independently mobile (with or without a device)? Yes is checked. History of elopement. b1. Does the resident have a history of elopement, 2. a desire to leave the building? 3. exit seeking with a purpose. 4. wandering activity. ba. If any of the above are checked, the resident is at risk for elopement. Proceed with elopement interventions and elopement risk care plan. R1's current care plan includes the following focus areas: a potential psychosocial well-being problem: Inability to problem solve, ineffective coping, lack of motivation, and social isolation. One of R1's interventions for this focus area is to allow R1 time to answer questions and to verbalize feelings and fears as accepted and needed. R1 has impaired visual function. R1 has impaired cognitive function related to Alzheimer's Disease. An intervention for this focus area includes ensuring R1 takes his prescribed antipsychotic medications to manage his delusions, hallucinations, and disorganized thinking. R1 has a brief psychiatric disorder. R1 has a need for 15-minute safety checks. R1's care plan documents that R1 may experience altered mood, impaired judgement, confusion, related to the diagnosis of Alzheimer's disease, brief psychotic disorder, and schizophrenia. This form also documents that R1 has an impaired cognitive function or impaired thought process related to Alzheimer's. R1's Care Plan does not include any interventions to address R1's exit-seeking or risk for elopement. The facility's Past Noncompliance Statement, dated 5/10/26, documents that staff became aware that R1 had exited the building, without signing out or staff directly observing his departure through a secured exit. The staff were unsure as to how this had occurred, as the doors to the facility are magnetically locked and require a code to disengage the system to exit the facility. R1's Progress Notes did not document that R1 left the building unsupervised, nor did they document a physical assessment following his return on 5/10/26. On 5/15/16 at 3:30pm, R1 sat up on the side of his bed and stated that he was waiting for his mom, dad, and brother to come pick him up to take him to the farm. R1 was unable to give any specific information concerning leaving the day he left the building. On 5/16/26 at 11:45am, R1 was sitting on the side of his bed, stated that he is waiting for his mom and dad to come pick him up, to go to the farm. At 1:30pm, R1 was sitting in a chair at the front door, stating he was waiting for the tractors to go by. On 5/18/26 at 12:35, R1 stated that he just got a loan for 4 million dollars so he and four of his neighbors can start a dairy farm. R1 stated that it wall make 1,4 million dollars a year. At 12:55pm, R1 was sitting in a chair at the front door and stated that he was waiting for his family to come pick him up. At pm, 1:55pm, R1 remained in the same chair, waiting for his family. On 5/19/26 at 1:45pm-3:00pm, R1 sat in a chair by the front door. R1 stated that his family is coming to pick him up. On 5/20/26 at 3:30pm, R1 was sitting in a chair at the front door. On 5/16/26 at 11:00am, V4, Licensed Practical Nurse/Care Plan Coordinator, stated that she was passing medications on 5/10/26, when R1 came up to her and mumbled something to her. V4 stated that she told him, Yeah, yeah, and he walked away. V4 stated that later, she was talking with V5, Certified Nursing Assistant Coordinator, when V5 received a call on her personal phone from an ex-employee. V4 told her to answer the call, and it was a neighbor calling to say that a resident (R1) was at her door. V4 stated that both she and V5 ran to the door, and R1 was walking back across the street to the parking lot. V4 stated that she did not know that R1 was outside unattended. V4 stated that it is unknown how R1 got outside because the doors are locked. V4 stated that R1 could have followed the flower delivery person out or someone gave him the code to the door. V4 stated that R1 will sit by the front door, waiting for his family to come pick him up. V4 also stated that R1 says the family is coming to pick him up on the tractor, but he has not had any visitors in quite some time. V4 stated that she did not document in R1's electronic medical record that he was outside of the facility unsupervised. V4 also stated that she did not notify R1's State Guardian of the incident. On 5/16/26 at 11:10am, V22, Licensed Practical Nurse/Minimum Data Set Coordinator, stated that the last time she saw R1 on 5/10/26 was in the dining room. V22 verified that R1 has a history of sitting at the front door, saying that his family is coming to pick him up to take him to the farm. V22 stated that she did not document in R1's electronic medical record that R1 left the building unsupervised. V22 stated that it is unknown how R1 got out of the building. On 5/16/26 at 12:50pm, V5 stated that she received a call on her personal phone from an old employee, so she answered it. V5 stated that it was V6, Neighbor, telling her that a resident (R1) was on her porch and rang the doorbell. V5 stated that she and V4 ran to the door, and R1 was standing at the edge of the property. V5 stated that R1 was assisted back into the facility. V5 stated that it is assumed that R1 followed a flower delivery person out the door unnoticed. V5 also stated that R1 has a long history of sitting at the doors, waiting for his family to come pick him up and take him to the family farm. On 5/18/26 at 8:40am, V18, State Guardian, stated that R1 did not have the mental capacity to be outside of the facility unsupervised. V18 also stated that R1 has a diagnosis of Schizophrenia with delusional disorder and Alzheimer's, so he should not be out unsupervised at all. V18 stated that R1 is very confused and always talking about leaving the facility, to go to his friend's house a couple of blocks away, or to the family farm. V18 stated that she was not notified of R1 leaving the facility unattended. On 5/18/26 at 11:00am, V4, Licensed Practical Nurse/Care Plan Coordinator, stated that no one is allowed to leave the facility unsupervised. V4 stated that if a resident is leaving with their family, or the staff has to sign them out before leaving. V4 also verified that R1's behavior, sitting at the door and stating that he is leaving with his family, was not care planned and should have been. On 5/18/26 at 12:30pm, V13, R1's Family, stated that R1 is not capable of being out in the community without supervision. V13 stated that R1 has been in a long-term care setting since the 1970's. V13 also stated that the R1 sits at the door waiting for his wife and children to come pick him up, but he has never been married or had children. V13 also stated that R1 thinks that the family still owns the farm, but it was sold many years ago. V13 stated that both of R1's parents have passed away. On 5/18/26 at 1:05pm, V6, Neighbor, stated that her doorbell rang at 12:06pm, when she answered the door, there was an elderly man with a walker on her porch. V6 stated that he started to ask her about the family that used to live there, she told him that they no longer live there, and he needed to go back across the street. V6 stated that she went to grab her phone, and when she went back to the door, R1 was already at the end of her driveway. V6 stated that she called the facility phone number, and there was no answer, so she called V5's personal number. V6 stated that V5 answered, so she told her that R1 was outside, unsupervised. On 5/18/26 at 1:55pm, V12, Psychiatric Nurse Practitioner, stated that R1 has a diagnosis of Alzheimer's with delusions and hallucinations, so he is not safe to be out in the community unsupervised. On 5/19/26 at 10:55am, V17, Social Service Aide, stated that R1 has a diagnosis of Alzheimer's and Psychosis. V17 also stated that R1 has a history of delusions, hallucinations, and fixates on the family farm from the past. V17 also stated that R1 states that his family is coming to pick him up to take him to the farm. V17 and V4 both verified that after reviewing the elopement risk assessment, R1 should have been triggered as an elopement risk, and interventions should have been put into place, but were not.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse for five of eight residents (R1, R3, R4, R7, and R9) reviewed for abuse in a sample of 9. The facility's Abuse, Prevention and Prohibition Policy, dated November 2025, documents each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. This form also documents that instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitation or enabled using technology. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. 1.R1's Brief Interview for Mental Status, dated 3/10/26, documents a score of 11, indicating that R1 is alert and oriented. On 4/10/26 at 12:15pm. R1 returned to her room from the dining room. R1 stated that there is a male who scares her. R1 stated that she had her hand resting on the corner of the table, and R2 came by and punched the top of her hand for no reason. R1 stated that every time R2 comes around, she leaves the area. R1 stated that her hand hurt really badly after R2 had hit it. R1 held out her hand, and there was swelling and slight discoloration noted of the middle finger and knuckles. The facility's Final Report, dated 4/3/26, documents that at approximately 10:45am it was reported that (R1) made the allegation that resident (R2) had made unwanted physical contact with her hand that was on a table in the dining hall. This form documents that an X-ray was completed and revealed a mildly displaced fracture. R1's X-ray dated 4/1/25, documents evidence of a mildly displaced fracture of the base of the first metacarpal bone. This form documents that there is reduced bone density seen and degenerative osteoarthritis changes in the small joints. R1's Progress Notes documented that R1 complained of generalized pain before the incident, but after she complained of pain in her left hand. R2's current care plan documents that R2 displays behavioral symptoms related to schizoaffective disorder, generalized anxiety disorder, and dementia, including refusal of care, responding to internal stimuli, and verbal or physical aggression when overstimulated. On 4/10/26 at 1:30 pm, V15, Certified Nursing Assistant, stated that she heard R1 yell Ouch, then said R2 hit me. V15 stated that R2 was propelling his wheelchair past R1 at the time, but she did not see him hit her. V15 stated that R1 was complaining of pain in her left hand. On 4/11/25 at 1:00pm, V3, Registered Nurse, verified that R1 complained of pain in her left hand after the incident with R2. 4/13/26 at 9:30am, V13, Medical Records, stated that heard R1 yell Ouch He hit me, and R2 was next to R1. 2. R7's Brief Interview for Mental Status, dated 1/22/26, documents a score of 11, indicating the R7 is alert and oriented. R7's Progress Notes, dated 3/15/26, documents that the resident (R7) is experiencing is resident was hit in the face with a plate by another resident in the dining room. R5's Brief Interview for Mental Status, dated 1/30/26, documents a score of 15, indicating the R5 is alert and oriented to person, place, and time. R5's current care plan documents that R5 exhibits physical aggression toward peers related to difficulty managing emotions, as evidenced by recent incidents of aggressive behavior toward other residents. The facility's Final Report, dated 3/24/26, documents Account: During the mid-day meal service, Resident 1 (R5) became acutely agitated. and exhibited signs of emotional distress. Staff initiated de-escalation interventions; however, the resident (R5) remained inconsolable. Resident #1 (R5) expressed a fixed belief that Resident #2 (R7) had made an offensive remark, though this could not be substantiated by staff or other residents present. This form documents that the investigation determined that a resident-to-resident incident occurred in which Resident #1 (R5), during a period of acute psychiatric distress and impaired perception, threw a plate that made contact with Resident #2 (R7). This form also documents that Resident #1 (R5) was transferred to the emergency department for further psychiatric evaluation and stabilization. On 4/10/26 at 12:45pm, R7 stated that she was sitting in the dining room, and R5 was talking very loudly about her sexual ideals. R7 stated that she got up and moved a couple of seats down from her, and she picked up her plate with food on it and threw it at her. R7 stated that it hit her on the right side of her face from her eyebrow to her cheek. R7 stated that she had a bruise for a while from the incident. On 3/13/26 at 8:45am, V4, Social Service Director, stated that R7 was talking to another resident when R5 said something to R7. V4 stated that a verbal altercation started, then R5 threw a lunch plate at R7. V4 verified that the plate hit R7 on the side of the face around her right eye to her cheek. V4 stated that R7 had a red line on her face from the plate. R4 stated that it took several staff to get R5 to calm down. V4 stated that it happened so fast that R5 could not be reached before she threw the plate. On 3/13/26 at 9:20am, V17, Certified Nursing Assistant, stated that R7 was talking with another resident when R5 chucked her plate full of food at R7. V17 stated that the plate hit her on the side of the face. V17 also stated that it took 3 staff to get R5 away from R7. On 3/13/26 at 9:40am, V16, Activity Aide, stated that she heard R5 and R7 yelling back and forth. V16 stated that R5 was telling R7 to shut up and leave. V16 stated that R7 then told R5 to leave, and R5 stood up and threw her lunch plate at R7, hitting her in the face. V16 also stated that staff were walking R5 out of the dining room, when she attempted to lunge at R7 again. 3. R3's electronic medical record documents a diagnosis of Disorganized Schizophrenia, Obsessive-Compulsive Personality Disorder, and Borderline Personality. R3's Brief Interview for Mental Status, dated 3/11/26, documents a score of 12, indicating the R3 is alert and oriented. R3's Progress Notes, dated 3/20/26, document that R3 was standing too close to another resident's (R5) boyfriend. This form documents that R5 hit R3 in the back area and was told, Do not touch him. R3 was not aware why R5 hit her. The facility's Final Report, dated 3/25/26, documents that the investigation determined that a resident-to-resident physical altercation occurred, initiated by Resident #1 (R5) striking Resident #2 (R3). The findings indicate that Resident #1 (R5) demonstrates impaired impulse control and behavioral dysregulation. This form also documents that Resident #2 (R3) was the recipient of the behavior with no contributing actions identified. R3 was observed several times throughout this survey walking in the halls, speaking, and laughing with staff and other residents. R3 did not display any adverse behaviors.R5's current care plan documents that R5 exhibits physical aggression toward peers related to difficulty managing emotions, as evidenced by recent incidents of aggressive behavior toward other residents. V18,s signed statement, dated 3/20/26, documents that R3 was walking around when she patted a resident on the back. V18 stated that R5 then hit R3 and said, Don't touch my boyfriend or me.On 4/13/26 at 10:50am, V14, Licensed Practical Nurse, stated that R3 was walking past the nurses' station where R5 was standing with another resident. V14 stated that R5 told R3 to get away from her, then R5 hit R3 in the lower stomach. 4. R4's Brief Interview for Mental Status, dated 12/16/25, documents a score of 15, indicating the R4 is alert and oriented to person, place and time. R4's Progress Notes, dated 3/17/26, documents that R4 was hit on the right side of the cheek by another resident (R6). The facility's Final Report, dated 3/20/26, documents that following a comprehensive review of the incident, the allegation was confirmed, as evidence showed that Resident #1 (R6) did strike (R4). R6's current care plan documents that R6 is vulnerable to peer conflict due to cognitive impairment and environmental triggers, with a history of resistance to resident altercations involving physical contact. This form also documents that R6 is at risk for resident-to-resident altercations related to behavioral triggers and environmental factors. V19's, Certified Nursing Assistant, signed statement dated 3/17/26, documents that she was in the dining room and heard a scuffle. V19 turned around, and two residents (R4 and R6) were throwing punches at each other. On 4/10/26 at 1:30pm, R4 stated that he was sitting in the dining room, and another resident came up and hit him in the head for no reason. On 4/10/26 at 1:45pm, V15, Certified Nursing Assistant, was sitting outside of R6's room. V15 stated that R6 has been on one-on-ones for quite some time. V15 stated that R6 has poor impulse control. 5. The facility's Final Report, dated 4/6/26, documents that it was reported at approximately 10:00am that Resident #1 (6) made unwanted contact with Resident #2 (R9) dining/living room area. R6's Progress Notes, dated 4/1/26, document that R6 had a physical altercation with a female peer (R9). 911 was called, and R6 was sent to the emergency room for an evaluation. On 4/13/25 at 9:30am, V13, Medical Records, stated that both R6 and R9 were in line for vending day. V13 stated that R9 started to yell at R6 to hurry up, when R6 turned around and hit R9 in the face. On 4/13/26 at 1:30pm, V1, Administrator, stated that R6 was on one-on-ones for 72 hours after his first incident with R4, but did not exhibit adverse behaviors, so they were stopped. V1 verified that after the incident with R9, R6 will be on permanent one-on-ones. V1 stated that because of the client population, it is impossible to stop every resident-to-resident incident.

Based on observation, interview, and record review, the facility failed to protect a resident from sexual abuse for one of four residents (R1) reviewed for abuse in a sample of four.Findings include:The facility's Abuse Prevention and Prohibition Policy, dated 03/2025, documents that each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. This form also documents that sexual abuse is defined as non-consensual sexual contact of any type with a resident.The facility's Initial Reportable, dated 10/6/25, documents that R2 was observed to have his hand on the breast of R1. R1 reported this contact as unwanted.The facility's Interview Template: Post-Altercation Event, dated 10/6/25, documents that R1 reported that while in the common area of the facility near the front door, resident 2 (R2) approached her and touched her chest with out her permission or consent. The facility's Interview Template: Post-Altercation Event, dated 10/6/25, documents that R2 reported that he approached the other resident (R1) and he touched her chest. V3, Social Service Aide/Certified Nursing Assistant, progress notes, dated 10/6/25, documents a one-on-one session following an incident involving another resident in the common area. It was observed that the other resident (R2) engaged in nonconsensual physical contact with the resident (R1). This note documents that R1 confirmed that the contact was nonconsensual. On 10/8/25 at 10:00am, R1 stated that another resident (R1) grabbed her breast when he was walking by her. R1 stated that she did not ask him to touch her, and it made her feel uncomfortable. R1 verified that she did not like the contact. On 10/8/25 at 10:45am, V4, Activity Aide, stated that he observed R2 reach out and grab R1's breast in the common area. V4 verified that he separated the two and reported the incident.On 10/8/25 at 1:00pm, V1, Administrator, stated that it was reported to him that R1 and R2 were passing each other, and R2 reached over and touched R1's chest. V1 stated that R2 told him that he did not know that the incident was wrong because R1 did not tell him to stop.:

Based on interview and record review, the facility failed to notify a resident's family of a resident's return from the hospital for one of three residents (R1), reviewed for family notification, in a sample of 5.FINDINGS INCLUDE:The facility policy, Significant Condition Change and Notification, dated 12/2024 directs staff, To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as: Transfer of the resident. Calls will be made to the resident's representative until they are reached. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given.R1's electronic medical record documents R1 was transferred to the local emergency room on 8/1/25 at 3:12 A.M. after experiencing increased behaviors and delusions. R1'S Nursing Progress Notes, dated 8/1/25 document, 8/1/2025 (R1) back from hospital at approximately 10:30 A.M., yelling and agitated and crying out, refused vitals, did report that she will run again. On 8/18/25 at 10:35 A.M., Z10/R1's Family Member stated, I am (R1's) guardian due to her mental health. They (facility staff) called me to tell me (R1) was running away and they had called the police and were having (R1) taken to the hospital. But no one ever called me to tell me (R1) came back (to facility). It wasn't until I called them (facility) on (8/2/25) and asked them, did I know what had happened to (R1). They (facility) are supposed to call me and let me know.On 8/19/25 at 1143 A.M., V1/Administrator verified that R1's mother (Z1) had not been called by facility staff to alert her that R1 had returned to the facility.

Based on interview and record review, the facility failed to update a plan of care after a resident made repeated attempts, on two different days, to elope from the facility, for one of one resident (R1), reviewed for care plans, in a sample of 5.FINDINGS INCLUDE:The facility policy, Care Planning, dated 12/2024 directs staff, Purpose: To address each resident's strengths, weaknesses and care needs. To use this assessment data to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning and wellbeing as possible. R1's Nursing Progress Notes, dated 7/29/25 at 3:35 P.M. document, (R1 is experiencing a change in condition. (R1) left building through the front door.Resident has had no further behaviors or attempts to exit building.R1's Nursing Progress Notes, dated 8/1/25 at 2:54 A.M. document,(R1) was observed by CNA (Certified Nursing Assistant) walking down the hallway, and turning towards the common room. A few seconds after it was observed by nurse on camera that (R1) was attempting to exit the facility. Writer, other nurse on floor, and (other staff) ran to front door as (R1) was observed walking out the door and into the parking lot. (R1) continued to walk forward and push past staff down the street and past the stop sign. (R1) continued to walk and push forward, while yelling throughout and became violent and combative swinging closed fists at nearby staff. (R1) repeatedly attempted to swing and physically assault staff. MD (Physician) was contacted and order received to send to hospital for psych (psychiatric) evaluation. Police were also then contacted as the facility staff was unable to get (R1) safely back to building. (R1) transported to local hospital.R1's Care Plan, dated (revised) 5/27/25 includes the following Focus Area: (R1) is an elopement risk/wanderer. This same plan of care includes the following Interventions: 4/10/25 Distract (R1) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 5/1/25 Monitor for fatigue and weight loss. 5/27/25 Calmly redirect (R1) and remind her that this is her home. Find a task, activity or simply a conversation to engage her in. No further interventions were implemented after R1's elopement from the facility on 7/29/25 or 8/1/25, were developed by the facility staff. On 8/19/25 at 1:10 P.M., V10/Care Plan Coordinator verified R1's care plan was not revised after R1's recent attempts on 7/29/25 or 8/1/25 to leave the facility unattended. At that time, V10 stated that the facility management team should have reviewed R1's plan of care after each elopement attempt and implemented new interventions to reduce the risk of R1 leaving the facility.

Based on observation, interview, and record review, the facility failed to follow diet orders for residents who receive mechanical soft diets, failed to document residents' noncompliance with mechanically altered diets, and failed to educate facility staff on residents who are on mechanically altered diets. These failures resulted in R1, who has a history of choking and requiring the Heimlich Maneuver, being able to purchase snacks from V5 (Medical Records) that were not part of R1's physician ordered diet texture. These failures have the potential to affect all 20 residents (R1, R4 through R22) who reside in the facility that receive a mechanically altered diet.These failures resulted in an Immediate Jeopardy that began on 7/12/25. While the Immediate Jeopardy was removed on 8/08/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.Findings include: The facility Inservice Training Handout: Understanding Diet Types in Skilled Nursing Facilities (SNFs), not dated, documents, Mechanical Soft Diet (Mechanically Altered) Definition: Soft, moist foods that require minimal chewing. Meats are ground or finely chopped. No hard, crunchy, or sticky textures. Important Guidelines: Always follow speech-language pathologist recommendations. Do not serve foods outside of resident's prescribed texture level. Use visual cues, consistency checks, and documentation.The facility training policy, titled What is a texture Modified Diet, not dated, documents, Mechanically altered or soft diets is used when there are problems with chewing and swallowing. Changes the consistency of a regular diet to a softer texture. Includes chopped or ground meats as well as chopped or ground raw fruits and vegetables. Foods to avoid on a Mechanical Soft Diet: Nuts and seeds, non-ground meats, breads with hard crust, hard candy, and raw, crunchy fruits and vegetables.R1's admission record documents R1's date of admission to the facility was 8/9/22 and his diagnoses included: Diabetes Mellitus due to underlying condition without complications, Dementia in other diseases classified elsewhere moderate with agitation, Hyperlipidemia, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction without residual deficits.R1's Minimum Data Set (MDS) assessment, dated 7/1/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment.R1's progress notes dated 7/12/25 documents, RN (Registered Nurse) called to dining room with reports of Resident choking RN reported to the dining room, observed resident sitting in chair at table and taking several bites of food without swallowing between bites, color is good, V/S (vital signs) stable, afebrile, breath sounds are clear to auscultation bilaterally, SAO2 (arterial oxygen saturation) 98% (percent) on room air, resident reports I don't know why I choked this was the first time that has happened. RN completed assessment and remained with the resident to observe eating pattern and noted that resident was eating fast and taking several bites of salad without swallowing after each bite, RN encouraged resident to swallow after each bite and to follow up with a drink of water before taking additional bites, resident demonstrated appropriate swallowing. Dr. (doctor) V6 informed at 2000 (8:00pm), POA (Power of Attorney) (V7), brother notified at 2010 (8:10pm) per phone conversation, RN contacted (Contracted Diagnostic Company) services for STAT (immediate) chest X-Ray, spoke with (Contracted Diagnostic Company) staff, STAT chest X-Ray ordered. Facility manager on duty, V3 (Assistant Director of Nursing/ADON) notified.On 8/5/25 at 10:30am, V8 (Certified Nursing Assistant/CNA) stated, I was serving the supper meal in the dining room when I heard another resident yell 'He's choking.' I immediately went to R1 and saw that he was unable to breathe so I got him (R1) to stand up and performed the Heimlich Maneuver on him. It took approximately four good thrusts before a small piece of food was dislodged and he started coughing so I stepped back and let him continue and he was able to cough up the rest of the lettuce up by himself (R1) and began breathing and talking. After I knew he (R1) was ok I went and got his nurse who completed an assessment on him.R1's facility SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note dated 7/12/25, documents, resident (R1) had a swallowing issue.R1's Physician Orders dated 7/14/25 document that R1's diet was changed to CCD (Controlled Carb Diet) diet Mechanical Soft texture, Regular/Thin consistency, no lettuce, or green leafy vegetables for diet related to Diabetes Mellitus due to underlying condition without complications.R1's current care plan documents, (R1) is a risk for aspiration and choking related to impaired swallowing function evidenced by actual choking incident requiring Heimlich Maneuver and (R1) requires a modified diet (mechanical soft) with thin liquids.R1's Incident Report for Choking/Emergency Intervention dated 7/12/25, documents at approximately 6:45pm R1 choked requiring the Heimlich Maneuver, R1 was assessed post choking, chest X-Ray was ordered, R1 monitored every four hours for 72 hours for respiratory changes, a repeat chest X-Ray to be done 72 hours after initial chest X-Ray, diet temporarily downgraded to mechanical soft pending Speech Therapy evaluation, Speech Therapy referral for evaluation initiated, R1 to be supervised at all meals, R1's Care plan updated, entered on facility Risk Management log and POA (Power of Attorney) notified.On 8/1/25 at 11:50am, R1 noted to purchase a can of potato chips, chocolate wafer bar and a candy bar from V5 (Medical Records) at the snack room. R1 stated he does not have a swallowing issue and does not remember choking or getting the Heimlich maneuver a couple of weeks ago.On 8/1/25 at 12:00pm, V4 (Dietary Manager) stated, If someone is on a Mechanical Soft Diet, they definitely should not be eating potato chips. However, we cannot deny someone something if they want to eat it, we can only educate them.On 8/1/25 at 12:10pm, V1 (Administrator) stated, It's a double edge [NAME]. Residents have the right to refuse orders and we can't keep them from buying snacks from vending. That would be impossible to supervise. All we can do is educate when we see them not following dietary orders.R1's progress notes dated 7/17/25 at 5:17pm, documents, Resident was noted in the dining room eating flaming hot (brand name of type of chip) that he purchased from another resident. Resident was educated that he is a mechanical soft diet and that he should not be eating those at this time d/t (due to) risk of choking. Resident was reminded of choking incident and why his diet has been modified. Resident refused to stop eating Cheetos but was supervised while eating and had no issues during this time. MD (Medical Doctor) notified. No further documentation noted in R1's medical record regarding education on diet.On 8/1/25 at 1:40pm, V3 (Assistant Director of Nursing/ADON) stated, We do not have vending machines. We have a staff member who opens a snack room for a period of time during the day so the residents can buy snacks.On 8/5/25 at 10:20am, V7 (R1's Power of Attorney) stated, I'm not recalling them calling me to notify me of (R1) choking and requiring the Heimlich Maneuver. They haven't called me about buying snacks that are hazardous either. They have called me recently about fights he (R1) has and suggestions on looking at places closer to me with a dementia unit but nothing about him (R1) choking, his diet or needing to see Speech. I have my faculties about me, and I would remember a call like that. V7 also stated that he would be willing to come to the facility if needed to get the Speech evaluation done if the facility would give him prior notice to get there. V7 stated, Ultimately I want him to be safe so whatever is in his best interest I'm willing to do.On 8/5/25 at 10:35am, V6 (Medical Director/Physician) stated, I had been made aware of his (R1) choking episode, but the facility has not contacted me about his (R1) noncompliance with following his down-graded diet or to speak with him (R1) or his family to go over the risk of not following the prescribed diet. It would be futile to attempt to educate him (R1) on the risk of not following his diet due to his poor cognition, he (R1) would forget within an hour anything I've told him. The staff should provide him with safe food options in accordance with his diet but I'm not sure how they will be able to manage that with his (R1) cognitive impairments.On 8/5/25 at 10:50am, V5 (Medical Records) stated, I am in charge of opening the snack room so residents can buy snacks. I have been given no guidance on resident diets up until last Friday (8/1/25) when I was told that I let a resident (R1) purchase chips and he was not supposed to have them but prior to that they have said nothing to me about resident diets. I'm familiar with therapeutic diet consistencies like Mechanical Soft or Pureed but I have no clue what residents in this building are receiving those types of diets. V5 also stated that he opens the snack room from 11am-1pm on Monday, Wednesday, and Fridays and 12-1 on the other days typically.R1's Speech Therapy Evaluation dated 8/4/25, documents, The ST (Speech Therapist) discussed with the DON (Director of Nursing) and the dietary manager about continuing to provide mechanical soft solids, and thin liquids, as tolerated. Cut up solids prior to placement on the table and try placing solids in individual bowls to assist with reduced rate of intake. ST also encouraged the staff to remind the patient at each meal to slow down and take sips of liquids every 2-3 (two-three) bites.On 8/5/25 V10 (Certified Nursing Assistant/CNA), V11 (Licensed Practical Nurse/LPN), and V12 (Registered Nurse/RN) all stated that they had just received in-servicing on R1's diet.On 8/6/25 at 11:20am, V14 (Speech Therapist) stated, I evaluated (R1) this past Monday for swallowing concerns due to his recent choking. He (R1) was downgraded by the facility and his (R1's) physician to a Mechanical Soft diet. He (R1) was not very receptive about my recommendations while watching him eat, he (R1) ate extremely fast and is very impulsive. Potato chips would not be part of a Mechanical Soft diet. If he (R1) were to get a bag of potato chips from a vending machine and eat them unsupervised there is a potential for him to choke, aspirate, or even die from choking because of the way he eats.On 8/6/25 at 11:30am, V12 (Registered Nurse/RN) stated, I don't have all my residents' diets memorized, so no I would not know if they were eating what they shouldn't be without going to look at their orders and unless they were having issues when I saw them snacking, I wouldn't question their diet.On 8/6/25 at 11:45am, V17 (Certified Nursing Assistant/CNA) stated, I do not know everyone that receives a Mechanical Soft diet, but I do know a few. I also know that they should not be eating anything hard.On 8/6/25 at 2:19pm, V18 (Registered Nurse/RN) reports that the vending room causes problems because the residents buy whatever they want.2. R4's admission record documents R4's date of admission to the facility was 2/24/20 and his diagnoses included: Diabetes Mellitus due to underlying condition with Diabetic Autonomic (Poly)Neuropathy, Type 2 Diabetes Mellitus without Complications, Magnesium Deficiency, Hyperlipidemia, Gastro-Esophageal Reflux Disease without Esophagitis, Heartburn and Constipation.R4's Minimum Data Set (MDS) assessment, dated 7/1/25, documents R4 has a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognition is intact.R4's Physician Orders dated 2/4/25, documents R4 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 11:20am, R4 observed in his room with bag of chips, bag of cheese curls, and a chocolate candy bar on his bed. R4 reports that staff do not tell him what snacks he shouldn't purchase due to diet restrictions.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R4's current care plans lacked non-compliance with diet textures prior to 8/7/25.3. R5's admission record documents R5's date of admission to the facility was 7/26/22 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Hyperkalemia, Deficiency of other specified B Group Vitamins, Hyperlipidemia, and Gastro-Esophageal Reflux Disease without Esophagitis.R5's Minimum Data Set (MDS) assessment, dated 7/2/25, documents R5 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact.R5's Physician Orders dated 2/4/25, documents R5 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 11:16am, R5 observed sitting in his room with 2 cans of potato chips, 2 Chocolate candy bars, 2 bottles of soda unopened in front of him on bedside table. R5 states that he does purchase items from the vending room, and he usually gets cans of chips, candy bars, and soda. R5 stated that staff do not advise him on what he should not purchase or any risk to eating what I buy.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R5's current care plans lacked non-compliance with diet textures prior to 8/7/25.4. R9's admission record documents R9's date of admission to the facility was 2/10/21 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Hyperkalemia, Deficiency of other specified B Group Vitamins, Hyperlipidemia, and Gastro-Esophageal Reflux Disease without Esophagitis.R9's Minimum Data Set (MDS) assessment, dated 6/9/25, documents R9 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact.R9's Physician Orders dated 3/5/25, documents R9 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency, supervision for all meals.On 8/6/25 at 11:30am, R9 observed lying in bed with head elevated. R9 reports that he purchases popcorn and drinks from the vending room. R9 stated, They tell me I shouldn't have popcorn, but it is my life, and I am going to live it.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R9's current care plans lacked non-compliance with diet textures prior to 8/7/25.5. R12's admission record documents R12's date of admission to the facility was5/1/04 and his diagnoses included: Type 2 Diabetes Mellitus without Complications, Dysphagia Oropharyngeal Phase, Unspecified Dementia Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance. Mood Disturbance, or Anxiety, and Constipation.R12's Minimum Data Set (MDS) assessment, dated 6/24/25, documents R12 has a Brief Interview for Mental Status (BIMS) score of 14/15, indicating cognition is intact.R12's Physician Orders dated 3/5/25, documents R12 has an order for Regular Diet Mechanical Soft texture, Regular/Thin consistency.On 8/6/25 at 1:42pm, R12 reports that he purchases food items from the vending room, but staff do not advise him on what food items to avoid because of dietary restrictions.On 8/8/25 at 10:30am, V22 (Minimum Data Set/Care Plan Coordinator) verified that R12's current care plans lacked non-compliance with diet textures prior to 8/7/25. V1 (Administrator) and V3 (Assistant Director of Nursing/ADON) were notified of the Immediate Jeopardy on 8/7/25 at 1:58pm.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R1 has remained free from any harm or poor outcomes since incident on 7/12/2025 through current date 8/7/20252. On 8/6/25 V1/Administrator completed educated 1:1 with V5 (Medical Records) on Modified Diets and Resident Rights 3. On 8/6/25 Education for all staff on Modified Diets and Resident Rights completed by Administrator/V1 and IDT (Interdisciplinary Team). 4. On 8/6/25 AD HOC QAPI/Quality Assurance and Performance Improvement meeting held by members of QA/Quality Assurance Team and noted opportunities for improvement and process changes. 5. On 8/6/25 the facility updated process on Vending: Staff members perform vending to obtain a current list of resident diets. Staff to encourage residents to obtain items that align with ordered diet. If a resident should use their right to choose items outside of modified diet, nurse to be alerted and resident to be educated, physician notified if necessary, and resident to be encouraged to consume said items in common area in staff visual to monitor for safety. 6. On 8/6/25 Administrator/V1 educated 1:1 with V5 on facility updated procedure for vending cart in relation to modified diet. 7. On 8/6/25 Education completed with other staff on updated procedure for vending cart in relation to modified diet staff completed by V1/Administrator and IDT. 8. On 86/25 reviewed current plan of care of R1 with V6/Medical Director. Consideration for resident physical, chronic mental health concerns, and well as resident rights and quality of life/preferred preferences reviewed. New orders received, responsible party made aware, and plan of care updated by V22/Care Plan Coordinator. 9. On 8/7/25 staff educated on plan of care changes by V1/Administrator and other IDT members completed. 10. On 8/6/25 staff educated by V13/Director of Nursing/DON and other IDT members on Electronic Medical Record and ease of noting current diet order in resident profile. 11. V1/Administrator or V13/DON to educate staff monthly on Modified Diets and Resident Rights and updated vending cart procedure through next QAPI review to assure understanding. 12. IDT to review all residents with modified diets to assure resident adherence to diet. If residents noted to utilize the right to choose or right to refuse and have noted to deviate from prescribed diet, IDT to assure education, notification to parties if applicable, and Refusal of Treatment consent and documentation if applicable, and updated plan of care.

Based on record review and interview the facility failed to follow the facility's Discharge/Transfer policy for 1 resident (R2) of 3 residents reviewed for hospitalizations in the sample of 22.Findings include:The facility's policy Discharge/Transfer Out Checklist (undated) documents: SBAR (Situation Background Assessment Recommendation) assessment completed prior to calling the provider. Provider order obtained and entered in (electronic health record) to send to ER (Emergency Room)/hospital.R2's medical record documents R2's diagnoses include, but not limited to: Paranoid Schizophrenia, Major Depression Disorder, and Hypertension.R2's medical record documents: Resident complains of multiple episodes of loose stool, nausea and abdominal pain, resident able to make needs known, requested to be sent to the hospital. DON (Director of Nursing) informed; resident sent to (hospital) 3:00 pm via ambulance for further evaluation. Resident is own self POA (Power of Attorney). On 8/1/25 at 11:50 AM R2 verified that he went to the emergency room recently, however R2 unable to provide any details of encounter.On 8/1/25 at 12:21 PM V3 (Assistant Director of Nursing) verified that facility Discharge/Transfer Out Checklist is what the facility uses as the policy. V3 confirmed that nurses are to complete SBAR (Situation Background Assessment Recommendation) form and call the emergency room with report when a resident is being sent to the hospital. V3 verified that R2 did not have an SBAR completed for his transfer to the emergency room on 7/10/25.On 8/1/25 at 1:48 PM V2 (Registered Nurse) verified that she sent R2 to the emergency room on 7/10/25 and she does not recall if she phoned the emergency room and provided report of resident condition to an emergency room nurse. V2 verified she is aware that SBAR (Situation Background Assessment Recommendation) form should be completed prior to sending a resident to the emergency department for evaluation.The facility was not able to provide any type of documentation regarding the transfer On 8/5/25 V3 (Assistant Director of Nursing) verified that there is not an order from the physician to send R2 to the emergency room for evaluation on 7/10/25. V3 stated, We were not aware that it was in our policy to obtain an order from the physician to send a resident to the emergency room for an evaluation.

Based on observation, interview, and record review the facility failed to prevent resident to resident physical abuse by a known perpetrator for two (R22 and R23) of 13 residents reviewed for abuse in the sample of 36. This failure resulted in R22 hitting R23 in the mouth which caused R23 to suffer bleeding from her mouth. Findings include: The facility Abuse, Prevention, and Prohibition policy and procedure, dated 12/2024, documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and means the individual must have acted deliberately, not that the individual must have intended to inflict, injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. This policy also documents that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The Final Report to the State Agency, dated 1/1/2025, documents, Original Complaint: It was reported to the abuse coordinator on 12/27/24 of an alleged physical altercation. While in the dining room (R22) allegedly struck (R23). The Account of events documents R22 and R23 were sitting in the dining room, R23 put her hand on R22's shoulder and began shouting. (R22) appeared to be startled, stood up and started to flail arms. Staff were present and in between residents at the time of the event to deescalate the situation. Remaining staff cleared dining room to ensure the safety of all other residents. R22 does not recall the incident and denies hitting anyone. The facility's undated Abuse Investigation documents a physical altercation occurred in the dining room with R22 striking R23. No injuries to R23. R23 approached R22, tapped R22's shoulder and yelled out. R23 stood up startled and began swinging his arms. Staff were immediately between the two residents. R22 did hit a staff member. All staff have interviews included in the investigation. The staff interviews for V4 CNA, V10 CNA, V35 CNA, and V43 CNA document they witnessed R22 attempting to hit staff members. V4 CNA witnessed R22 hit R23 and V35 CNA. V9 RN (Registered Nurse) documented multiple staff stated R22 hit multiple staff members and (R23). The investigation documents other residents were removed from the dining room. V1 Administrator's Abuse Investigation does not include names of potential staff and resident witnesses, tablemates, or who was in the dining room at the time of the altercation. The Investigation includes random Resident Abuse Allegation Interviews which include three non-specific abuse questions as: 1. Has a peer ever become physically aggressive toward you in the past week; 2. If yes, who did you notify; 3. Do you feel safe? These statements all document No to questions number one and two and yes to question number three. Due to questions asked it is not possible to determine if they had witnesses or specific details regarding the actual incident between R22 and R23. The Clinical Record for R22, includes the following diagnoses: Schizoaffective Disorder, Alcohol Dependence with Alcohol - Induced persisting dementia, Mild Neurocognitive Disorder, Insomnia, and Severe Manic Episode with Psychotic symptoms. R22 has severe cognitive impairment and history of verbal and physical behaviors directed towards others. The current Care Plan for R22 documents R22 with history of behavioral problems exhibited by verbal and physical aggression. A Physician Progress Note for R22, dated 2/12/25 at 4:04 pm, documents: R22 with psychotic disorder in ETOH (ethyl alcohol) induced Dementia. (R22) remains on 1:1 supervision due to his highly impulsive behaviors and mood swings. This note also documents R22 is erratic in mood. The Progress Notes for R22, dated 12/27/24 at 7:52 am, documents R22 receives one-to-one monitoring with staff. In the dining room waiting for breakfast (R22) and another resident were talking, other resident touched (R22's) arm, (R22) escalated very quickly, and hit other resident in the face. Multiple staff members are present and attempted to redirect (R22). (R22) continued to hit two other staff members in the face. (R22) then left the dining room, with his 1:1 staff and went to couch to lay down. Administrator, Physician, and local Law Enforcement were notified. Local Law Enforcement took statements and (R22) was sent out to a local hospital for evaluation. 12/27/24 at 10:16 am, R22 returned from the local hospital with no new orders and continued with one-to-one staff. The Clinical Record for R23, includes the following diagnoses: Schizoaffective Disorder, Bipolar II Disorder, Drug Induced Subacute Dyskinesia, Delusional Disorders and Chronic Obstructive Pulmonary Disease. R22 is cognitively intact. The current Care Plan for R23 documents R23 with a history of behavioral problems of yelling, cursing at staff, exit seeking, refusing medications, verbal, and physical aggressions, making false accusations, and attention seeking. The Progress Notes for R23, dated 12/27/24 at 7:48 am, documents R23 stated I touched peer and said hi, peer then back slapped me. Residents were immediately separated. Incident was witnessed by staff. Resident was assessed and no bruises or lumps noted at that time. 12/27/24 at 9:13 am, Resident came into SS (social service) office to discuss how they were doing. Resident stated that they were doing fine but still upset. SS will continue to follow up with resident. On 3/14/25 and 3/18/25 between 8:00 am through 4:30 pm, R22 had a staff member assigned to do one-to-one monitoring and noted to be walking about the facility independently. On 3/18/25 at 10:05 am, V35 CNA stated she was R22's one-to-one monitor on 12/27/24 and was sitting in the dining with R22. (R23) was also at the table and reached over and touched (R22) on the shoulder and started yelling. (R22) stood up and was swinging his arms. R22 did hit (R23) in the mouth and she was bleeding. R22 also hit V35 in the arm. V35 CNA stated she put all the information in her statement. On 3/18/25 at 10:12 am, V10 CNA stated she did not see (R22) hit (R23) but did see blood on R23's nose. There were multiple staff already dealing with the incident so (V10) just helped get residents out of the dining room. On 3/18/25 at 10:40 am, V9 RN (Registered Nurse) stated It was a big incident. Stated she did not witness the incident just heard that R23 tapped R22's shoulder and R22 freaked out. After reading her typed interview, V9 RN confirmed that there were multiple staff who stated R22 hit multiple staff and hit R23. On 3/18/25 at 11:26 am, V4 Social Service Assistant stated she was in the dining room, heard someone yell and when looked saw R22 stand up really quick and his arms went up. V4 stated she thinks someone got hit and heard R22 hit R23 but did not see it happen. V35 CNA was at the table, another nurse and there were residents but does not remember who they all were. On 3/18/25 at 1:43 pm, V44 Agency RN stated she was working the day the fight happened in the dining room between R22 and R23. R22 was sitting at the end of the table with a resident on each side of him. R23 was on R22's right side. R23 said she went to rub R22's arm and R22 flipped out and stood up. R22 back handed her in the face. I had never seen him lash out like that before. R23 did tell (V1 Administrator) that R22 hit her. (R22) also hit three or four staff who were right there. The dining room was evacuated and R22 calmed down and stopped being belligerent. Oh yes he meant to hit her. It was very willful. He was angry. R22 hit R23 two times, hit V35 CNA, and another staff member. The police did come and R22 did go out to the hospital and came back later that same day with no new orders. On 3/18/25 at 1:32 pm, V1 Administrator stated she is the Abuse Coordinator, she did the investigation for the physical altercation between R22 and R23. V1 stated the altercation occurred in the dining room. R23 reported she put her hand on R22's shoulder, yelled and R23 raised his arms up. V1 Administrator stated V35 CNA said R22 stood up and had hit (R23) and a staff member. V1 Administrator confirmed R22 did hit R23 and stated, no injuries were noted that I can recall.

Based on interview and record review, the facility failed to prevent and protect residents from verbal, mental, and physical abuse from occurring for 15 (R8, R12, R25, R41, R46, R72, R77, R82, R87, R89, R91, R96, R108, R110, and R113) of 15 residents reviewed for abuse in the sample of 51. This failure resulted in R41 being punched in the nose causing R41's nose to bleed and R25 being pulled down a hallway by her hair. Findings include: The facility's Abuse Prevention Program, dated 11/28/16, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including; but no limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, and any other individuals. 1. R110's Face Sheet, dated 2/7/24, documents R110's diagnoses including Paranoid Schizophrenia, Suicidal Ideation's, Hallucinogen Dependence with Induced Psychotic Disorder, Anxiety, Huntington's Disease and Major Depressive Disorder. R110's Facility local State Agency Report, dated 12/3/23, documents an altercation between R110 and R8. R8 notified staff that R110 laid in R8's bed and R110 struck R8's leg. The Report also documents an Incident Investigation Form, dated 12/3/23 at 9:50 am, stating that R110 was in the hallway having a verbal outburst and jumped over the counter at the desk and started kicking and thrashing. No injuries were noted and all parties were notified. R110's Nursing Note, dated 12/3/23 at 10:31 am, documents that R110 was involved in an altercation with (R8) and R110 was kicking objects and jumped over the Nurses' Station Desk. The Nursing Note also documents that R110 had been kicking and hitting R110's roommate (R8). No injuries were noted. R110's Facility local State Agency Report, dated 12/26/23, documents an altercation between R110 and R91. R110 was in a state of delusion, being disruptive in room. Staff went to check on (R110) at this time. (R110) exits room and directed outburst towards staff. The Report documents that R91 stated that R110 was yelling at the nurse and (R110) approached (R91) and began swinging her arms, making contact. R72 states that there was shouting and that R72 tried to help staff. The Report's Incident Investigation Form, dated 12/26/23 at 10:45 am, documents that R110 was in R110's room shouting and came charging out of R110's room swinging R110's arms, then R110 shoved R72, and proceeded down the hallway, and started slapping R91. No injuries were noted and all parties were notified. R110's current Care Plan documents that R110 has the potential to be physically aggressive related to poor impulse control. 2. R113's Face Sheet, dated 2/7/24, documents R113's diagnoses including Schizophrenia, Major Depressive Disorder, Anxiety Disorder and Catatonic Disorder due to known Physiological Condition. R113's current Care Plan documents that R113 has the potential to respond physically when provoked by peers, is known to display fluctuations in mood and uses Psychotropic medications (Haldol) related to behavior management. The Facility local State Agency Report, dated 1/27/24, documents that R41 has diagnoses including Schizoaffective Disorder/Depressive Type, Major Depressive Disorder, Recurrent Severe Without Psychotic Feature, Attention Deficit Disorder, Insomnia and Anxiety. Facility local State Agency Report, dated 1/27/24, documents an altercation between R113 and R41. R113 and R41 were on the Facility Smoking Patio, and that (R41) punched (R113) in the back of the head, so (R113) punched (R41) in the face and R41's face was bleeding. The Report's Incident Investigation Form documents that R41 stated, that R113 was making fun of R41's girlfriend and was trying to get her in bed and (R113) would not stop saying things, so I palmed (R113) in the back of the head and (R113) punched me in the nose. R113's Nursing Progress Note, dated 1/27/24 at 9:45 am, documents that R113 and R41 were involved in an altercation on the Smoking Patio and that (R113) states that another Resident (R41) hit him. R113's Quality Assurance Progress Note, dated 1/30/24, documents an altercation on 1/27/24, between R113 and R41, wherein R41 struck R113 and that R113 struck R41 back. On 2/6/24 at 10:45 am, V11 (Certified Nursing Assistant/CNA) stated, (R113) was out smoking on the patio and someone yelled at me that (R41) had a bloody nose. (R41) said that (R41) hit (R113) in the back of the head, so (R113) hit (R41) in the nose. On 2/6/24 at 11:50 am, V20 (Certified Nursing Assistant/CNA) stated, (R113) and (R41) were on the smoking patio and (R41) had a bloody nose. I was told that (R41) smacked (R113) in the back of the head and that (R113) punched (R41) in the face and (R41) got a bloody nose. They were fighting over a girl. 30678 3. The current Care Plan for R108 documents (R108) has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against this Resident. Behavior exhibited: yelling, cursing, making animal sounds instead of words, throwing items, laying on the floor, and taking other's belongings. Type of reprisal to guard against: physical aggression toward others. Those who may seek reprisal: Other residents. Resident's specific information: Diagnosis: schizophrenia, anxiety, PTSD (Post-Traumatic Stress Disorder). The Facility Reported Incident, dated 1/31/24, documents a witnessed altercation occurred on 1/31/24 between R25 and R108 and the police were called. R25 was sitting in a wheel chair and R108 grabbed R25 by the hair and pulled (R25) down the hallway approximately 5 feet. The signed and dated witness interview statements, dated 1/31/24, from V5 Housekeeping Supervisor, V17 Activity Director, V16 and V21 CNA's (Certified Nursing Assistants) document R108 pulled the facility fire alarm and then began roaming the hallways. R25 was sitting in a wheel chair propelling in the hallway and R108 grabbed R25 by the hair and began pulling R25 backwards. These staff intervened and separated the residents. The Progress Note for R108, dated 1/31/24 and 1:56 pm, documents (R108) was being combative and we were not able to redirect her. (R108) involved in a physical altercation with another resident (R25). (R108) was sent out to hospital via ambulance. On 2/6/24 at 3:00 pm, V4 Regional Director of Operations stated she did this investigation, sent the initial and final together because it was a witnessed incident. R108 was agitated that day, pulled the fire alarm and then was wandering the halls. When R108 passed R25 in a wheel chair, R108 grabbed R25's hair and began pulling her wheel chair backwards by R25's hair, about five feet. R25 and R108 were separated immediately, R108 was sent to a local hospital for a psychological evaluation, R25 was assessed for injury, the police were called, and a report was filed with report number 24-ECPA-00205. V4 Regional Director of Operations confirmed this allegation as substantiated due to being witnessed by staff. 4. The facility's final Abuse Investigation dated, 1/23/24, documents an alleged physical altercation occurred between R46 and R77. This report documents V1 Former AIT (Administrator in Training) was notified on 1/19/24 that R77 impulsively reached arm out, made contact with R46 and R46 struck R77 back. V9 RN witness interview statement, signed and dated 1/19/24, documents (R77) sitting in w/c (wheel chair) hysterically laughing by Nurses Station. (R46) walking by, (R77) reached out arm impulsively and made contact with (R46). (R46) struck (R77) back on right arm/shoulder, was upset about situation. V24 RN witness interview statement, signed and dated 1/19/24, documents This RN observed (R77) reach out to strike at another Res (resident) as they walked past other Res. (R46) then turned and hit (R77) in the arm stating 'that's what you get for hitting me.' R77's signed and dated interview, dated 1/19/24, indicates R77 did not recall the incident. R77 made sexual comments to V2 DON (Director of Nursing) during interview. A second interview attempt was made on 1/20/24 with another related verbal response. R46's Statement, dated 1/19/24, documents resident stating The guy in the hallway punched me real hard so I hit him back. On 2/6/24 at 3:00 pm, V4 Regional Director of Operations confirmed this allegation as substantiated due to being witnessed by staff. 33960 5. R89's Care plan, dated 11/15/23, documents, The Resident is known to display fluctuations in mood related to schizo-affective disorder, Parkinson. (R89) is noted to have inappropriate behaviors and responses such as spitting on/toward staff and peers, knocking over ice carts and laundry carts. A Facility Final Report (to State Agency) for incident on 11/14/23, no date available, documents, Original Complaint: It was reported to the abuse coordinator of an alleged altercation. While in the dining room R89 allegedly shouted at R96, R96 made contact with R89 after. Account: R96 states R89 was in the way. R96 asked R89 to move several times. R89 raised his voice at R96. R96 then made contact with R89 while making her way around him. Determination: It appears as the dining room was congested. R89 became over stimulated and started shouting. R96 was simply trying to pass by. Incident Investigation Form with V20 (CNA-Certified Nursing Assistant), dated 11/14/23, documents, I heard yelling and came around corner to see (R89) have a hold of (R96's) arm. On 2/6/24 at 11:20 a.m., V20 stated, I just came around the corner and saw (R89) holding (R96's) arm. Incident Investigation Form with V21 (CNA), dated 11/14/23, documents, (R96) had pushed elbow into (R89) and (R89) grabbed (R96's) wrist. 6. A facility Final Investigation Report (to State Agency), no date available, documents, It was reported to the abuse coordinator of an alleged altercation on 1/22/24. While in the common areas residents (R72 & R89) had a verbal disagreement that led to physical contact. Account: R89 states he was trying to retrieve a cup. R72 states she will not be disrespected in her house and shouted at R89. R72's statement, dated 1/22/24, documents, I won't be disrespected in my house. I got in his (R89's) face and yelled at him and he hit me for no reason. V12's (Business Office Manager) written statement, dated 1/22/24, documents, I was coming around the nurses station when I heard yelling in the living room. As I rounded the corner I saw (R89) and (R72) arguing. As I was walking towards them to separate them, (R89) reached out and struck (R72). I ran to them, (R89) had (R72) in a bent over hug from the side. On 02/07/24 11:13 AM V12 stated, I was coming from the nurses' station and heard yelling. When I got in the fireplace area, (R72's) back was to me, but I could see that (R89) had struck (R72) in the chest area. Then, he had her in like a bent over hug like position. 33970 7. The Facility's Final report for Incident on 10/5/23 documents that R87 he asked R72 to stop talking. R72's written statement documents R72 told R87 if he asked again she would strike him. R72 then stuck R87 on the arm and R87 backhanded R72 across the face. The Account documented that the account of the incident was taken by R72 and R87 and written statements from peers in the dining room during the incident that R72 slapped R87's arm and R87 smacked R72 with the back of his hand across the face. On 2/5/24 at 1:30 PM R72 stated I was only joking around with (R87) and lightly tapped him on the arm and he backhanded me across the face. It hurt, but I didn't have any bruising or anything. He apologized for over reacting. 8. The Facility's Final Report for incident on 11/1/23 documents that on 11/1/23 R72 got in R12's personal space and would not move. R12 then pushed R72 to the side. The Account section of the Final Report documented that the account of the incident was taken by R12 and R72 and V11(Certified Nurse Aide) who witnessed the incident and confirmed that R12 physically shoved R72 out of her way and walked past her. 9. The Facility's Final Report for incident on 12/1/23 documents that R72 was in the living room talking with R82 and R12 began being verbally aggressive towards both R72 and R82. R12 then got up and made contact with R72's arm before walking out of the room. The Account section of the Final Report documents the account of the incident by R12, R72 and R82 who witnessed the incident and V11 (Certified Nurse Aide) who overheard the incident and confirms that R12 made contact with R72's arm while walking away. On 2/6/24 V11 (Certified Nurse Aide) stated I didn't actually see (R12) make any sort of contact with (R72) but (all three residents) told me it was like (R12) just kind of bumped her arm against (R72)'s arm aggressively. On 2/6/24 at 1:30 PM R72 stated (R12) is just a b***h and thinks she runs this place, We can't sit by each other at anything anymore and our rooms had to get changed.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical and verbal abuse by R16, a [AGE] year old independent ambulatory man, with a known history of frequent resident to resident altercations with 1:1 Staff present, failed to institute new safety interventions to protect against resident to resident altercations, failed to provide supervision to protect a resident R1, with offensive behaviors, from retaliatory physical and verbal abuse despite 1:1 supervision. These failures had the potential to affect all 118 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5/8/23, the facility remained out of compliance at a Severity Level 2 as the facility continues to conduct ongoing Abuse Identification and Prevention Training, protecting residents during an altercation training, and effectively providing 1:1 supervision training with all current staff, Agency Staff and newly hired staff and the Quality Improvement Program conducts random audits to ensure facility staff's compliance with resident behavior monitoring, implementing abuse interventions, staffs' understanding of what to do in a situation of an altercation and to effectively provide 1:1 supervision, and the Abuse Prevention Program. Findings include: The facility's Abuse Prevention Program, dated 11/28/16, documents, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This facility is committed to protecting our resident from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. The policy also documents, Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. 1. A Facility 5 Day Final Report, dated 4/28/23, documents, Original complaint: It was reported on 4/25/23 that while in the common areas R16 allegedly called R1 a 'b**ch' and told her she needed to go home. Residents will be offered 1:1 time with Social Services once a week for 3 weeks. A written statement signed by V19 (Business Office Manager), dated 4/25/23, documents, I was sitting in the office, on my computer. When I heard yelling in the TV room. I got up to see what was happing. (R16) was stood in front of the couch, in front of (R1). He called her a b**ch. Then, I overheard him threatening to cut (R1). As of 5/3/23, R1 nor R16's medical records have no documentation of 1:1 sessions with Social Services. On 5/2/23 at 10:00 a.m., R1 was sitting outside smoking. R1's 1:1 staff member, V17 (unit aide), was watching her through the window from inside of the facility. V17 stated, I have never witnessed a physical altercation with (R1) until today. She gets verbally aggressive a lot with other residents. Today (R1) and (R16) got verbal with each other and she started calling him a b**ch then he slapped her a few times in the face. On 5/2/23 at 1:30 p.m., R17 was observed propelling himself towards V1's Office. R17 was bleeding from his mouth and his right hand was actively bleeding. At that time R17 stated, He (R16) punched me in the mouth. All I was trying to do was help him open his ice cream. On 5/2/23 at 1:40 p.m., V13 (Social Services) stated, (R16) will walk down the hall and say stuff or come in here and if it's not taken care of right away he has an outburst. It's like something is going on with him. R17's Incident Note, dated 5/2/23 at 1:44 p.m., documents, R17 assessed with minor skin tear 0.2 cm (centimeters) x 0.2 cm to left hand and swollen bottom lip. R16's Incident note, dated 5/2/23 at 2:51 p.m., documents, R16 verbally aggressive with nurse during assessment and asking R16 about what happened. (R16) states that other resident (R17) spoke racial slurs to him so he punched him in the face. On 5/2/23 at 2:47 p.m., V18 CNA stated, I'm (R1's) 1:1 tonight. I was never told that (R1) and (R16) had an incident this morning. That would have been nice to know. I try to keep (R15) and (R16) away from (R1). (R16) is so unpredictable you never know what he's going to do. When he got in (R1's) face (4/25/23) (R16) told (R1) he was going to slice (R1). He's a little scary. (R1) likes to instigate things and get other residents upset then they want to go after her. (R16) is very hateful and gets angry with (R1) as well. He's hit her before. I don't know what to do in the case of another resident trying to hit (R1). All I know to do is to try and redirect them. I haven't had any training about these situations. I know that (R1) has spit on other residents and they've hit her. I can't believe (R16) hit (R17). (R17) is the sweetest man ever and wouldn't instigate anyone to hit him. See (R16) is unpredictable. On 5/3/23 at 12:20 p.m., V17 stated, (R1) and R16 had two incidents yesterday. The one where he slapped her across the face in the morning, and then in the afternoon they had a verbal altercation. Right after he hit her, (V1 Administrator in Training) came up on the commotion. (R16) went off on (V1). He started yelling and cussing at her. I didn't notify anyone about what happened because (V1) told me she had it all taken care of. Around 1:15 p.m., (R1) sat next to (R16). I asked her to not sit there and we could sit somewhere else, and she refused to move. She reached over and touched (R16's) hair, and he said, 'Keep your f**king hands off of me.' (R1) wouldn't move so I asked (R16) if he would move, and he told me, 'White lady you aren't going to tell me what the f**k to do.' The office door was closed when I left, so I put a note under the door to let (V2 Assistant Administrator in Training) know what happened with that incident. R1 and R16's current medical records have no documentation of abuse investigations regarding both altercations that occurred on 5/2/23. There is also no documentation of interventions implemented following each altercation to prevent R16 from further assaulting any other residents. On 5/3/23 at 11:25 a.m., V23 Registered Nurse stated, I was working yesterday when (R16) punched (R17) in the face. (R17) told me he was trying to help (R16) with opening his ice cream at lunch and (R16) said (R17) called him a racial slur. (R16's) baseline is agitated. It doesn't take much to get him worked up and he thinks everyone is against him racially. We didn't change anything supervision wise either for (R16). I had no idea that (R16) hit (R1) yesterday (5/2/23) morning. No one told me. On 5/3/23 at 11:38 a.m., R16 was ambulating independently down the hall. R16 stated, I don't know what you're talking about when asked about the 5/2/23 incident and started yelling and cussing. On 5/3/23 at 11:50 a.m., V21 Certified Nursing Assistant stated, I didn't know that (R16) and (R1) had an incident yesterday (5/2/23). He was irritable the whole day yesterday. It started even at breakfast he was antagonizing people and yelling so I took him back to his room for breakfast. Anyone that walked by him yesterday he would exchange words with them. When he got to lunch he was yelling at residents as well. He's like that today too. I came into the end of the argument yesterday. He had punched (R17). I took (R17) from the room. I'm not aware of us doing anything different with (R16). On 5/3/23 at 12:10 p.m. V22 Registered Nurse stated, I wasn't aware that (R1) and (R16) had an altercation yesterday morning and I was (R1's) nurse. V22 also stated that (R16) is able to independently ambulate throughout the entire facility. On 5/3/23 at 1pm, V13 (Social Services) stated, I didn't know that (R16) had an incident with (R1) in the morning. I knew he had two incidents in the afternoon. I never did work with him or do anything with him regarding the incidents. V13 also confirmed that she has not done any 1:1 sessions with R1 or R16 since their incident on 4/25/23. On 5/3/23 at 2pm, V1 (Administrator in Training) stated, I did not know that (R16) hit (R1) when I walked up on them yesterday morning. I knew he was irritated, and he started cussing at me, but V17 never told me R16 had slapped R1. I didn't know that there was a verbal altercation that afternoon either. (V17) should have verbally told us that the incident occurred, not put a note under the door. There was no note under the door. We have told them and told them to report everything to us, and that if they don't they will be fired. This is ridiculous. We didn't start any kind of investigation because we never knew he slapped her or had a verbal altercation with her. All we knew was he had hit (R17) that afternoon. On 5/4/23 at 9:30 a.m., R17 was sitting in his room watching television. He was completely alert and oriented. R17 had a scab on his left hand from what appeared to be a skin tear and his lower lip was swollen with a cut. R17 appears elderly and frail. R17 has a walker in front of him, but he said he is unable to ambulate more than a step or two, so he uses a wheelchair. R17 indicated he is currently on Hospice, because I'm just getting old and going downhill. R17 stated he's lived here about six months, but his family wants him to move because they are concerned this is not the safest place for him. R17 stated, I was in the dining room and he (R16) was sitting next to me. (R16) was trying to open his ice cream, but was having a hard time. He put his ice cream down and I picked it up to open it, before I could even react, he (R16) was standing up from his chair and punched me in the face. Somehow in the scuffle my hand got busted open and was bleeding, my lip was busted open and was bleeding. (R16) kept yelling that I called him a n****r, but I didn't. Someone separated us. (R16) moved so fast, I didn't even have time to push my wheelchair out and away from him. When R17 was questioned if he was afraid to live in this facility or if he was afraid of any of the residents, including (R16). R17 stated, I'm not going to be afraid. I know I can't defend myself very well, but I won't live like that. On 5/4/23 at 10:18 a.m., R12 stated he was a witness to the incident on Tuesday between (R17) and (R16). R12 stated, I was sitting at the table next to them. (R17) was trying to help the guy (R16) and he just stood up and started swinging. (R17) never had a chance. He's confined to a wheelchair, what could he possibly do to defend himself? I mean, the other guy can walk. He (R16) tried saying (R17) said racial slurs to him, but he never did. The guy (R16) got (R17) good. His lip was bleeding all over. I'm just over being in this place. I was supposed to just be here for therapy and then go home, but I'm not sure I can finish my last 30 days here. It's just chaos, all the time. On 5/4/23 at 10:40 a.m., R18 stated, I was out there when (R16) hit (R17). That poor old man (R17) is in the wheelchair and can't defend himself, and (R16) just hauled off and punched him (R17) in the face. I saw blood on (R17's) face. (R17) didn't do anything. (R16) gets irritated pretty easily especially with (R1). On 5/4/23 at 11:35 a.m., V1 confirmed that an investigation was not started immediately after the incidents on 5/2/23 between (R1) and (R16). Therefore, the facility did not implement anything to prevent R16 from further assaulting any other residents. The facility's Room Roster, dated 5/1/23, documents that 118 residents reside in the facility. 2. R1's Nurse's notes, dated 3/20/24 at 9:00 a.m., document, (R1) out on patio for smoke pass and spit in another resident's (R4) face. Continue 1:1's. R1's Nurse's notes, dated 3/24/23 at 6:00 p.m. document, (R1) spit on another resident (R15) while sitting on the couch. (R1) agitating resident previous to spitting on him by touching him when asked to stop. Facility Initial Report email, dated 4/11/23, documents, Resident to resident incident: Residents involved R4, R1. Alleged resident to resident physical altercation. V35's (Activity Assistant) written undated statement documents, I was on the patio when (R1) started calling (R4) names and then (R1) spit in (R4's) face. Then, (R4) got up and smacked (R1's) head on the wall. Then they stopped after I got in between them. V32's (Activity Assistant) written statement, dated 4/11/23, documents, (V35) and I were passing and lighting cigarettes (R1) and (R4) started to yell back and forth. (R1) then spit in (R4's) face. R4 then smashed the back of (R1's) head into the brick wall. CNAs (Certified Nursing Assistants) and nurses came out and had it handled. (R1) went in but then came out again. She was calling staff members, 'b**ch,' and spitting at them. R7's written but undated statement, documents, (R1) keeps spitting on people and (R4) pushed (R1) into the wall and spit back on (R1). Then they were separated. R2's written undated statement, documents, (R1) spit on (R4) twice and (R4) got up to defend herself and pushed (R1's) head against the wall. They were separated after that. R20's written undated statement documents, (R1) spit on (R4) and (R4) pushed her face and pushed her down. After that they were separated. R4's written undated statement, (R1) spit on me and so I pushed her head against the brick wall. Then we were separated. R5's written undated statement documents, We were out for smoke break and (R4) asked (R1) to not touch her when she sat next to (R4). (R1) then spit in (R4's) face then (R4) grabbed (R1) by the throat and smashed her head off the brick wall then I pulled (R4) off (R1) and the fight stopped. R19's written undated statement documents, I saw (R1) spit on (R4) and then (R4) punched her and beat her head against the brick wall. V4's (Resident Care Coordinator) written undated statement documents, (R1) ran out of the C wing door. (R1) upset because she got into an altercation with (R4). She was outside on patio and called (R4) a b**ch. (R4) stated say it one more time. (R1) did. (R4) struck her. (R1) struck back and they were separated. A facility 5 day Final Report, dated 4/16/23, documents, It was reported on 4/11/23 that while both residents (R1 & R4) were in the facility's courtyard during a scheduled smoke pass that (R1) allegedly called (R4) a derogatory name, (R4) then returned the verbal gesture. It was then reported that (R1) allegedly expectorated on (R4). Reports continued that (R4) then allegedly struck (R1) with her hand then (R1) allegedly struck (R4) in return. Both residents have been placed on list to be seen by Psych Nurse Practitioner for evaluation and recommendations for further treatment. On 5/3/23 at 2:35 p.m., V32 (Activity Assistant) was sitting outside of R13's room whom she was supervising as a 1:1. V32 stated, I was on the smoke patio the night that (R4) hit (R1's) head off of the wall. We were on smoke break. I don't know who (R1's) 1:1 was that day. The 1:1 tends to sit inside of the building watching her through the window. They are not always with her. I heard commotion and (R1) spit in (R4's) face. Then that's when (R4) smacked (R1's) head off of the wall. I ran inside to get help. I haven't ever been told what the rules are when it comes to supervising a 1:1 resident. I think you just have to visualize them. I work activities in the evening, but sometimes when I get here they tell me I have to do 1:1 with either (R13) or (R1). I'm not the person to ask what we are supposed to do in the case of a resident fight. I haven't gotten any training on this stuff. I just get handed the 1:1 sign off sheet. On 5/4/23 at 11:35 a.m., V1 stated, After the 4/11/23 incident, I talked to (R4) about controlling her anger. When the altercation starts staff should separate them immediately and get them calmed down. I don't know how (R1) ended up still getting hit even though she had a 1:1. I wasn't there to witness it. They should be interjecting and getting in between the residents. I've talked to (V31 Unit Aide) about stepping in when things are escalating. We have educated staff to de-escalate the situation. I don't think staff are afraid to intervene. (R1) is not instigating the other residents, it's the other residents that are having the behaviors towards (R1). There was no formal training done after this incident (4/11) just talking to the staff. R1's Behavior note, dated 4/13/23 at 9:19 p.m., documents, (R1) on patio calling people names threatening to spit on them. Residents came inside after smoke break. (R1) spit at (R2). (R2) told her to spit again. She spit again. (R2) attacked her. The residents were separated and they attacked each other again. They were separated and started spitting at each other in between staff. A facility 5 Day Final Report, no date, documents, It was reported that (R1) allegedly called (R2) a 'b**ch' which caused (R2) to return the verbal gesture. It was reported that (R1) then alleged spat in (R2's) face. (R2) allegedly hit (R1) in face and spat back on (R1). R2's Incident Investigation Interview form, dated 4/14/23, documents, (R2) stated that while near the nursing station (R1) spat on (R2). That is when (R2) hit (R1). R2's Nurse's Notes, no date, document, (R2) stated that (R1) was calling her names spitting at her and she pinned (R1) to the wall and hit her. R2's Behavior note, dated 4/13/23 at 9:29 p.m., documents, (R1) on patio calling people names threatening to spit on them. Residents came inside after smoke break. (R1) spit at (R2). (R2) told her to spit again. (R1) spit again. (R2) attacked her. The residents were separate and they attacked each other again. They were separated and started spitting at each other in between staff. On 5/4/23 at 10:35 a.m., R2 stated, (R1) had spit on me at least three different times, and I couldn't take it anymore. The last time she spit on me I punched her in the face twice. She had a 1:1 with her, but they don't do anything to interfere or stop anything. They might ask her to not spit and that's it. These little teenagers don't do anything. R1's Incident Investigation Interview, dated 4/25/23, documents, (R16) walked by and called me a f**king b**ch and a 'ho' and told me I needed to go home. Facility 5 Day Final Report, dated 4/28/23, documents, Original complaint: It was reported on 4/25/23 that while in the common areas (R16) allegedly called R1 a b**ch and told her she needed to go home. Residents will be offered 1:1 time with social services once a week for 3 weeks. R1's Incident note, dated 4/26/23 at 6:45 p.m., documents, This nurse was notified by staff member that this resident was exchanging curse words with a male resident (R15), this resident became increasingly agitated and spit on (R15) in his face. V33's (Unit Aide) written statement, no date, documents, (I) was walking with R1, she and R15 was exchanging words (cursing) with each other. R1 got mad and spit on R15 in his face and walked away to the nurses' station. R15's Incident Investigation Interview form, dated 5/1/23, documents, (R15) states (R1) got mad at him for not saying 'hi' they exchanged words and then she spit on him. A facility 5 day final report, dated 5/1/23, documents, It was reported on 4/26/23 that (R1) and (R15) allegedly exchanged curse words with one another. (R1) became upset and allegedly spit on (R15). (R1) still remains on 1:1 supervision. Residents will be offered 1:1 time with social services once a week for three weeks. A facility Five Day Final Report, dated 5/2/23, documents, It was reported on 4/27/23 that during an afternoon smoke pass (R4) had touched (R1). At that time (R1) was spitting everywhere and allegedly spit on (R4). (R4) states she just reacted and allegedly hit her. Residents will be offered 1:1 time with social services once a week for three weeks. R4's Incident Investigation Interview form, dated 4/27/23, documents, At 1:30 p.m. smoke pass out on patio, I was sitting in a chair (R1) touched me and I (said) don't touch me. She was spitting everywhere and then spit on me on my face. My reaction was to push her away but she was close and my arm and hand made contact with her. V34's (Activity Assistant) written statement, dated 4/27/23, documents, (R1) spit at (R4). Unit aides came between them. I continued lighting cigarettes. I turn around to yelling and (R4) hitting (R1). V17's (Unit Aide) written interview, dated 5/1/23, documents, Have you ever witnessed (R1) and (R4) be inappropriate towards one another? Yes smoke pass or in the TV room. Usually (R1) says hello and (R4) says, 'Don't talk to me.' R1's response is always, 'B**ch. On 5/2/23 at 10:50 a.m., R4 was alert lying in bed. R4 stated, (R1) spits at me and in my face all the time. No one does anything to stop her even her 1:1. Both times I hit (R1) I just got so fed up I couldn't take it anymore. R1's Care plan, dated 5/1/23, documents, (R1) has potential to be physically aggressive related to Bipolar and TBI with poor impulse control. The care plan also documents the following intervention: (R1) was called a 'b**ch ' and told to go home by another resident. Offered 1:1 time with social services once a week for three weeks. Still remains on 1:1 supervision. (R1's) care plan has no revision to include (R1's) behavior of spitting on other residents causing altercations. On 5/1/23 at 11:35 a.m., R13 stated, I never see the 1:1's for (R1) or (R14) and if I do they are on their phones not watching them. All you ever see is these little teenage 1:1's who are too busy texting their friends or taking pictures of themselves. They don't care about where their residents are at. On 5/2/23 at 10:00 a.m., R1 was sitting outside smoking. Her 1:1 staff member, V17 (Unit Aide) was watching her through the window from inside of the facility. V17 stated, I have never witnessed a physical altercation with (R1) until today. She gets verbally aggressive a lot with other residents. Today (R1) and (R16) got verbal with each other and (R1) started calling (R16) a b**ch then he slapped her a few times in the face. When she starts to get verbal with other residents, I try to remove her, but she's stubborn. I can't always get the other resident to leave either. When (R1) gets verbal, the other residents get mad and hit (R1). On 5/2/23 at 11:20 a.m., V33 (Unit Aide) stated, (R1's) behaviors depend on who she is sitting with. If she's sitting with (R16) or (R15) it's trouble. At smoke time, (R1) likes to cut in line and that does not go over well with the others. If (R1) is mad she will hit and kick other residents. I try telling her we need to leave or go for a walk, go for a break, we can go sit in her room or go down the hall. I try giving her ice too. Most of the time she will not get up. So, I have to go get the nurse. The nurse doesn't really help a lot of times because they just do the same thing I already did, and it doesn't help. I may ask the other resident then to move, and sometimes that will help. (R16) will just keep arguing with her. (R16) gets in her face. The other day I had to get (V1 Administrator in Training) because (R16) was in her face. The incident (4/13/23) with (R2) started outside. They were arguing about something during smoke pass. I told (R1) to put her cigarette out so we could go inside to get away from it. Then, (R1) came in and (R1) spit on (R2) and (R2) hit (R1). The incident (4/26/23) with (R15) was (R1) got done eating dinner and sat next to (R15). (R15) said he didn't want her to sit there and asked her to move. I tried to get (R1) to move. (R1) wouldn't move so (R15) started to get rude and then (R1) got rude and kicked (R15). Basically we are just taught to try to redirect them, and if that doesn't work then get the nurse. Not much else is taught to us if we aren't able to redirect them we have to leave the residents alone to get the nurse. On 5/2/23 at 1:40 p.m., V13 (Social Services) stated, (R1) has been on 1:1 ever since I got here. (R1) spits on other residents quite a bit. I talk to her about being inappropriate, but (R1) doesn't remember it. (R1) doesn't remember long term. (R1) wouldn't remember spitting on people. Certain people (R1) is not supposed to be by like (R16) because they get each other riled up. I haven't been documenting the 1:1 sessions because I haven't been doing them. On 5/3/23 at 12:20 p.m., V17 stated, (R1) and (R16) had two incidents yesterday. The one where he slapped her across the face in the morning, and then in the afternoon they had a verbal altercation. Around 1:15 p.m., (R1) sat next to (R16). I asked (R1) to not sit there and we could sit somewhere else, and she refused to move. (R1) reached over and touched (R16's) hair, and (R16) said, Keep your f**king hands off of me. (R1) wouldn't move so I asked (R16) if he would move, and (R16) told me, White lady you aren't going to tell me what the f**k to do. On 5/3/23 at 12:00 p.m., V12 Registered Nurse stated, I don't know how other resident's are able to hit (R1) if she has a 1:1 with her at all times. I question it all the time. I know (R1) likes to instigate and spit on residents and get verbal. She picks at other residents all the time. On 5/3/23 at 1:40 p.m., V36 CNA (Certified Nursing Assistant) stated, If you are 1:1 with (R1) she just has to be within visual distance. On 5/3/23 at 1:05 p.m., R1 was sitting on the couch in the TV room. R1's 1:1 staff member, V37 (CNA), was sitting approximately 15 feet away from R1. On 5/4/23 at 11:35 a.m., V1 stated, The staff are all educated on redirecting the residents and trying to deescalate the situation. When V1 was asked how the perpetrators are able to hit R1 even with 1:1 staff present, V1 stated, Are you expecting this little teenage boy to jump in between these residents who are fighting? Have you seen these residents and how big they are? I educate these teenagers but they don't process this information well. V1 also stated, The 1:1 staff member should be within arms' length of the resident they are supervising. On 5/4/23 at 12:05 p.m., V9 (Regional Clinical Director) stated, What are you wanting us to do? Do you want the staff members to push the resident out of the way so there is no physical contact. The staff member pushes the resident, and the resident gets hurt then you are after us because that staff member wasn't trained properly. Regardless of what we do is wrong. We are doing our best here with this population that we have in this facility. I've gotten IJs (Immediate Jeopardy's) for this. On 5/4/23 at 12:15 p.m., V4 (Resident Care Coordinator) stated, Can you tell us what we are supposed to be doing here if we aren't taking care of these residents like we are supposed to? What do you want us to do? We are doing everything we can with (R1). We have call's out to other facility's to see if they could take better care of her, but we haven't heard back from any of them. On 5/8/23 at 2:15 p.m., V31 was sitting in front of fireplace while R1 was sitting on the couch in the TV room. V31 stated he got training on Thursday and they went over that the 1:1's needed to watch their residents better. V31 also stated, When it comes to watching (R1) I just need to have visual contact of her (R1 was approximately 20 feet away from V31 sitting on a couch). R16 walked up in front of R1 bent over and grabbed her thigh and was laughing. R16's 1:1 staff member V28 (CNA) was walking with R16 and did not address the interaction. V31 stated, We are supposed to keep (R1) and (R16) separated they need to be at least six feet apart. The Immediate Jeopardy started on 4/25/23 when R16 called R1 a b**ch and threatened to cut R1. On 5/4/23 at 1:25 p.m., V1 (Administrator in Training), V2 (Assistant Administrator in Training), V3 (Director of Nursing), V4 (Resident Care Coordinator) and V5 (Corporate Staff) were notified of the Immediate Jeopardy and Substandard Quality of Care. On 5/8/23, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. V1 and V2 were educated on Abuse Identification and Prevention by V9 (Regional Clinical Director) on 5/4/2023. 2. V1 and V2 initiated staff education on Abuse Identification and Prevention on 5/4/2023. 3. V2 educated by V9 on what to do in the situation of an altercation to protect the residents on 5/4/2023. 4. V2 initiated education to staff on what to do in the situation of an altercation to protect the residents on 5/4/2023. 5. V2 educated by V9 on how to effectively provide 1:1 supervision on 5/4/2023. 6. V2 initiated education to staff on how to effectively provide 1:1 supervision on 5/4/2023 7. Residents with known history of altercations to be monitored through internal QAA process through behavior monitoring program and reviewed by Quality Assurance Team during weekly behavior QAA, Quarterly QAA and more frequently as needed. 8. Quality Assurance Team to be review implementation and effectiveness of interventions put into place to prevent further abuse through daily QA meeting 9. Facility newly hired PRSC to initiate Social Service programming with residents to include conflict resolution techniques and impulse control. 10. Quality Assurance Team to conduct random rounds/interviews ensure staff is aware of what to do in a situation of an altercation. This will be done weekly for four weeks by V2. 11. V1 or designee to ensure any staff member who is performing 1:1 duties will be educated on how to effectively provide 1:1 supervision. 12. In-servicing training by V2 on Abuse Prevention Policy with all staff will continue monthly for the next 3 months, then quarterly times three by V2 or V3 (Director of Nursing). 13. All new employees to be in-serviced on Abuse Prevention Policy upon hire during orientation process prior to working with residents.

Based on observation, interview and record review, the facility failed to investigate an allegation of sexual abuse made by R6 against R9 (on 1/05/23) and protect R6 from potential further abuse, failed to investigate and implement measures to prevent an ongoing sexual relationship between a resident (R6, who lacks the mental capacity to legally consent) and R15, failed to investigate multiple allegations of abuse made by residents during Resident Council meetings, which included sexual abuse, verbal abuse, staff retaliation and misappropriation, and failed to investigate an allegation of verbal abuse made by R3 against V3 (Registered Nurse) on 1/24/23. Additionally, the facility failed to investigate inner thigh bruising found on R1's inner thighs and facial bruising found on R5, both injuries of unknown origin. These failures have the potential to affect all 116 residents that reside in the facility, as no measures were taken by V1 (Administrator in Training) to ensure residents within the facility were protected from potential further abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02/02/2023, the facility remains out of compliance at a Severity Level 2 as the facility's Quality Improvement Program conducts random audits to ensure facility staff's compliance with the Abuse Prevention Program, with an emphasis on Abuse Reporting, Investigation of Abuse Allegations, and staff's understanding of Abuse Prevention Training. Findings include: The Abuse Prevention Program policy (revised 11/28/2016), documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and 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 mistreatment, exploitation, neglect or abuse of our residents. The policy later documents, The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse: Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Sexual Abuse is non-consensual sexual contact of any type with a resident. 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 their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or 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. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident's consent. Mistreatment means inappropriate treatment or exploitation of a resident. Section IV of the policy documents, Internal Reporting Requirements and Identification of Allegations: Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property to a supervisor and administrator. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Supervisors shall immediately inform the administrator or his/her designated representative (specified by the administrator in the case of a planned absence) of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. Section V of the policy documents, Protection of Residents: The facility will take steps to prevent mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property while the investigation is underway. Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse or misappropriation of resident property shall not complete their shift as a direct care provider to residents. The policy further documents, under Section VI, Internal Investigation of Allegations and Response: 1. Appointing an Investigator. Once the administrator or designee receives an allegation of mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property: the administrator will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident and follow the Resident Protection Investigation Procedures. 2. Following the Resident Protection Investigation Procedures. The appointed investigator will follow the Resident protection Investigation Procedures, attached to this policy. The Procedures contain specific investigation paths depending on the nature of the allegation, procedures for investigation, interview parameters, and reporting requirements. 3. Confidentiality. The investigator shall do as much as possible to protect the identities of any employees and residents involved in the investigation until the investigation is concluded. After a conclusion based on the facts of the investigation is determined, internal reports, interviews and witness statements shall be released only with the permission of the administrator or the facility attorney. Even if the facility investigation is not complete the administrator will cooperate with any Department of Public Health investigation into the matter. 4. Updates to the Administrator. The person in charge of the investigation will update the administrator or designee during the progress of the investigation. The administrator or designee will keep the resident or resident's representative informed of the progress of the investigation. 5. Final Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The policy documents, under Section VII, External Reporting of Potential Abuse: 1. Initial Reporting of Allegations. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH immediately after forming the suspicion (but not later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming the suspicion. A written report shall be sent to the Department of Public Health. The written report should contain the following information, if known at the time of the report: Name, age, diagnosis, and mental status of the resident allegedly abused or neglected; Type of abuse reported (physical, sexual, theft, neglect, exploitation, verbal, or mental abuse); Date, time, location, and circumstances of the alleged incident; Any obvious injuries or complaints of injury; and, Steps the facility has taken to protect the resident. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property and that an investigation is being conducted. The facility policy, titled Injuries of Unknown Origin (revised 4/18/16), documents All injuries of Unknown Origin will be investigated to determine the potential cause of the injury. Upon identification of the cause, interventions will be established to prevent any further injury by the IDT (Interdisciplinary Team) or Administration. All Injuries of Unknown origin will be discussed at the daily (Quality Assurance) meeting. The policy advises, Determine if the injury may be related to mistreatment of a resident: Bruising noted about the face or neck area; Bruising/reddened areas noted on wrists or lower forearms - similar to finger placement, or any part of the body that may indicate finger placement; Handprints/bruising noted to buttocks. The policy instructs staff to Identify and establish interventions for prevention of any further injuries: Possible Abuse - Begin following Abuse Prevention Program. 1. A Grievance/Complaint Report, dated 1/05/23 and completed by V4 (Social Services Director), documents R6 complained (R9) rubbing on her butt, putting arm around her (and) saying 'Baby, give me a kiss,' touched her breast, looked up her dress. Also, going up (and) down A Hall (at) night, (R6) claimed, 'I can hear (R9) through the wall.' Resident Council Meeting minutes dated 1/10/23 document (R9) needs to be on a 1 on 1 at all times, overnights too. Residents are not comfortable in his presence and are scared of him. (R9 is) very violent, overly sexual, calling names, going through resident's rooms, (R10, R6, R11 and R12) have all brought attention to this. A Resident Council Concern/Complaint form, dated 1/10/23 by V16 (Activities Director), documents Residents would also like if (R9) was out of the facility because they feel unsafe. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: Other concerns: (R9) is touching and grabbing women in a sexual behavior. (R9) is pinning residents against walls and counters as well. (R6) stated that (R9) has looked up her skirt, grabbed her breast, and rubbed his penis on her many times. It was stated in resident council that (R9) does not have a 1:1 anymore, and (R13 stated R9) touched my boobs and rubbed his penis on me. (R11 stated R9) is getting into people faces and personal space and touching the way she don't want to be touched. Upon entering the facility on 1/24/23 at 9:10 am, V1 (Administrator in Training) was asked for all the facility's Abuse Allegations investigated and reported to the Illinois Department of Public Health in the last 90 days. V1 provided three separate investigations, none of which involved R9, and indicated those were the only Abuse Allegation Investigations she had. On 1/24/23 at 3:15 pm, V4 (Social Service Director) stated R6 told her on 1/05/23 that R9 was rubbing on her butt, breast and saying inappropriate sexual statements to her, wanting a kiss and telling her to drop that a**. According to V4, R6 stated she could hear R9 wandering the halls at night, all night, going into others' rooms. V4 stated R6 was very upset over the fact that R9 had been on 1:1 supervision in the past for similar behavior but was taken off 1:1 supervision and was allowed to do this to her. V4 stated she wrote up the statement from R6 on 1/05/23 and then took it to morning meeting with all the Department Heads on 1/06/23 to be discussed. V4 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present in that meeting. V4 stated she felt what R9 was doing to R6 was sexual abuse, but R9 doesn't have the ability to understand that his behavior is sexually inappropriate. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated she typed the 1/10/23 Resident Council Meeting Minutes and then completed a form with each concern on it and delivered those concerns to the appropriate Department Head, including V1. V16 stated V1 was present at the 1/10/23 Resident Council Meeting, as she was invited by the residents due to all the concerns. V16 stated multiple residents brought up R9's behavior in that meeting, complaining that R9 is very sexual. (R9) will literally come up behind a person, grab their hips, get real close and dance with them. V16 stated residents complained that R9 would make sexual comments to people as well. They piped in and said (R9) had been overly sexual towards them. They didn't bring up specific times but chimed in when it was brought up. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she attended the most recent Resident Council Meeting (1/10/23). V10 confirmed that V1 and V2 were present for that meeting. V10 stated during the meeting, R6 and some other female residents complained about R9 being sexually inappropriate. V10 stated R6 verbalized in the Resident Council Meeting R9 rubbed his penis on her and rubbed her boobs. On 1/25/23 at 10:34 am, R11 stated she did complain at the Resident Council Meeting this month about (R9). R11 stated, (R9) will get in my face and yell real loud at me, saying all sorts of mean stuff. R11 stated this had been going on for awhile and staff would see it happening and do nothing. R11 then stated, (R9) has touched me, but I don't want to say where; he scares me. On 1/30/23 at 10:18 am, R6 was interviewed over the phone, as she was admitted to the hospital. R6 stated R9 touches my boobs, tries to kiss me, and will come up to me and rub his penis on me through his clothes. (R9) will hold on to me from behind. It makes me feel uncomfortable and this happens almost every single day. R6 stated R9 will call her names, like N****r, C**t, and B***h when she pushes him away. R6 stated the problems with R9 started over a year ago, and she has told many staff, including V1 (Administrator in Training), V2 (Assistant Administrator in Training) and V4 (Social Services Director). R6 stated, Staff do nothing and (R9) is allowed to come down my hall all of the time. R6 stated sometimes R9 is 1:1 with staff and at other times he's not, especially at night. R6 described how she is afraid to come out of her room, unable to go get ice, and eats meals in her room to hide from R9. R6 stated she is afraid of R9 and R9 makes her feel uncomfortable. R6 stated she is coming back to the facility soon and is very worried about what might happen to her with R9 still in the facility. On 1/25/23 at 12:59 PM, V1 (Administrator in Training) stated R6 came to her with concerns that R9 was getting too close to her. V1 could not recall what day that occurred, but indicated it was recent, within the month. V1 denied knowledge of the 1/05/23 grievance completed by V4 regarding R6 and R9. V2 (Assistant Administrator in Training) was in the office during this interview and denied knowledge of the grievance as well. V1 and V2 denied V4 bringing to the attention of Management that R6 had complaints of R9 touching her sexually during the 1/06/23 morning management meeting. V1 stated, Had I known, I would have reported an allegation of sexual abuse. V1 stated the only thing R6 told her was that (R9) was getting in her personal space, but not that (R9) had physically touched her. V1 stated she did not have any documented evidence of this conversation with R6, or any subsequent actions taken. V1 confirmed that she was in attendance for the Resident Council meeting on 1/10/23. V1 stated she did not interview the four female residents that spoke out about R9's behavior. V1 stated, I recall (R6) speaking out against (R9) and (R10) as well. I do not remember the other two residents having specific concerns with (R9). I can't tell you my exact immediate follow up. I did not interview any residents that had concerns. At some point, I had a conversation with (R6 about R9), but I do not know when and did not document the details. On 2/02/23 at 1:59 pm, a follow up interview was conducted with V4 (Social Service Director) regarding R6's allegation against R9 and the 1/06/23 Morning Meeting with Management. V4 stated it was clearly discussed in that meeting that R9 had increasing behaviors, going in and out of resident rooms at night, and what R6 reported on 1/05/23. V4 stated Management suggested at that R9 go on 1:1 supervision or they find placement for him elsewhere. V4 stated they discussed R9 being placed back on 1:1 supervision so it didn't escalate to a reportable incident. If (V1 and V2) stated they didn't know this, they are lying. On 1/30/23 at 9:17 am, V1 stated in a follow up interview she has still not initiated any kind of formal investigation into the sexual abuse allegations reported to her last week involving R6 and R9. V1 stated she was completely unaware of R9's sexually tendencies until the survey team brought it to her attention last week. V1 stated V31 (Administrator) is still unaware of the allegations of sexual abuse by R9. 2. An official court document, dated 4/10/2017 documents V30 (R6's Mother) and V37 (R6's Father) as being appointed Guardians of the Estate & Person of (R6), a disabled adult, and are authorized to have, under direction of the Court, the care, management, and investment of the ward's estate and the custody of the ward, and to do all acts required by them by law. A Resident Profile Face Sheet documents R6 was admitted to the facility on [DATE]. A Subpart S Eligibility Screening, dated 5/13/22, documents under Section B that R6 has the diagnoses of Schizo-affective Disorder and Bipolar Disorder, and under Section E - (checked for yes) Are impairments in these areas primarily due to the resident's serious mental illness listed in Section B. (Checked for yes) Resident's impairment cannot be primarily due to any of the following (Check box if impairment is due to diagnosis listed): with Mental Retardation circled. Physician's Orders, dated 1/01/23, document R6 has the current diagnoses of Anxiety, Schizoaffective Disorder, Intellectual Disability, and Chronic Post Traumatic Stress Disorder. On 1/31/23 at 1:05 pm, V10 (Ombudsman) stated V30 (R6's Mother) contacted her today, very upset and concerned about R6 being in a sexual relationship with a male resident in the facility. V10 stated V30 discussed this with the Social Services Department in December, but the facility was not doing anything to stop R6 from having sexual intercourse with this resident. V30 stated the concern is that R6 does not have the mental capacity to consent to a sexual relationship with someone. On 1/31/23 at 2:44 pm, V30 stated, Around the beginning of November, (R6) told her me she had been caught having sex with this man (R15), in his room and her room, multiple times, and I'm concerned because I'm (R6's) State appointed guardian and (R6) has the mental capacity of a 10-[AGE] year old. I spoke to (V1) immediately after I found out, and (V1) told me (R6) was a consenting adult and there was nothing they could do about her having sex with this man, who is twice her age. On 2/02/23 at 1:30 pm, V30 stated she reviewed her phone records and she spoke with V1 on 11/08/22 about R6 and R15 having sex. V30 stated V1 told her R6's BIMS (Brief Interview for Mental Status) was too high, and they were able to consent to a sexual relationship. V30 stated she told V1 that she did not agree, as (R6) has the mentality of a teenage girl. On 2/01/23 at 1:17 pm, R6 stated she has sex with R15. R6 stated, (R15) is my boyfriend and we are going to get married. R6 was asked where she has sex with R15 and she stated, Wherever, and Oh we've been caught by people. R6 was asked if she had sex with R15 in his room or hers, and she stated both. R6 was asked what happens when they get caught and R6 stated, They just tell us not to do it again. My Mom knows. I told her. I told her we want to get married. On 2/2/23 at 10:00 a.m., R6 stated, We (R6 and R15) have sex. We've tried to have a baby three or four times to get out of here and move to Chicago, but I guess this thing is working (pointing to her birth control implant in her left upper arm). On 2/02/23 at 1:59 pm, V4 (Social Services Director) stated she talked to both R6 and R15's families regarding their sexual relationship in December, but (R6 and R15) had a high enough BIMS, so they could not stop them. V4 stated, (V1) was fully aware (of their sexual relationship); she has talked to (R6 and R15's) family regarding this. V4 stated they did discuss developing a care plan with individualized interventions to keep R6 and R15 from having sexual relations, but that never transpired. On 2/01/23 at 2:33 pm, V14 (Social Service) stated she has heard from multiple staff and residents that R6 and R15 are in a sexual relationship. V14 stated, The first time I heard about them having sex, (R6) was in the hospital. It was a couple of months ago. Since (R6) was in the hospital, it was after the fact, and I did not report it to (V1). V14 stated there was a recent Care Plan meeting with R6's parents, V4 (Social Service Director) and V15 (Social Services). V14 stated, The main topic of that meeting was (R6's) sexual relationship with (R15). On 2/01/23 at 3:55 pm, V1 (Administrator in Training) stated, All I know regarding (R15 and R6) is that (R6) told her Mom that they are getting married, and I have never been told they were in a sexual relationship. V1 stated she would expect staff to tell her if they had knowledge of them being in a sexual relationship. V1 stated she personally does not feel R6 has the mental capacity to consent to a sexual relationship. 3. Resident Council Meeting minutes, dated 1/10/23 document the following concerns: LPN (is) stealing narcotics, CNAs (Certified Nursing Assistants) yelling at residents is not okay and needs to stop, and (CNAs) retaliating with residents when they have an issue with things. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Administration, under Concern/Complaint it states in the notes section, CNAs and nurses are retaliating when they (residents) bring issues to them that staff does not agree with, and (R2) also brought up LPNs (Licensed Practical Nurses) stealing narcotics. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/18/23, documents Department: CNAs, under Concern/Complaint: Residents believe that the CNAs yelling at residents is not okay, and They are also concerned that the CNAs are retaliating when the residents bring up issues to them that they do not agree with. A Resident Council Concern Form, completed by V16 (Activities Director) on 1/10/23, documents Department: Nursing, under Concern/Complaint: Certain Nurses are retaliating against residents who give them issues. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: (Nursing Staff) ignore residents when residents need help. One resident stated the less cognitive a resident is the worse it is for them, Residents being forced to stay in their rooms or go to their rooms, It was stated that when (R3) had a fainting episode staff makes fun of him because the staff think he is faking it (V11/Registered Nurse)(is the main one), (R3 stated) backlash is horrible from staff. Nurses get in your face and saying f**k you, you're going to your room. Resident is staying in his room due to being uncomfortable. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she was present for the 1/10/23 Resident Council Meeting and several residents attended. V10 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present for the entire meeting. V10 stated R2, who is the Resident Council [NAME] President, was voicing most of the concerns, and R2 even had all his concerns typed up, giving everyone a copy. V10 stated other residents were agreeing with R2's issues brought forth. V10 stated several resident concerns were abusive in nature. V10 stated R2 verbalized he has witnessed nursing staff, specifically V3 (Resident Care Coordinator), take resident medications home with her after she dispenses medication from the pill sleeve. V10 stated multiple residents complained of staff retaliating when they complain about something, staff will be mean to them, make fun of residents, and yell at them. V10 stated she has discussed abuse concerns with V1 before, but she does not act on them. At that time, V10 provided a copy of the typed concerns from R2 that was given to everyone in attendance at the 1/10/23 Resident Council Meeting. R2's documented Grievance List from 1/10/23, provided by V10, documents the following statements: (Licensed Practical Nurse, name withheld) pulls meds, while pulling meds, when she grabs meds out of lock box (for narcotics), she pops all meds into dispensing cup, except the narcotic, it gets popped onto the top of (the medication) cart and slipped into her pocket. On 1/24/23 at 3:45 pm, V16 (Activities Director) was interviewed regarding all the abuse concerns documented from the Resident Council Meeting on 1/10/23. V16 confirmed that V1 and V2 were present for the meeting that day. V16 stated that staff retaliation against residents was mentioned by R2, but he didn't expand on it so she was unaware of what R2 meant specifically. V16 stated it was discussed during the meeting that residents have observed nursing staff popped the narcotic pill out, put it to the side of the medication cart, then slide it into her pocket. V16 recalled R2 stating that if residents do something that the CNAs don't like, they will raise their voices at them. V16 went on to say that she documented all the resident concerns and gave specific concern forms to each Department Head, as well as a copy of the Resident Council Meeting Minutes to V1 (Administrator in Training). On 1/25/23 at 12:59 pm, V1 (Administrator in Training) confirmed that she was present for the 1/10/23 Resident Council Meeting, and she had received a copy of the 1/10/23 Resident Council Meeting notes. V1 stated, I still want to go through and talk to residents. When I get complaints, I don't always jump. V1 stated, My approach to the wrong medications being given and narcs (narcotics) being stolen was to wait and see how med (medication) pass was going. My thought process is it not over. I'm waiting to sneak up and see what I catch. V1 stated she did complete a Narcotic Count at the medication carts, which was fine. V1 stated she at some point asked V3 (Licensed Practical Nurse/Resident Care Coordinator) if anything had been reported regarding missing narcotics, and the answer was no. V1 stated she did not conduct a full investigation into the misappropriation of resident's narcotics, nor did she report the allegation to the State Agency. V1 stated she just started getting copies of the Resident Council Meeting minutes and she received the copy from the (1/10/23) meeting minutes last week. V1 stated she did read the minutes when she received them and acknowledged There were several serious concerns brought up at the meeting. V1 stated she did not interview any residents that had specific concerns, but she did have a conversation with R6. V1 stated she could not recall any specifics regarding the allegation of CNAs yelling at residents, but I decided to do a broad in-service regarding bedside manner and customer service that day, as it was a scheduled in-service day. V1 did admit that the allegations that came from the Resident Council Meeting could lead to an abusive situation. V1 stated she did ask R16 in that moment during the Resident Council Meeting what staff were yelling at residents and then R16 denied anything occurred. V1 stated she did not interview in private or probe further, with any other residents regarding the concerns. V1 stated, I didn't view the complaints warranted interviewing specific residents in private to determine what CNAs are yelling at residents and what they are yelling at them for. V1 stated she did not interview any staff regarding other staff's behavior. When V1 was questioned about the statement made by R2 that staff are retaliating against them when they complain, V1 stated she talked to my Department Heads and instructed them to do 'Angel Rounds,' inquiring as to if residents have concerns about retaliation. V1 was unable to provide any documentation related to the information gathered during 'Angle Rounds.' V1 stated, she did not recall the word retaliation being used in the Resident Council Meeting but concluded retaliation is concerning. 4. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated 1/19/23, she informed V1 that R3 had reported to her V27 (Licensed Practical Nurse) was hitting him in the leg when she passes medication and that V3 (Licensed Practical Nurse/Resident Care Coordinator) had yelled at R3 a few days prior. V10 said she specifically told V1 that R3 reported to her V3 yelled at him to Shut the f**k up and threatened to call the police on him. V10 stated V1 informed her that she had already spoken to V3 about the situation and that was not what had happened. V10 stated she was concerned that V1 did not report or investigate this a[TRUNCATED]

Based on observation, interview and record review, the facility Administration failed ensure a safe living environment and quality care and services were provided to all residents, failed to provide leadership and institute their Abuse Prevention program and failed to have an effective, comprehensive approach to numerous significant resident concerns regarding the quality of resident life within the facility. The facility has been unable to maintain consistent Administrative leadership over the last 12 months. V1 (Administrator in Training) failed to respond to resident allegations of abuse, neglect and mistreatment. Cross reference to F600, F610 and F692 (Identified Immediate Jeopardies) and additional findings at F584, F607, F609, F693, F741, F760 and F943. These failures have the potential to affect all 116 residents currently living in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02/02/2023, the facility remains out of compliance at a Severity Level 2 as the facility's Quality Improvement Program monitors Resident Council Meeting Minutes, reviews ongoing resident concerns obtained from Department Managers through daily rounds with the residents, monitors for compliance with the Abatement Plan submitted, and review Abuse Allegations and Grievances. Findings include: The facility's Administrator Job description summary documents, The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents, and equipment in a way that the purpose of the facility shall be maintained in accordance with all establish practices, policies, laws, and applicable state regulations. The Administrator will manage and conduct the business of the facility in a manner that protects the facility license and certification at all times. The major goal of the Administrator is to provide an atmosphere, in which residents may achieve their highest physical, mental, and social well-being. The job description summary further documents Responsibilities: 1. Operate a facility in compliance with all federal and state, rules, and regulations; 2. Operate the facility in accordance with establish policies and procedures; 3. Assist in developing and establishing a budget, and managing within it; 4. Appoint a Director of nursing and other department heads; 5. Supervise department heads; 6. Assure, proper facility and department operation through the implementation of the specified quality assurance program. A second Administrator Job description provided by the facility documents Job Summary: The Administrator is responsible for directing day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern long-term care facilities to ensure that appropriate care is provided to the residents in the facility. The administrator is responsible for delegating the administrative authority, responsibility necessary for carrying out the assigned duties. Job Relationships: works effectively and maintains a cooperative, working relationship with members of the regional team, Department heads, government agencies, personnel, visitors, family members, staff, and residents. The Administrator's Job description, further documents under Resident rights: 1. Maintain confidentiality of all resident information. 2. Ensure that the residence rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints are well established and maintained at all times. 3. Resident complaints and grievances and make written reports of actions taken. 4. Review and respond to resident/family council concerns as needed. The Facility Assessment, last updated on April 20, 2021, documents We are dedicated to assisting the elderly population in maintaining the highest possible quality of life, for the longest possible time. We are committed to providing an environment where the dignity of each individual is assured. We believe that a person is unique, deserving of dignity and respect. That each person possesses unique qualities which make up distinct personality. Although a person may lose the ability to function, as before, that person still possesses, this unique quality, which must be recognized and respected. That all aspects of a person must be considered: physical, mental, spiritual, and social, when assessing and providing care for all individuals, the staff must be accessible, perceptive and open to recognize needs and provide care for residence. That involvement with significance of others is beneficial to residents, family members, and staff in planning and providing quality care. During the last 12 months, the facility has been cited by the State Agency at F835 on 2/10/22 and 10/30/22 for lack of effective Administrative leadership. Upon entering the facility on 1/24/23 at 9:15 am, V1 (Administrator in Training) introduced V2 as her Assistant Administrator in Training and V3 (Licensed Practical Nurse/Resident Care Coordinator) as her Acting DON (Director of Nursing). V1 indicated this was the facility's current Administrative Staff. V31's (Vice President of Business Development and Strategy/Regional Director of Operations) Nursing Home Administrator's license is hanging on the wall of the facility. On 1/25/23 at 11:25 am, V1 stated she started as the facility's Administrator in Training under V31's (Vice President of Business Development and Strategy/Regional Director of Operations) Administrator's License on 8/22/22. V1 stated she stated she has the paperwork to apply for her Temporary Administrator License, but that documentation has not been submitted at of this time. V1 stated her testing date to become a Licensed Nursing Home Administrator is currently unknown. On 2/09/23 at 3:56 pm, V1 confirmed that V43 was the previous Administrator in Training (not a licensed) over the building, and he held that position from 2/16/21 - 7/15/22. According to record review and interviews, Administration failed to effectively act upon the following events regarding quality of care, quality of life and resident abuse: 1. Administration failed ensure all staff received necessary education and training. The following staff stated they had not received education on the Abuse Prevention Program since they began employment at the facility: V16 (Activities Director), V4 (Social Services), V25 (Licensed Practical Nurse), V21 (Unit Aide), V9 (Unit Aide), V18 (Certified Nursing Assistant), V34 (Unit Aide), V5 (Certified Nursing Assistant), V33 (Certified Nursing Assistant), and V23 (Housekeeper). Additionally, V1 confirmed the facility has not provided any education or training for new staff on managing residents with behavioral health needs. This includes: V2 (Assistant Administrator in Training), V3 (Resident Care Coordinator/Licensed Practical Nurse), V11 (Licensed Practical Nurse), V51 (Licensed Practical Nurse), V52 (Registered Nurse), V53 (Registered Nurse), V7 (Registered Nurse), V54, V63, V33, V64, V65, V19 (all Certified Nursing Assistants), V34, V55, V9, V35, V56, V57, V58 (all Unit Aides), V59 (Transportation Aide), V15 (Social Service), V14, (Social Service), V60 (Activities Aide) and V61 (Activities Aide), as cited at F943 and F741. 2. Administration failed to acknowledge, immediately report, and investigate allegations of verbal abuse, sexual abuse, and misappropriation, brought forth by residents of the facility during a Resident Council Meeting (1/10/23) in which V1 and V2 were present for, as cited at F600, F607, F609 and F610. 3. Administration failed to recognize that R9 was to be on 1:1 supervision when out of his room, per his Plan of Care, due to a history of sexually inappropriate behavior towards others, as cited at F600. This failure allowed R9 to have unsupervised access to female residents. R6 reported on 1/05/23, R9 had touched her sexually. R6, R11 and R13 reported on 1/10/23, R9 had touched them in a sexually inappropriate manner. 4. Administration failed to respond to numerous grievances and concerns voiced by residents during Resident Council (1/10/2023), affecting the quality of care and quality of life of those living in the facility, as cited at F584, F585, and F600. 5. Administration failed to recognize that R6, who has a State appointed Guardian, lacked the mental capacity to consent to known ongoing sexual relationship with R15, as cited at F600 and F610. 6. On 1/25/23 and 1/26/23, the State Surveyors discussed with V1 and V2 the following concerns regarding abuse within the facility: a.) R6 reported to V4 on 1/05/23 that R9 was touching her sexually. b.) R6, R11 and R13 reported in the January 10, 2023, Resident Council Meeting that R9 had touched them sexually, which was confirmed by V10 (Ombudsman). c.) R3 reported to V1, on 1/16/23, verbal abuse by V3. V10 reported R3's same allegation of abuse to V1 again, on 1/19/23, along with an allegation of physical abuse by V27 (Licensed Practical Nurse). d.) R1 was found to have suspicious inner thigh bruising of unknown origin when admitted to the hospital on 1/17/23, which was reported to the facility by hospital staff. e.) On 1/24/23, R5 had visible eye bruising of unknown origin, reportedly present for 2-3 days. At the time these concerns were originally discussed with V1 and V2, they had not been investigated or reported to the State Agency per the facility's Abuse Prevention Program. Upon returning to the facility on [DATE], V1 had yet to implement their Abuse Prevention Program regarding these allegations by initiating abuse investigations and suspending staff suspected of abuse, as cited at F607, F609 and F610. 7. Administration failed to ensure that R20, who is nonverbal and depends on enteral nutrition, received gastrostomy tube (g-tube) feedings for adequate nutritional intake and implement dietician recommendations to prevent significant weight loss. R20 went nine days without receiving any type of nutritional intake causing her emotional/psychological distress as well as pain related to hunger pains. R20 has also lost 20 lbs (11.4% weight loss) since R20 was admitted on [DATE] (five months). On 1/26/23 at 8:15 am, V10 (Ombudsman) stated, I'm in the building frequently, not as often as I'd like. At least 1-2 times per week. I come in and (V1's) door is always closed. If I go to (V1) with concerns she never acts on them. I've gone to her with abuse concerns that she doesn't look into. V10 went on to explain about an allegation of verbal and physical abuse she received from R3 on 1/19/23, that she spoke to V1 about that day. V10 stated she informed V1 that R3 told her V27 (LPN) would hit him in the leg when she passes his medication, and that V3 verbally abused him a few days prior. V10 stated V1 was not concerned with the allegations made and indicated that she had already discussed the situation with V27 and V3's behavior towards R3; however, V10 stated, I've discussed abuse concerns with (V1 before), but she doesn't act on them like she should. I'm concerned it wasn't reported or investigated as it should have been. V10 stated residents complain about the way V3 and V8 (Certified Nursing Assistant) speak to them, and she stated she has witnessed (V8) blow off medical concerns. V10 stated she was present for the 1/10/23 Resident Council Meeting, and V1 and V2 were in attendance, as they had been invited due to numerous resident concerns. V10 stated R2 (Resident Council [NAME] President) was voicing most of the concerns and other residents were agreeing with him. V10 stated some of the allegations made during the meeting were abusive in nature. V10 stated it was alleged that (V3) would take resident medications home with her. V10 stated R16 complained about staff not administering her pain medications. V10 stated residents complained of staff retaliating when they complain about something, like staff will be mean to them, make fun of residents, and yell at them. During the meeting, V10 stated she heard concerns about residents being yelled at by CNAs, nursing staff not doing their medication passes, giving medications late, and doubling up on medication passes. V10 stated, As soon as the State cleared the facility in November from their Annual Survey, everything changed back to how it previously was. When the facility was trying to get back into compliance, residents were happier, and Administration was responsive to my concerns. Residents felt like they could go to Administration at that time. But, since November, things have greatly changed. I will bring concerns to (V1), who acts like she cares but never acts on my issues. (V1) stands up for her employees, not the residents. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated she has been working as an Agency Nurse at the facility for several months now. V32 stated, Management is poor, and nothing gets done. V32 stated V1 will remove documentation from resident records and tell staff not to chart resident incidents, altercations, or elopements. V32 stated she had V1 tell her just last month not to document that R21 had eloped from the facility and had to be brought back by a member of the community that found her. V32 stated R6 and R15 have been caught having sex in their rooms and staff have been instructed by V1 to not let R6 in R15's room. V32 stated R9 has been taken off 1:1 monitoring for inappropriate sexual behaviors, because the facility didn't have the staff to constantly monitor him. V32 stated this even happened after State cited us for abuse (involving) R9 in 2022. V32 stated everyone, including V1, was aware that R6 had alleged sexual abuse by R9 on 1/05/23. V32 stated she texted V1 a few days after R6's allegation (1/05/23) was made, because R9 was being sexually inappropriate with R14, and V1 got upset with her for notifying her of the situation. V32 stated she has witnessed V3 yell at R3. V32 stated narcotics were reported missing about two months ago, but it was not investigated as diversion. V32 stated V3 will prep her medication prior to her medication pass, by putting the resident's pills in a cup so V32 can just hand them out to the resident. V32 stated she knows this is not proper practice, but it is how the medication is routinely handled. V32 stated she has noticed at times resident's that are to be receiving narcotics, the narcotic is not always in the cup prepped by V3. V32 stated, I have caught staff sleeping at night on third shift. I took pictures and sent them to (V1), but nothing happened to the staff. V32 indicated she has witnessed staff that are to be providing 1:1 supervision for resident watching movies/videos on their phone, especially at night. V32 stated new staff receive no training on how to handle the mentally ill population or abuse, and they have high school students providing 1:1 supervision at night, who have zero training. V32 stated V27 will hide in V3's office when she is supposed to be working on the floor. V32 indicated she has come on shift to find that V27 had not given R20 her bolus tube feedings or medications. V32 stated, I just told the Agency I couldn't work there anymore; residents are not taken care of, and there is such poor management in that building. On 2/02/23 at 1:59 pm, V4 (Social Services) stated she left her position on 2/24/23, because Administration was being extremely hostile to me after talking to you (State Surveyors). It was a very uncomfortable situation. V4 stated she came into her role in Social Services with no training from the facility on what her job was, what constituted abuse, or how to deal with the mentally ill population. V4 stated that V1 has known about R9's sexual behaviors. V4 stated R9 was openly discussed in the Morning Meeting with all of the Department Heads on 1/06/23. V4 stated they specifically discussed in that meeting, R9 going in and out of resident rooms at night, and that R6 reported R9 touched her sexually the day prior. V4 stated, at that time, it was suggested by the team that R9 go back on 1:1 supervision or they find placement for him elsewhere. V6 stated she recalls the discussion about placing R9 on 1:1 supervision, because Management didn't want things to escalate to a reportable incident. V4 stated the Social Service staff had also talked to both R6 and R15's family regarding their sexual relationship in December 2022. V4 stated V1 was fully aware of the situation, but V1 felt R6 and R15 had a high enough BIMS (Brief Interview for Mental Status) that they could not stop them from engaging in sex. V4 stated V1 spoke to both R6 and R15's families about their sexual relationship. The CMS-672 (Resident Census and Conditions of Residents), dated 1/24/23 and signed by V1 (Administrator in Training), documents 116 residents currently live in the facility. The Immediate Jeopardy began on 12/15/22 when R9 was removed from 1:1 supervision, giving R9 the opportunity to commit sexual and verbal abuse to female residents. V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were notified of the Immediate Jeopardy regarding R9 on 1/30/23 at 9:22 a.m. The facility submitted the original Abatement Plan to the State Agency on 1/31/23. A revision was requested and the final amended Abatement Plan was submitted on 2/01/23. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A Director of Nursing (V48) was hired and started 1/31/23. 2. V1 qualifies to be a LNHA (Licensed Nursing Home Administrator), has completed all portions of the application for Licensure with the IDFPR (Department of Professional Regulation), and her application was mailed 1/31/23. 3. V2 and V48 have mailed their applications to receive a temporary Administrator's License, so they can test to become a LNHA. 4. On 1/30/23, Regional Director of Operations in-serviced V1 on the Facility's Abuse Prevention Program, Abuse Occurrence Investigations form, CMS Abuse Critical element Pathway, Resident Rights, Injuries of Unknown Origin, QAA Policies and Processes and Resident Grievance/Complaint policies. 5. On 3/02/23, V1 is scheduled to attend LNHA training conference, provided by several members of the facility's Governing Body, contracted leaders, Regional Director of Operations,Regional Director of Clinical Operations and Wound Care Specialist. 6. Regional Team Members will be on site at minimum 3 days each week to monitor for continued compliance and training of Administration Team Members. 7. V49 (Serious Mental Illness Expert in Long Term Care) will consult with the facility quarterly, until deemed unnecessary. 8. V10 (Ombudsman) has been contacted to hold in-service on abuse with facility staff.

Based on observation, interview and record review, the facility failed to ensure residents (R6, R10, R11, R18) were free from sexual and verbal abuse by R9, who had known history of sexually inappropriate behaviors towards females, for five of 12 residents reviewed for abuse in a sample of 25. These failures resulted in R6 being groped in a sexual manner and verbally abused, experiencing psychological distress. This facility was previously cited for sexual abuse on 1/09/22 for R9 groping R6's breast. Additionally, the facility failed to prevent known, ongoing sexual relations between R9 and R6, who is Intellectually Disabled, unable to consent, and has a State Appointed Guardian. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 02/03/2023, the facility remains out of compliance at a Level 2 as the facility continues to conduct ongoing Abuse Prevention Training with all current staff and newly hired staff and the Quality Improvement Program conducts random audits to ensure facility staff's compliance with the Abuse Prevention Program, with an emphasis on Abuse Reporting, Investigation of Abuse Allegations, and staff's understanding of Abuse Prevention Training. Findings include: The Facility policy, titled Abuse Prevention Program (revised 11/28/2016) documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitations defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and 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 the occurrences of mistreatment, exploitation, neglect, or abuse of our residents. This will be done by: Conducting required pre-employment screening of employees; Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, exploitation, neglect and abuse immediately to supervisory personal; Training on activities that constitute abuse, neglect, exploitation and misappropriation of resident property; Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property; including, prohibiting staff from using any type of equipment to keep, distribute photographs and recording of residents that are demeaning or humiliating; Identifying occurrences and patterns of potential mistreatment, exploitation, neglect and abuse of residents and misappropriation of resident property; Dementia management and resident abuse prevention; Immediately protecting resident involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegation of mistreatment, exploitation, neglect, abuse or residents and misappropriation of resident property; promptly and aggressively, and making the necessary changes to prevent future occurrences; and Procedures for reporting of potential incidents of abuse, neglect, exploitation or the misappropriation of resident property. This facility is committed to protecting our residents from abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. The Abuse Prevention Program documents Sexual Abuse is non-consensual sexual contact of any type with a resident. 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 their mental ability to comprehend or disability. 1. R9's Pre-Admission Screening System, dated 11/18/21, from prior to R9's admission (11/24/21) to the facility and obtained from R9's medical records at the facility, documents, Behavior Assessment Summary: (R9) is a [AGE] year-old male who was admitted to hospital due to being actively psychotic. (R9) has a history of hospitalization s and being aggressive. Behavior type: Antisocial behavior; Criminal justice system involvement; Fire setting or arson; Physical assault/injury threatening to others; Poor judgement placing self or others at risk; Property damage; Self injurious behaviors; Serious wandering, elopement; Sexual aggression. A Cumulative Diagnosis Log (no date) documents R9 has the current diagnoses of Schizoaffective Disorder, Bipolar Type and Hypersexuality. A Minimum Data Set assessment, dated 11/30/22, documents R9 can ambulate independently. A Final Incident Report to State Agency, dated 1/14/22, summarized that R9 had grabbed R6's breast as she was near the ice machine in the kitchen area, and R6's account of what had occurred was substantiated by resident interviews that had witnessed the incident. R9's current Plan of Care documents (beginning 3/15/22) (R9) has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against the resident. Behavior exhibited sexually inappropriate, yelling out, verbal outbursts, and instructs staff 1 on 1 (at) all times when out of room and council on appropriate interactions (with) peers (and) staff as needed per his behaviors. The Care Plan also documents, R9 has displayed verbal aggression, inappropriate touching, wanders, irregular thoughts. A Psychosocial Assessment, dated 11/30/22 identifies R9 has behaviors of being socially inappropriate, wandering, seducing/soliciting, seeking intimate contact, and masturbating. Daily Resident Monitoring documents R9 was decreased from 1 on 1 supervision to Resident Monitoring - 15 minutes - Staff (must) make visual contact with resident every 15 minutes on the following dates: 12/15/22, 12/16/22, 12/17/22, 12/18/22, 12/20/22, 12/21/22, 12/23/22, 12/25/22, 12/26/22, 12/27/22, 12/30/22, 12/28/22, 12/31/22, 1/01/23, 1/02/23, 1/03/23, 1/04/23, and 1/05/23. All of R9's 15 Minute Monitoring reports document his location as being in either the hallway, dining room, resident room, television room or patio. R9's medical record contains no documented rationale for decreasing his level of supervision to every 15-minute checks on those dates. Daily Resident Monitoring logs for the dates of 12/11/22, 12/13/22 and 12/14/22 indicate Resident Monitoring - One to One, however, on those three dates the One to One is crossed out with an ink pen and R9's location is only documented every hour on the hour. On 2/16/23 at 11:37 am, V9 (Unit Aide) clarified the December Resident Monitoring for R9, as her initials are on several of R9's monitoring logs. V9 was given R9's logs from 12/11/22, 12/13/22 and 12/14/22 and asked about the One to One that was crossed out on the top of the log sheet. V9 stated There was, like a week in December when we took (R9) off 1:1 and he was just on every 15-minute checks, so the 'One to One' was crossed out on certain days so people would know he (R9) was not 1:1 on those days, but a every 15-minute check. I'm not sure who made that decision to decrease his supervision. A Grievance/Complaint Report dated 1/05/23 and completed by V4 (Social Services), documents R6 complained (R9) rubbing on her butt, putting arm around her (and) saying 'Baby, give me a kiss,' touched her breast, looked up her dress. Also, going up (and) down A Hall (at) night, (R6) claimed, 'I can hear (R9) through the wall.' Resident Council Meeting minutes dated 1/10/23 document resident complaints that (R9) needs to be on a 1 on 1 at all times, overnights too. Residents are not comfortable in his presence and are scared of him. (R9 is) very violent, overly sexual, calling names, going through resident's rooms, (R10, R6, R11 and R12) have all brought attention to this. A Resident Council Concern/Complaint form, dated 1/10/23 by V16 (Activities Director), documents Residents would also like if (R9) was out of the facility because they feel unsafe. A documented summary of V10's (Ombudsman) notes from the 1/10/23 Resident Council Meeting include the following information: Other concerns: (R9) is touching and grabbing women in a sexual behavior. (R9) is pinning residents against walls and counters as well. (R6) stated that (R9) has looked up her skirt, grabbed her breast, and rubbed his penis on her many times. It was stated in resident council that (R9) does not have a 1:1 anymore, and (R13 stated R9) touched my boobs and rubbed his penis on me, and (R11 stated R9) is getting into people's faces and personal space and touching the way she don't want to be touched. On 1/26/23 at 4:11 pm, R9 was ambulating throughout the building, into the common areas and up and down hallways. R9 was being followed by V28 (Dietary Manager) who was approximately 15 feet or more behind him watching a video on her cell phone as he ambulated throughout the hallways. R9 eventually returned to his room and V28 sat down in chair outside his room. When asked why R9 needed 1:1 supervision, V28 stated for his behaviors. When V28 was asked as to what type of behaviors R9 exhibited, V28 stated she did not know. On 1/24/23 at 3:15 pm, V4 (Social Service) stated R6 told her on 1/05/23 that R9 was rubbing on her butt, breast and saying inappropriate sexual statements to her, wanting a kiss and telling her to drop that a**. According to V4, R6 stated she could hear R9 wandering the halls at night, all night, going into others' rooms. V4 stated R6 was very upset over the fact that R9 had been on 1:1 supervision in the past for similar behavior but was taken off 1:1 supervision and was allowed to do this to her. V4 stated she wrote up the statement from R6 on 1/05/23 and then took it to morning meeting with all the Department Heads on 1/06/23 to be discussed. V4 stated V1 (Administrator in Training) and V2 (Assistant Administrator in Training) were present in that meeting. V4 stated R9 was eventually put back on 1:1 supervision, but not until another incident occurred a week later. V4 was uncertain of the details or nature of that incident. V4 stated she felt what R9 was doing to R6 was sexual abuse, but R9 doesn't have the ability to understand that his behavior is sexually inappropriate. On 1/24/23 at 3:45 pm, V16 (Activities Director) stated she typed the 1/10/23 Resident Council Meeting Minutes and then completed a form with each concern on it and delivered those concerns to the appropriate Department Heads. V16 stated V1 was present at the 1/10/23 Resident Council Meeting, as she was invited by the residents due to all the concerns. V16 stated multiple residents brought up R9's behavior in that meeting, complaining that R9 is very sexual. (R9) will literally come up behind a person, grab their hips, get real close and dance with them. V16 stated residents complained that R9 would make sexual comments to people as well. They piped in and said (R9) had been overly sexual towards them. They didn't bring up specific times but chimed in when it was brought up. V16 stated she started at the facility in August, and in the last 3 months R9's sexual behavior has become more frequent. V16 stated R9 was taken off and put back on 1:1 supervision multiple times in a month and V16 discussed this with V1 several times, as it was concerning to her. V16 stated, I've brought this up to (V1) several times, but (R9) still does things. I really don't know if what he is doing is sexual abuse or not. I really can't say. I never received any kind of abuse training when I started in August or since then. On 1/26/23 at 8:15 am, V10 (Ombudsman) stated she attended the most recent Resident Council Meeting (1/10/23). V10 confirmed that V1 and V2 were present for that meeting. V10 stated during the meeting, R6 and some other female residents complained about R9 being sexually inappropriate. V10 stated R6 verbalized in the Resident Council Meeting R9 rubbed his penis on her and rubbed her boobs. V10 stated she was in the facility on 1/19/23 and R9 was roaming the hallway unsupervised and groped her buttocks. V10 indicated that each time she has been in the facility recently, on 1/03/23, 1/10/23 and 1/19/23, R9 was not on 1:1 supervision and residents have complained to her that R9 isn't supervised enough. V10 stated she spoke with V1 on 1/19/23 about R9's behaviors and lack of supervision, and V1 told her, The facility does not want to have (R9) on 1:1 at all times because it is expensive. V10 stated R6 tries to run away from the facility and recently cut her head when she put it through her bedroom wall. V10 stated she talked with R6 about this behavior and R6 stated she did all those things because staff wouldn't listen to what she had to say or help her. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated R9 had been on 1:1 supervision for his sexual behaviors, but it stopped because the facility didn't have enough staff to provide constant supervision of him. V32 stated she heard that R6 reported R9 touched her inappropriately on 1/05/23, but nothing was done about it. V32 stated a few days after 1/05/23, R9 went up to R14 and started humping her from behind, rubbing his crotch on her. V32 stated she texted V1 to tell her about the situation, since R6 had just reported something similar on 1/05/23, but V1 just got upset with her for texting her at night. V32 stated she was concerned because she thought R9 was to be supervised 1:1 all the time after the last abuse (Illinois Department of Public Health deficiency) written on him, from what I was told. V32 stated she has even witnessed R9 do sexually inappropriate dancing during Moves and Grooves, which is an activity ran by V16 (Activities Director). V32 stated It was almost like staff were encouraging this behavior from (R9) and didn't understand it was wrong and inappropriate. V32 stated she has witnessed night shift Unit Aides watching movies on their phones when they are to be providing residents, R9 included, with 1:1 supervision. On 2/01/23 at 5:40 pm, V34 (Unit Aide) stated about two months ago, R9 was going up to residents and 'air humping' them, rubbing himself on males and females. It was so bad the police had to be called, but the police said they couldn't do anything with him. V34 stated R9 was being supervised 1:1 that day and still acting out towards other residents sexually, because staff couldn't stop him. V34 stated he has provided R9 with 1:1 supervision before and R9 will not want to stay in his room and will want to walk around the building. He is fast. Some residents get scared of (R9) because he will yell at them. I've been told in the past, from other staff and (R6) that (R9) needs to be watched for doing inappropriate things to her. On 1/25/23 at 10:35 a.m., V19 (Certified Nursing Assistant) stated, (R9) likes pulling his pants down exposing himself and dancing around inappropriately laughing; it's common behavior. He wanders in and out of resident's rooms. On 1/25/22 at 10:50 a.m., V25 (Licensed Practical Nurse) stated, (R9) is like a vampire; sleeps all day then awake at night and starts acting out. He is very animated. He is sexually aggressive verbally. Last night he was sexually inappropriate with me. On 1/26/22 at 10:40 a.m., V14 (Social Service) stated, (R6) complained to me about (R9) because he grabbed her butt. I think this happened in about November. (R6) said she didn't like him talking to her because he touched her butt and things like that. I reported these things to (V4/Social Services Director). On 1/26/22 at 10:50 a.m. V15 (Social Services) stated she was aware of R9's sexual advances, stating for instance he went behind (R14), grabbed her breast and pretended to hump her. It happened over the weekend, and I was told about it the following Monday when I came in, so I didn't report it to anyone. It was either the weekend of 12/31/22 or 1/07/23. V15 then stated, The other thing I'm aware of is (R9) grabbing (R6's) breast. This incident wasn't long before (R14's) incident or maybe the same weekend. On 1/26/22 at 2:10 p.m., V8 (Certified Nursing Assistant) stated R9 will say sexually inappropriate statement to residents. V8 stated, I know he's tried to grab females, like (R6), going up behind her inappropriately. (R6) reported to me that (R9) wouldn't quit following her and tried to grab her. I told her to talk to Social Services, because I know something may have been done previously, but she still complains about it. I didn't report anything to (V1). I would say it was sexual abuse because (R9) is inappropriate with it. (R9) will randomly just get in a mood where he gets sexually inappropriate. I want to say he did have a 1:1, but he is quick (moving). I don't know who determines if he needs a 1:1. He has come off then he will be put back on is because he's been sexual or trying to poop outside. On 1/25/23 at 10:17 am, R10 stated R9 has never done anything sexually or physically inappropriate to her, but she has heard from other residents that he can be physically and sexually aggressive. R10 stated, (R9) will follow me a lot; he doesn't make sexual advances, just grabs his genitals in front of me. R10 stated she has told several staff that I think (R9) is at the point where he wants a woman; he is a young, after all. (R9) asked me to get him a {Name Brand adult men's magazine} magazine recently and that makes me think he is sexually frustrated. On 1/26/23 at 4:21 pm, R3 stated R9 has been on and off 1:1 supervision since he was admitted . R3 stated R9 was most recently returned to 1:1 supervision after the January Resident Council Meeting, when all that stuff was brought up about (R9) being really sexual with the female residents, touching them and rubbing himself against them. But even after that, (R9) will just roam free some nights. He goes in and out of other resident rooms. I think he looks for food, but who knows what all he's doing in there. I've seen (R9) come up behind the girls and be sexual with them, touching them in places he shouldn't, just out in the open and in front of staff. They don't do anything most of the time. Some of the staff will tell him to stop or distract him away from the girls, but (R9) pretty much does what he wants. On 2/01/23 at 12:50 pm, R18 stated, (R9) has grabbed my arm and pulled me in to him, making me sit on his lap. It made me uncomfortable. I didn't like it. Staff were around; it was by the fireplace, but they didn't stop him. I got up on my own after he let me go. This wasn't that long ago, maybe a month. On 1/25/23 at 10:34 am, R11 stated she did complain at the Resident Council Meeting this month about (R9). R11 stated, (R9) will get in my face and yell real loud at me, saying all sorts of mean stuff. R11 stated this had been going on for awhile and staff would see it happening and do nothing. R11 then stated, (R9) has touched me, but I don't want to say where; he scares me. On 1/30/23 at 10:18 am, R6 was interviewed over the phone, as she was admitted to the hospital. R6 stated R9 touches my boobs, tries to kiss me, and will come up to me and rub his penis on me through his clothes. (R9) will hold on to me from behind. It makes me feel uncomfortable and this happens almost every single day. R6 stated R9 will call her names, like N****r, C**t, and B***h when she pushes him away. R6 stated the problems with R9 started over a year ago, and she has told many staff, including V1 (Administrator in Training), V2 (Assistant Administrator in Training) and V4 (Social Services Director). R6 stated, Staff do nothing and (R9) is allowed to come down my hall all of the time. R6 stated sometimes R9 is 1:1 with staff and at other times he's not, especially at night. R6 described how she is afraid to come out of her room, unable to go get ice and eats meals in her room to hide from R9. R6 stated she is afraid of R9 and R9 makes her feel uncomfortable. R6 stated she is coming back to the facility soon and is very worried about what might happen with R9 still in the facility. R6 stated she recently put her head into the wall of her room because she was angry and frustrated with living in the facility. R6 also stated she tried to leave the facility last Sunday, which was why she was in the hospital. When R6 was asked why she tried to leave, she stated she was angry about everything. Having to live there. (R9) not leaving me alone. Staff not listening to me about (R9) and other things. Staff being mean to me. (R9) follows me around all the time calling me names. Staff don't stop him. When R6 was asked if she feels safe in the facility, she stated not at all. R6 stated the last time she tried to run away from the facility she was angry about everything and stated, It was not a good day. I had enough of that place. R6 stated she really wanted to kill herself that day, and just get it over with. R6 stated as she was leaving the building, V6 (Certified Nursing Assistant) was walking behind her and telling her to just go ahead and hang myself. So, that's what I was trying to do, get out of there and kill myself. R6 was interviewed again, after returning to the facility, on 2/01/23 at 12:48 pm. At that time, R6 stated, Just last night (R9) was following me around, he called me a Retarded B***h while staff were with him, following him as he walked around. On 1/31/23 at 1:45 pm, V30 (Police Officer) stated he said he has responded to the facility several times over R6's threats of suicide. V30 stated R6 always tells him that she can't stand to live there anymore because the staff don't listen to her or help her. On 1/25/23 at 12:59 PM, V1 stated R6 came to her with concerns that R9 was getting too close to her. V1 could not recall what day that occurred, but indicated it was recent, within the month. V1 stated, We had actually been trying to wean (R9) off 1:1. V1 stated she had no knowledge of the 1/05/23 grievance completed by V4; however, V1 acknowledged that R9's Resident Monitoring Logs document he was placed back on 1:1 supervision at 12:00 am on 1/06/23. V1 stated she did not know what behavior had occurred for R9 to be returned to a higher level of supervision, nor could she find documentation as to why. V2 was in the office during this interview and denied knowledge of the grievance as well. V1 and V2 denied V4 bringing to the attention of Management that R6 had complaints of R9 touching her sexually during the 1/06/23 morning management meeting. V1 stated, Had I known, I would have reported an allegation of sexual abuse. V1 stated the only thing R6 told her was that (R9) was getting in her personal space, but not that (R9) had physically touched her. V1 stated she did not have any documented evidence of this conversation with R6, or any subsequent actions taken. V1 explained, (R9) is able to be taken off and on 1:1 based on his behavior. They will review his behaviors and if they increase, or if he is not able to be redirected, it can be reimplemented. That's in his Plan of Care. V1 confirmed that she was in attendance for the Resident Council meeting on 1/10/23. V1 stated she did not interview the four female residents that spoke out about R9's behavior. V1 stated, I recall (R6) speaking out against (R9) and (R10) as well. I do not remember the other two residents having specific concerns with (R9). I can't tell you my exact immediate follow up. I did not interview any residents that had concerns. At some point, I had a conversation with (R6 about R9), but I do not know when and did not document the details. 2. An official court document, dated 4/10/2017 documents V30 (R6's Mother) and V37 (R6's Father) as being appointed Guardians of the Estate & Person of (R6), a disabled adult, and are authorized to have, under direction of the Court, the care, management, and investment of the ward's estate and the custody of the ward, and to do all acts required by them by law. A Resident Profile Face Sheet documents R6 was admitted to the facility on [DATE]. A Subpart S Eligibility Screening, dated 5/13/22, documents under Section B that R6 has the diagnoses of Schizo-affective Disorder and Bipolar Disorder, and under Section E - (checked for yes) Are impairments in these areas primarily due to the resident's serious mental illness listed in Section B. (Checked for yes) Resident's impairment cannot be primarily due to any of the following (Check box if impairment is due to diagnosis listed): with Mental Retardation circled. Physician's Orders, dated 1/01/23, document R6 has the current diagnoses of Anxiety, Schizoaffective Disorder, Intellectual Disability, and Chronic Post Traumatic Stress Disorder. R6's Current Plan of Care, which has not been updated since 9/09/22, documents R6 has Impaired Communication (expressive), ambulates independently and has risk factors that require monitoring and intervention to reduce potential for self-injury. A Hospital History and Physical, dated 1/23/23, documents R6 as alert and oriented, but with limited judgement and insight, and below average intelligence. Behavior Tracking for October, November and December 2022 and January 2023 documents R6 is being monitored for the following targeted behaviors: Self Harm/Suicidal Ideations, Repetitive Verbalizations, Physical Aggression Towards Others, Intrusive Thoughts, Verbalized Hallucinations/Delusions, Exit Seeking, Depression, Self-Isolation, and Verbal Aggression Towards Others. Nursing Notes, dated 10/22/22, document (R6) got upset because she was asked to leave boyfriend's room and move down to lobby. She went down D Hall to another resident room. She was redirected to leave the hall because of COVID. (R6) got agitated and walked out of the facility through D Hall. Resident was not easily redirected. Walked down to the graveyard, took off all her clothing and laid naked in (a) field. Stated 'I want to die.' The cops were informed. Effort to get (R6) up not successful. Rescue team informed, got her up and was taken to (hospital). Nursing Notes, dated 12/18/22, document (R6) found in male patient's bed. They were wearing clothes. (R6) said she thought it was ok, as long as they don't have sex. Encouraged (R6) not to go in male resident room. She was easily redirected. Physician's Orders, dated 2/01/23, document R15 has the current diagnoses of Schizoaffective Disorder, Bipolar type, Catatonic Schizophrenia, and Psychosis. A Surrogate for Decision Making form, dated 12/29/22, documents V36 (R15's Sister) is R15's legal Surrogate Decision Maker. A Social Service Progress Note, dated 12/29/22, documents (R15) has a girlfriend (R6) and family does not want them having sexual relations. R6 and R15's medical record contain no documented evidence of a plan developed or implemented to ensure R6 and R15 were not engaging in sexual activities with each other. On 1/31/23 at 1:05 pm, V10 (Ombudsman) stated V30 (R6's Mother) contacted her today, very upset and concerned about R6 being in a sexual relationship with a male resident in the facility. V10 stated V30 discussed this with the Social Services Department in December, but the facility was not doing anything to stop R6 from having sexual intercourse with this resident. V30 stated the concern is that R6 does not have the mental capacity to consent to a sexual relationship with someone. On 1/31/23 at 2:44 pm, V30 stated V30 found out this summer that R6 was in a relationship with R15. V30 stated she was concerned, because R15 is twice R6's age, but she was just calling R15 her boyfriend. V30 stated nursing staff in the facility started telling her she should press her daughter for more information about her relationship with R15. V30 stated it was as if the staff knew R6 needed to tell her what was really going on with her and R15. V30 stated, Around the beginning of November, (R6) told me she had been caught having sex with this man (R15), in his room and her room, multiple times, and I'm concerned because I'm (R6's) State appointed guardian and (R6) has the mental capacity of a 10-[AGE] year old. I spoke to (V1) immediately after I found out, and (V1) told me (R6) was a consenting adult and there was nothing they could do about her having sex with this man, who is twice her age. On 2/02/23 at 1:30 pm, V30 stated she reviewed her phone records and she spoke with V1 on 11/08/22 about R6 and R15 having sex. V30 stated V1 told her R6's BIMS (Brief Interview for Mental Status) was too high, and they were able to consent to a sexual relationship. V30 stated she told V1 that she did not agree, as (R6) has the mentality of a teenage girl. V30 went on to say, This is my baby (R6) and I feel like (R15) is a predator. On 2/01/23 at 12:52 pm, R15 stated he is in a sexual relationship with R6. R15 stated they have sex in his room or hers, or sometimes on the couch. R15 stated they had been having sex for a while now. On 2/01/23 at 1:17 pm, R6 stated she has sex with R15. R6 stated, (R15) is my boyfriend and we are going to get married. R6 was asked where she has sex with R15, and she stated, Wherever and Oh we've been caught by people. R6 was asked if she had sex with R15 in his room or hers, and she stated both. R6 was asked what happens when they get caught and R6 stated, They just tell us not to do it again. My Mom knows. I told her. I told her we want to get married. On 1/31/23 at 12:59 pm, R3 stated, (R6 and R15) are in a sexual relationship. Everyone knows, including staff. They will lay on the couch in the common area on the other side of the fireplace, where no one can see them if they walk through, make out and fondle each other. They are smart and try to hide it. Staff will let them sit real close on the couch during a movie and say 'Now don't touch each other,' but it doesn't work. This has gone on since I've lived here. On 2/02/23 at 1:59 pm, V4 (Social Services) stated she talked to both R6 and R15's families regarding their sexual relationship in December, but (R6 and R15) had a high enough BIMS, so they could not stop them. V4 stated, (V1) was fully aware (of their sexual relationship); she has talked to (R6 and R15's) family regarding this. V4 stated they did discuss developing a care plan with individualized interventions to keep R6 and R15 from having sexual relations, but that never transpired. V4 stated R6 openly talked about being sexual with R15. V4 stated, It was common knowledge amongst staff, that they would have sex; it would trickle down to residents and then to Social Services. On 2/01/23 at 2:33 pm, V14 (Social Service) stated R6 does think R15 is her boyfriend. V14 stated she has heard from multiple staff and residents that R6 and R15 are in a sexual relationship. V14 stated, The first time I heard about them having sex, (R6) was in the hospital. It was a couple of months ago. Since (R6) was in the hospital, it was after the fact, and I did not report it to (V1). V14 stated there was a recent Care Plan meeting with R6's parents, V4 and V15. V14 stated, The main topic of that meeting was (R6's) sexual relationship with (R15). V14 stated, (R6) is cognitively there, but she does have a State appointed guardian. I feel she (R6) is able to consent to a sexual relationship. On 2/01/23 at 2:58 pm, V15 (Social Services) stated she is aware that R6 and R15 are in a relationship, and she has heard from other residents that they have a sexual relationship. V15 could not recall exactly when she heard this, but she assumed V1 knew about it because it was talked about openly. V15 stated she could not recall exactly what was discussed at the December 2022 Care Plan meeting with R6's parents and V4. V4 stated she is unsure if anything has been done to stop R6 and R15 from having a sexual relationship, stating, I'm not here at night, so I don't know what's done when I'm gone. I assumed (V1) would handle that, but (R6) can consent to a sexual relationship if she wants. <b[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a resident (R20), who is non-verbal, received gastrostomy tube (g-tube) feedings for adequate nutritional intake as ordered by the physician, implement dietician recommendations to prevent further weight loss, obtain daily weights, and document dietary meal intakes to prevent significant weight loss for three of four residents (R1, R5, R20) reviewed for weight loss in the sample of 25. As a result of this failure R20 went nine days without receiving any type of nutritional intake causing her emotional/psychological distress as well as pain related to hunger pains. R20 has also lost 20 lbs (11.4% weight loss) since R20 was admitted on [DATE] (five months). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 2/23/23, the facility remained out of compliance at a Severity Level 2. The facility is ensuring all in-house licensed staff and QAT (Quality Assurance Team) members are educated on administering g-tube feedings, processing physician's orders, notifying the physician of dietician recommendations and a resident not receiving scheduled g-tube feedings. The facility is also ensuring that all licensed staff are educated on who to contact when needing g-tube feeding equipment that is not available within the facility, g-tube feeding pump safety, procedures during an emergency with a g-tube, and proper handling of g-tube equipment. Also, the facility is reviewing all of the residents for weight loss to ensure the physician and dietician were notified of any significant weight losses. As well as developing a system to audit the g-tube feeding formulas ordered and used. Findings include: The facility's Resident Weight Monitoring policy, dated 9/08, documents, If there is an actual significant weight change, the resident, family/guardian, physician, and dietitian are notified. The date of notification for physician and family/guardian is documented on the Report of Monthly Weight form. The Food Service Manager and/or dietician reviews the resident's nutritional status and makes recommendations for intervention in the nutrition progress notes. The Food Service Manager and/or dietitian notify nursing of any recommendations that have been documented. Nursing then contacts the physician to convey recommendations and obtain any new orders. Significant unplanned weight changes are reviewed in the weekly Weight Committee Meeting. The Weight Committee will also identify any gradual weight loss or gain trends. Significant changes in weights are documented in the care plan with goals and approaches/interventions listed. The facility's Therapeutic & Mechanically Altered Diets policy, dated 4/06, documents, It is the policy of the facility that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietician. A therapeutic diet is a diet ordered to manage problematic health conditions. Examples include caloric specific, low-salt, low-fat, low lactose, no sugar added, and supplements during meals. The policy also documents, A physician's order is written for all diets including therapeutic and mechanically altered diets. All physician ordered diets are planned in writing. Portion sizes are evident for each item on the menu extensions. The facility prepares and serves all therapeutic and mechanically altered diets as planned. The facility's Enteral Tube Feeding Bolus Procedure policy, no date available, documents, It is the policy of the Facility to provide nutrition via Nasogastric or Gastrostomy tubes when ordered by physician. The resident may receive nutrition and hydration either by intermittent, continuous, or bolus feeding into the stomach by means of a tube when the oral route cannot be used. The policy also documents, Report unusual observations/findings to the physician. Report observations regarding feeding tolerance to the dietician. Document information related to feeding on flow record and/or TAR (Treatment Administration Record)/MAR (Medication Administration Record). 1. On 2/6/23 at 2:00 p.m., R20 was lying in her bed on her right side with her eyes open. When spoken to she lifted her head, made eye contact and laid back down without responding. On 2/6/23 at 3:30 p.m., R20 was partially sitting up in bed with a flat affect and no verbalization. Questions asked to R20. R20 did not respond verbally. However, did respond at times with a thumbs up or thumbs down partially, but it was hard to understand her response. R20 became frustrated and laid back down facing the wall. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's Admission weight on 8/6/22 was 176 lbs (pounds). R20's Physician's orders, dated 8/22, documents that R20 was admitted on [DATE] with an order to receive Jevity 1.2 237 ml (milliliters) via gastrostomy tube every three hours. R20's Dietitian Nutritional Assessment, dated 8/19/22, documents, (R20) admitted on regular finger food diet with thin liquids and chopped meats. Tube feeding order of Jevity 1.2 237 ml via gastrostomy tube every three hours for 24 hours if (R20) eats less than 50%. 60 ml FWF (Free water flush) before and after feedings. Tube feeding order provides 2275 kcals/day, 105 g (grams) protein/day and 1530 FW/day. FWF provides 960 ml FW (Free Water)/day. No intakes available for review at this time. CBW (Current Body Weight) 176 lbs. Weight trending down since admission. (R20's) meeting estimated fluid and kcal requirements with current tube feed order. Tube feed order provides above protein needs. Nurse reports encouraging resident to eat without success. (R20) is eating 0%. Tube feeding order fully utilized due to 0% intakes. Continuous feed not appropriate at this time due to (R20) attempts to elope. Recommend weekly weights. Monitor weight, intake, medications, labs, skin integrity, tube feeding tolerance. R20's Dietary Services Communication, dated 8/22/22, documents, Observations: Tube feeding to hold if GRV (Gastric Residual Volume) is greater than 100 ml. Aspen Guidelines state hold if tube feeding GRV is greater than 500 ml. Dietary Recommendations: Recommend discontinue current GRV order. Recommend hold tube feeding if GRV is greater than 500 ml. Recommend weekly weights. The communication also documents that R20's physician acknowledged and approved the recommendation. R20's MAR (Medication Administration Record), dated 8/6-8/30/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 8/7 - 6:00 p.m., 3:00 a.m.; 8/8 - 6:00 p.m., 3:00 a.m.; 8/9 - 3:00 a.m.; 8/10 - 6:00 p.m., 9:00 p.m., 3:00 a.m.; 8/11 - 6:00 a.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 8/12 - 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 8/13 - 3:00 a.m.; 8/14 - 6:00 a.m., 12:00 p.m., 12:00 a.m., 3:00 a.m.; 8/15 - 6:00 a.m.; 8/16 - 12:00 a.m., 3:00 a.m.; 8/18 - 9:00 p.m.; 8/19 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 8/20 - 6:00 p.m.; 8/22 - 9:00 p.m.; 8/25 - 9:00 a.m., 3:00 p.m., 6:00 p.m. 9:00 p.m.; 8/30 - 6:00 p.m.; 8/31 - 9:00 p.m. for a total of 36. R20's TAR (Treatment Administration Record), dated 8/6/22-8/31/22, documents that R20 is to be a daily weight. However, during the time span of 8/6-8/31 only one weight was obtained on 8/29/22. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 9/22 weight was 170 lbs (6 lbs 3.4% weight loss in one month). R20's Dietary Notes, dated 9/21/22 and signed by V40 (Registered Dietician), document, CBW 170 lbs. Gradual weight loss since admission. Regular pureed diet with thin liquids. 0% intakes recorded for three meals. Tube feeding order of Jevity 1.2 237 ml via gastrostomy tube every three hours for twenty four hours if less than 50% intakes. 60 ml FWF plus tube feeding order plus FW provides 2275 kcals/day, 105 g protein/day, 2490 FW a day. R20 meeting estimated kcal and fluid requirements with current tube feeding order. R20 tolerating tube feedings per nursing notes. Nurse reports R20 drinks but does not eat anything as per above. V40 recommendations for GRV signed last month; per nurse. Tube feeding not be held due to GRVs. Continuous feed would be appropriate overnight due to R20 receives 1:1 care. Continuous feed may assist with weight control. Recommend Jevity 1.2 at 150 ml/hour for twelve hours overnight with 200 ml FWF three times a day during feedings. Tube feeding provides 1800 ml volume/day, 2160 kcals/day, 99.9 g protein per day, 1453 FW per day. 200 ml FWF three times a day provides 600 ml FW per day. New tube feeding recommendations meet estimated nutrient needs. Monitor weight intake, medications, labs, skin integrity, tube feeding tolerance, tube feeding order. R20's Dietary Services Communication, dated 9/21/22 and signed by V40, documents, Observations: Nurse requests continuous feed for tube feeding. Gradual weight loss. Recommendations: Recommend Jevity 1.2 at 150 ml/hr for 12 hours overnight with 200 ml FWF three times a day during feedings. The communication also documents that the physician acknowledged and approved the recommendation on 10/20/22. R20's current medical record has no documentation of V40's 9/21/22 recommendation being followed through with until signed by the physician on 10/20/22. R20's MAR, dated 9/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 9/1 - 6:00 p.m.; 9/6 - 6:00 p.m., 9:00 p.m.; 9/7 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 9/8 - 9:00 p.m.; 9/10 - 9:00 p.m.; 9/11 - 12:00 a.m., 3:00 a.m.; 9/12 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/14 - 9:00 p.m.; 9/19 - 6:00 p.m.; 9/20 - 6:00 p.m., 9:00 p.m.; 9/21 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 12:00 a.m., 3:00 a.m.; 9/22 - 6:00 p.m.; 9/23 - 6:00 p.m.; 9/24 - 6:00 p.m.; 9/25 - 6:00 p.m., 9:00 p.m.; 9/26 - 12:00 a.m., 3:00 a.m.; 9/27 - 6:00 p.m.; 9/28 - 6:00 p.m.; 9/29 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/30 - 6:00 a.m. for a total of 40. R20's TAR, dated 9/22, documents that R20 is to be weighed daily as of 9/6/22 and there is no documentation of a weight being obtained on the following dates: 9/7, 9/15-9/17, 9/19-9/25, 9/29-9/30. R20's Food & Fluid Intake Sheet, 9/22, documents that R20 refused the following meals: 9/23 lunch, 9/24 breakfast & lunch, 9/26 breakfast, 9/30 breakfast & lunch. The sheet also zero documented for intake on the following meals: 9/1-9/2 all three meals, 9/4 all three meals, 9/6-9/7 all three meals, 9/8 supper, 9/10 all three meals, 9/14 supper, 9/15-9/16 all three meals, 9/25 lunch, and it has no documentation for R20's intakes on the following days: 9/3 all three meals, 9/5 all three meals, 9/8 breakfast & lunch, 9/9 all three meals, 9/11-9/13 all three meals, 9/14 breakfast & lunch, 9/17-9/19 all three meals, 9/20 breakfast & lunch, 9/21-9/22 all three meals, 9/23 breakfast & supper, 9/24 supper, 9/26 supper, 9/27-9/29 all three meals, and 9/30 supper. R20's Nurses' notes, dated 9/27/22 at 12:00 p.m., document, R20 continues to yell out and it is very difficult to understand her needs. Seems to be in pain. This date is also date in which there is no documentation of R20 receiving a scheduled g-tube bolus. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 10/22 weight was 160 lbs (10 lbs 5.9% weight loss in one month). R20's Dietary notes, dated 10/18/22 and signed by V40, document, CBW 163 lbs. Gradual weight loss for 30 days noted. Tube feeding order of Jevity 1.2 237 ml via gastrostomy tube every three hours for twenty four hours if less than 50% intakes. Tube feeding order plus FW provides 2275 kcals/day, 105 g protein/day, 2490 FW a day. R20 meeting estimated kcal requirements; however, receiving above protein and fluid requirements with current tube feeding order. Extra protein may be appropriate due to failure to thrive diagnosis and continued weight loss. 0% PO (by mouth) intakes recorded for three meals. V28 (Dietary Manager) confirms little to no intakes as per above. Continuous feed may assist with weight control as per previous. Recommend Jevity 1.2 at 150 ml/hour for twelve hours overnight with 200 ml FWF three times a day during feedings and 30 ml FWF twice a day before and after medications. New tube feed order provides 1800 ml volume/day. 2160 kcals/day, 99.9 g protein/day, 1453 ml FW/day. New tube feed order meets estimated nutrient needs. R20's Dietary Services Communication, dated 10/18/22 and signed by V40, documents, Observation: Gradual weight loss for 30 days. Tube feed bolus. Recommendations: Recommend Jevity 1.2 at 150 ml/hr for 12 hours overnight with 200 ml FWF three times a day during feedings and 30 ml FWF twice a day before and after medications. The communication also documents that the doctor acknowledged and approved the recommendation on 10/20/22. R20's Physician's orders, dated 10/22, document that R20 received an order on 10/20/22 for Jevity 1.2 at 150 ml/hr for 12 hours overnight with a 200 ml flush three times during feedings and a 30 ml flush twice a day before and after medications. R20's MAR, dated 10/22, has no documentation of R20 receiving her Jevity 1.2 237 ml every three hour bolus on the following dates/times: 10/1 - 3:00 p.m., 3:00 a.m.; 10/6 - 9:00 p.m.; 10/7 - 6:00 p.m.; 10/9 - 9:00 p.m.; 10/12 - 9:00 p.m.; 10/13 - 9:00 p.m., 12:00 a.m.; 10/16 - 9:00 p.m.; 10/17 - 6:00 p.m., 12:00 a.m., 3:00 a.m.; 10/27 - 12:00 a.m., 3:00 a.m.; 10/28 - 9:00 p.m., 10/29 - 9:00 p.m.; 10/30 - 12:00 p.m., 9:00 p.m.; 10/31 - 9:00 p.m. for a total 19. R20's MAR also documents that R20's order to receive Jevity 1.2 at 150 ml/hr overnight with 200 ml FWF three times a day during feedings was not started until 10/27/22 and there is no documentation of R20 receiving the overnight feeding on 10/29 or 10/30. The as needed medication information page of R20's MAR also documents that R20 received as needed Tramadol 50 mg for yelling out/symptoms of pain twice on 10/9, 10/17, 10/27, 10/29, and 10/30 which were also days that R20 has no documentation of receiving scheduled g-tube boluses. R20's Food & Fluid Intake Sheet, 10/22, documents that R20 had zero for intake on the following meals: 10/1-10/5 all three meals, 10/6 breakfast & lunch, 10/9-10/10 all three meals, 10/11 supper, 10/13 all three meals, 10/15 breakfast, 10/17 all three meals, 10/20 supper, 10/21-10/22 all three meals, 10/25 supper, 10/28 breakfast, 10/29 breakfast & lunch, 10/30 supper, 10/31 breakfast & lunch, and it has no documentation for R20's intakes on the following days: 10/6 supper, 10/7-10/8 all three meals, 10/11 breakfast & lunch, 10/12 all three meals, 10/14-10/15 lunch & supper, 10/16 all three meals, 10/18-10/19 all three meals, 10/20 breakfast & lunch, 10/23-10/24 all three meals, 10/25 breakfast & lunch, 10/26-10/27 all three meals, 10/28 lunch & supper, 10/29 supper, 10/30 breakfast & lunch, 10/31 supper. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 11/22 weight was 161 lbs (15 lbs 8.5% weight loss in three months). R20's MAR (Medication Administration Record), dated 11/22, documents that R20 was to receive Jevity 1.2 for twelve hours overnight at a rate of 150 ml/hr being turned on at 8:00 p.m. and turned off at 8:00 a.m. The MAR has no documentation of R20 being administered the feeding on 11/3, 11/5, 11/6, and 11/9 as well as 11/1, 11/2, 11/7, 11/8 were circled as R20's tube feeding was not administered. In the same section that this tube feeding is signed off is a handwritten statement, On hold; pending discontinue - R20 doesn't remain still. The MAR documents that R20 was restarted on Jevity 1.5 237 ml bolus every three hours on 11/9 at 12:00 p.m. There is no documentation of R20 receiving the bolus on the following dates/times: 11/9 - 12:00 a.m. & 3:00 a.m.; 11/10 - 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/12 - 9:00 p.m.; 11/13 - 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/14 - 12:00 a.m., 3:00 a.m.; 11/15 - 9:00 p.m., 11/16 - 6:00 a.m., 12:00 a.m., 3:00 a.m., 11/17 - 6:00 p.m.; 11/18 - 6:00 a.m., 6:00 p.m.; 11/19 - 6:00 p.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 11/20 - 6:00 p.m.; 11/21 - 6:00 p.m.; 11/22 - 6:00 a.m.; 11/24 - 6:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/25 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m.; 11/26 - 3:00 p.m.; 11/27 - 6:00 a.m., 6:00 p.m.; 11/29 - 3:00 p.m., 6:00 p.m. for a total of 41. The as needed medication information page of R20's MAR also documents that R20 received as needed Tramadol 50 mg twice on 11/5, twice on 11/6, and once on 11/9 for yelling out/symptoms of pain which were also days that R20 has no documentation of receiving any type of g-tube feeding. R20 also received the as needed Tramadol on 11/18, twice on 11/19, twice on 11/20, and on 11/25 which were days that R20 has no documentation of receiving scheduled g-tube boluses. R20's Psychiatric Nurse Practitioner Progress note, dated 11/8/22, documents, Assessment & Plan: Anorexia. R20's Physician notification form, dated 11/9/22, documents, R20 has gastrostomy tube and was ordered for 12 hour of Jevity 1.2 at 50 ml/hr. R20 does not remain still and is constantly getting up and walking halls. Unsafe to be hooked to machine for any length of time. Please consider returning to bolus feeds of Jevity 1.5 237 ml every three hours. The form also documents the physician's order to refer to dietician for orders. R20's current medical record has no documentation of V40 being notified regarding R20's continuous tube feeding being discontinued and boluses started. R20's Dietary Notes, dated 11/16/22 and signed by V40, document, CBW 161 lbs. Significant weight loss noted: 8.5% in 90 days. Tube feeding order of Jevity 1.2 237 ml bolus every three hours via gastrostomy tube with 60 ml FWF before and after feedings and 30 ml FWF twice a day before and after medications. Resident meeting estimated kcal and protein needs with current tube feeding order. Resident receiving above estimated fluid needs. Nurse reports continuous feed discontinued due to resident does not stay in bed for long periods of time throughout the night. Per nurse resident is tolerating feeds at this time. Recommend decrease flushes to 40 ml before and after feedings to provide 2290 ml FW/day. Meeting estimated fluid needs. Recommend 60 ml high calorie supplement twice a day by mouth to assist with weight control. R20's Physician's orders nor MAR, dated 11/22, have any documentation of V40's 11/16/22 recommendation being followed through with. R20's Food & Fluid Intake Sheet, 11/22, documents that R20 refused the following meals: 11/3 all three meals, 11/4-11/5 breakfast & lunch, 11/7 breakfast & lunch, 11/8 supper, 11/9 all three meals, 11/10-11/12 breakfast & lunch, 11/19 all three meals, 11/24 all three meals, 11/26 breakfast & lunch, 11/28 breakfast & lunch, and 11/29 supper. The sheet also has no documentation for R20's intakes on the following days: 11/1 breakfast & lunch, 11/2 all three meals, 11/4-11/5 supper, 11/6 all three meals, 11/7 supper, 11/8 breakfast & lunch, 11/10-11/12 supper, 11/13-11/18 all three meals, 11/22-11/23 all three meals, 11/25 all three meals, 11/23 supper, 11/27 all three meals, 11/28 supper, 11/29 breakfast & lunch, and 11/30 all three meals. R20's Behavior tracking, no date available however V1 verified on 2/16/23 this was R20's 11/22 behavior tracking, documents that R20's target behavior is Inappropriate Behavior. The tracking also documents that R20 exhibited this behavior continuously on 1st shift of 11/5-11/8, 11/12, 11/14-11/15, and 11/19-11/21. 11/5-11/8/22 were four days that the facility has no documentation of R20 receiving any type of g-tube feeding. There is also no documentation of R20 receiving scheduled bolus doses on 11/14, 11/15, 11/19 and 11/20/22. R20's Report of Monthly Weights and Vitals, dated 2022, documents R20's 12/22 weight was 157 lbs (4 lbs in one month, 13 lbs 7.6% weight loss in three months). R20's Dietary notes, dated 12/13/22 and signed by V40, documents, CBW 157 lbs. Significant weight loss noted: 7.65% in 90 days. Weight trending down in 30 days. Refusals documented for three meals. Tube feeding order of Jevity 1.2 237 ml bolus every three hours via gastrostomy tube with 60 ml FWF before and after feedings and 30 ml FWF twice a day before and after medications. Resident meeting estimated kcal and protein requirements with current tube feeding order. Recommend: 90 ml high calorie supplement twice a day due to continued weight loss. Discussed continued weight loss with Director of Nursing who would like to trial bolus feeds four times a day. Recommend Jevity 1.2 474 ml bolus four times a day with 40 ml FWF before and after feedings and 30 ml FWF twice a day before and after medications. Meets estimated nutrient needs. R20's Dietary Services Communication, dated 12/14/22 and signed by V40, documents, Observations: Tube feeding. 7.65% weight loss in 90 days. Recommendations: Jevity 1.2 474 ml bolus four times a day with 40 ml FWF before and after feedings and 30 ml FWF before and after medications. 90 ml high calorie supplement twice a day. The communication also documents that R20's physician acknowledged and approved the recommendation. R20's MAR, dated 12/22, has no documentation of R20 receiving her Jevity 1.5 237 ml every three hour bolus on the following dates/times: 12/3 - 6:00 a.m., 6:00 p.m.; 12/4 - 3:00 p.m., 6:00 p.m.; 12/7 - 9:00 p.m.; 12/13 12:00 a.m., 3:00 a.m.; 12/17 - 6:00 a.m., 6:00 p.m., 9:00 p.m.; 12/19 - 6:00 p.m.; 12/21 - 6:00 p.m., 9:00 p.m.; 12/22 - 9:00 p.m.; 12/26 - 3:00 p.m. for a total of 15. R20's MAR also has no documentation of R20 receiving 60 ml of high calorie supplement twice a day nor the 12/13/22 recommendations of 90 ml of high calorie supplement twice a day due to continued weight loss. The as needed medication information page of R20's MAR also documents that R20 received as needed Tramadol 50 mg twice on 11/5, twice on 11/6, and once on 11/9 for yelling out/symptoms of pain which were also days that R20 has no documentation of receiving any type of g-tube feeding. R20 also received the as needed Tramadol on 11/18, twice on 11/19, twice on 11/20, and on 11/25 which were days that R20 has no documentation of receiving scheduled g-tube boluses. R20's TAR, dated 12/22, documents that R20 should be daily weights, however there is no documentation of any weights obtained for the month of December. R20's Food & Fluid Intake Sheet, 12/22, documents that R20 refused the following meals: 12/1-12/2 all three meals, 12/3 supper, 12/4 breakfast & lunch, 12/5 all three meals, 12/6 breakfast & lunch, 12/17 breakfast & lunch, 12/18 all three meals, 12/19-12/20 breakfast & lunch, 12/22 breakfast & lunch, 12/27 breakfast, 12/20 breakfast & lunch, 12/31 all three meals. The sheet also has no documentation for R20's intakes on the following days: 12/3 lunch, 12/4 supper, 12/6 supper, 12/7-12/10 all three meals, 12/11 supper, 12/12-12/13 all three meals, 12/14 lunch & supper, 12/15 all three meals, 12/16-12/17 supper, 12/19-12/20 supper, 12/21 all three meals, 12/22 supper, 12/23-12/26 all three meals, 12/27 lunch & supper, 12/28-12/29 all three meals, and 12/31 supper. R20's TAR, dated 1/23, documents that R20 is to be weighed on a daily basis, however no weights are documented for 1/1-1/4. R20's most recent weight documented was 156 lbs (weight loss of 11.4% since admission-five months) on 1/19/23, and then this order was discontinued on 1/20/23. R20's Dietary Services Communication, dated 1/19/23 and signed by V40, documents, Observation: Tube feeding assessment. Dietary recommendations: Jevity 1.5 375 ml bolus four times a day with 90 ml FWF before and after feedings and 30 ml FWF before and after medications. The communication also documents that R20's physician acknowledged and approved the recommendation on 1/20/23. R20's MAR, dated 1/23, documents from 1/7-1/20 R20 had an order to receive Jevity 1.2 474 ml bolus four times a day, and there is no documentation of R20 receiving the bolus on 1/11 at 6:00 a.m. and 12:00 a.m. The MAR also documents that this order was discontinued on 1/20/23 and Jevity 1.5 375 ml bolus four times a day was started. There is no documentation of R20 receiving that bolus on 1/21 at 6:00 p.m. or 1/30 at 12:00 p.m. Also, R20's dietician recommendation to initiate 90 ml of high calorie supplement twice a day was started on 1/7/23, however it was discontinued on 1/20/23. R20's Medical record has no documentation of an order to discontinue R20's 90 ml of high calorie supplement twice a day on 1/20/23. R20's Food & Fluid Intake Sheet, 1/23, documents that R20 refused the following meals: 1/1 all three meals, 1/2 breakfast & lunch, 1/3 all three meals, 1/5 breakfast & lunch, 1/6 lunch, 1/7-1/8 supper, 1/9 all three meals, 1/10 breakfast, 1/11 breakfast & supper, 1/12 breakfast, 1/13 all three meals, 1/14-1/15 breakfast, 1/16 breakfast & lunch, 1/17-1/19 breakfast, 1/20 all three meals, 1/21 breakfast & lunch, 1/22 breakfast, 1/23 breakfast & lunch, 1/24 breakfast, 1/25 all three meals, 1/27-1/29 breakfast & lunch, 1/30 all three meals, 1/31 breakfast. The sheet also has no documentation for R20's intakes on the following days: 1//2 supper, 1/4 all three meals, 1/5 supper, 1/6 breakfast & supper, 1/7-1/8 breakfast & lunch, 1/10 lunch & supper, 1/12 lunch & supper, 1/14-1/15 lunch & supper, 1/16 supper, 1/17-19 lunch and supper, 1/21 supper, 1/22 lunch & supper, 1/23 supper, 1/24 lunch & supper, 1/26 all three meals, 1/27-1/29 supper, and 1/31 lunch & supper. R20's Physician's orders, dated 2/23, document that R20 has an order dated 1/20/23 to receive Jevity 1.5 375 ml bolus four times a day via gastrostomy tube. However, there is no documentation of R20 having an order to receive the high calorie supplement 90 ml twice a day. R20's MAR, dated 2/23 obtained on 2/6/22 at 3:00 p.m., documents that R20 has an order to receive Jevity 1.5 375 ml bolus four times a day. The MAR also documents that as of 2/6/23, there is no documentation that R20 received her bolus on 2/4 at 6:00 p.m. & 12:00 a.m. and 2/5 at 6:00 a.m. and 12:00 a.m. nor that she received the high calorie supplement 90 ml twice a day from 2/1-2/6/23. R20's Food & Fluid Intake Sheet, as of 2/6/23 dated 2/23, documents that R20 refused the following meals: 2/1 breakfast & lunch, 2/2 breakfast, 2/3 all three meals, 2/4 breakfast, 2/5 all three meals, and 2/6 breakfast and lunch. The sheet also has no documentation for R20's intakes on the following days: 2/1 supper, 2/2 lunch & supper, 2/4 lunch & supper. R20's care plan, dated 8/19/22, has no documentation of a revision to include R20's significant weight loss. On 2/04/23 at 11:10 am, V32 (Registered Nurse/RN) stated, (V27/Licensed Practical Nurse/LPN) was not feeding (R20) who was to get a tube feed. Several weeks ago, I came on shift and (V27) was giving me report. She was saying how (R20's) tube feeding had been infusing all night. I started to question her, because (R20) didn't have an infusion pump or continuous feeding. (V27) argued that (R20) did have an infusion pump and I just let it go. As soon as (V27) left, I went to (R20's) room. The door was closed. I was right, they didn't' start (R20) on continuous pump, she was still on bolus feedings. (R20) can't talk much, but can say 'yes' or 'no.' She was really agitated when I went in her room, needed oral care, it was obvious it hadn't been done. I asked (R20) if she got fed by the nurse before me and she indicated 'No.' So I gave her her feeding. When I went to the MAR, it was signed off by (V27) as being given. Honestly, I don't think (V27) went into her room all night. We don't even have a tube feeding pump in the building. (R20's) behaviors will increase because she is hungry; I've seen it other times. I will come in and she will be agitated, and her feedings will not be documented as given. As soon as I feed her, her agitation stops. On 2/7/23 at 12:00 p.m., V11 (RN) stated, There was an issue with the facility getting a tube feeding pump when we first got the order. So, it wasn't started right away. I actually spoke with (V40) myself to try and do something different than boluses every three hours because when it's busy it's not easy to get them done every three hours. If you missed one dose by getting side tracked or busy by the time you were able to do it, she was due for her next one. So, she might miss a dose. On 2/7/23 at 12:40 p.m., V40 (Registered Dietician) stated, (R20) should not be losing weight with the amount of calories and protein that she gets on a daily basis from her tube feedings. It gets frustrating. I make recommendations and they don't get followed up with. I added the high calorie supplement twice a day hoping that would help. I was not notified when they changed the tube feeding from continuous overnight back to the boluses. I didn't know about it until I came in for my monthly visits. They should have consulted with me about what to put her on. On 2/7/23 at 1:20 p.m., V24 (Registered Nurse) stated, I don't know that (R20) always gets her feedings or if she does if they are late. I don't want to assume, but her behaviors are escalated when I suspect it. It seems like she has an increase in behaviors. She complains of pain at times too. She will normally tell me she has a headache which could be part of hunger pains. She doesn't eat, and then nurses may not be giving her all of her boluses. This breaks my heart. She can't verbalize. She can't tell us that she is hungry. On 2/7/23 at 4:10 p.m., V41 (Medical Director) stated, (R20) should not have gone without receiving her tube feedings. I agree that these issues needed to be addressed. The DON (Director of Nursing) should be overseeing these things and making sure they are followed through with. However, I know they haven't had a DON for a while. I should have been notified when the facility wasn't able to get the tube feeding supplies and (R20) went without feedings before 11/9/22. On 2/8/22 at 10:15 a.m., V11 (RN) stated, I know I don't give her high calorie supplement 90 ml with any of my medication passes. V11 confirmed there is no order on the 2/23 MAR for (R20) to receive high calorie supplements at all. V11 stated, (R20) doesn't have many behaviors. When she first got here, she was exit seeking mainly. Now though she will sit on the floor; she learned that from an old roommate. Now the only thing I really notice is the yelling out occasionally. Sometimes, if you ask her, she will say she's having pain; she will shake her head 'yes.' Sometimes, I feel like her yelling out is related to her feedings. I will ask her if she's hungry and she will say 'yes' at times. The yelling out is sometimes when she's due for a feeding as well. There's times too that it's hard to understand what she wants because she will shake her head 'yes' and 'no' to respond to our questions, but sometimes 'yes' looks like 'no' and 'no' looks like 'yes,' and I can't decipher what is wrong. On 2/8/22 at 5:20 p.m., V1 (Administrator in training) stated, (R20's) high calorie supplement was discontinued (1/20/23) in error by one of the nurses. There was no physician order to discontinue the high calorie supplement. On 2/1/23 at 2:25 p.m., V28 (Dietary Manager) stated, Significant weight loss is 5 lbs or more in one month. I don't know the significant weight loss percentages. The CNAs are responsible for charting the residents' intakes at meals. I use the meal intakes for my quarter assessments. I've noticed lots of holes where meals are not charted. I let the nursing department know about it. On 2/16/23 at 11:35 a.m., V48 (Director of Nursing) stated, The doctor and the dietician should have been notified prior to 11/9 that there was no equipment to administer (R20's) continuous feeding. They should have known that we had to keep the boluses going, and then contacted letting them know when the continuous feeding was actually started. The boluses should have continued until the continuous feeding

Based on observation, interview, and record review, the facility failed to administer a gastrostomy tube feeding as ordered for one of one resident (R20) reviewed for gastrostomy tube feedings in the sample of 25. As a result of this failure R20 had a significant weight loss of 20 lbs (11.4% weight loss) since R20 was admitted on [DATE] (five months). Findings include: The facility's Enteral Tube Feeding Bolus Procedure policy, undated, documents, It is the policy of the Facility to provide nutrition via Nasogastric or Gastrostomy tubes when ordered by physician. The resident may receive nutrition and hydration either by intermittent, continuous, or bolus feeding into the stomach by means of a tube when the oral route cannot be used. The policy also documents, Report unusual observations/findings to the physician. Report observations regarding feeding tolerance to the dietician. Document information related to feeding on flow record and/or TAR (Treatment Administration Record)/MAR (Medication Administration Record). On 2/6/23 at 2:00 p.m., R20 was lying in her bed on her right side with her eyes open. When spoken to, she lifted her head, made eye contact and laid back down without responding. On 2/6/23 at 3:30 p.m., R20 was partially sitting up in bed with a flat affect and no verbalization. Questions asked to R20. R20 did not respond verbally. However, did respond at times with a thumbs up or thumbs down partially, but it was hard to understand her response. R20 became frustrated and laid back down facing the wall. R20's Report of Monthly Weights and Vitals, dated 2022, documents: R20's Admission weight on 8/6/22 was 176 lbs (pounds); 9/22 weight was 170 lbs (6 lbs 3.4% weight loss in one month); 10/22 weight was 160 lbs (10 lbs 5.9% weight loss in one month); 11/22 weight was 161 lbs (15 lbs 8.5% weight loss in three months); 12/22 weight was 157 lbs (13 lbs 7.6% weight loss in three months). R20's TAR (Treatment Administration Record), dated 1/23, documents R20's most recent weight was 156 lbs (20 lbs 11.4% weight loss in five months) on 1/19/23. R20's Physician's orders, dated 8/22, documents that R20 was admitted on [DATE] with an order to receive Jevity 1.2 237 ml (milliliters) via gastrostomy tube every three hours. R20's MAR (Medication Administration Record), dated 8/6-8/30/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 8/7 - 6:00 p.m., 3:00 a.m.; 8/8 - 6:00 p.m., 3:00 a.m.; 8/9 - 3:00 a.m.; 8/10 - 6:00 p.m., 9:00 p.m., 3:00 a.m.; 8/11 - 6:00 a.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 8/12 - 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 8/13 - 3:00 a.m.; 8/14 - 6:00 a.m., 12:00 p.m., 12:00 a.m., 3:00 a.m.; 8/15 - 6:00 a.m.; 8/16 - 12:00 a.m., 3:00 a.m.; 8/18 - 9:00 p.m.; 8/19 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 8/20 - 6:00 p.m.; 8/22 - 9:00 p.m.; 8/25 - 9:00 a.m., 3:00 p.m., 6:00 p.m. 9:00 p.m.; 8/30 - 6:00 p.m.; 8/31 - 9:00 p.m. for a total of 36. R20's Dietary Services Communication, dated 9/21/22 and signed by V40 (Registered Dietitian), documents, Observations: Nurse requests continuous feed for tube feeding. Gradual weight loss. Recommendations: Recommend Jevity 1.2 at 150 ml/hr for 12 hours overnight with 200 ml FWF three times a day during feedings. The communication also documents that the physician acknowledged and approved the recommendation on 10/20/22. R20's MAR, dated 9/22, documents that R20 is to receive Jevity 1.2 237 ml via gastrostomy tube every three hours, and there is no documentation that R20 received the Jevity bolus on the following dates/times: 9/1 - 6:00 p.m.; 9/6 - 6:00 p.m., 9:00 p.m.; 9/7 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 12:00 a.m., 3:00 a.m.; 9/8 - 9:00 p.m.; 9/10 - 9:00 p.m.; 9/11 - 12:00 a.m., 3:00 a.m.; 9/12 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/14 - 9:00 p.m.; 9/19 - 6:00 p.m.; 9/20 - 6:00 p.m., 9:00 p.m.; 9/21 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 12:00 a.m., 3:00 a.m.; 9/22 - 6:00 p.m.; 9/23 - 6:00 p.m.; 9/24 - 6:00 p.m.; 9/25 - 6:00 p.m., 9:00 p.m.; 9/26 - 12:00 a.m., 3:00 a.m.; 9/27 - 6:00 p.m.; 9/28 - 6:00 p.m.; 9/29 - 6:00 a.m., 12:00 a.m., 3:00 a.m.; 9/30 - 6:00 a.m. for a total of 40. R20's Dietary Services Communication, dated 10/18/22 and signed by V40, documents, Observation: Gradual weight loss for 30 days. R20's Physician's orders, dated 10/22, document that R20 received an order on 10/20/22 for Jevity 1.2 at 150 ml/hr for 12 hours overnight with a 200 ml flush three times during feedings and a 30 ml flush twice a day before and after medications. R20's MAR, dated 10/22, has no documentation of R20 receiving her Jevity 1.2 237 ml every three hour bolus on the following dates/times: 10/1 - 3:00 p.m., 3:00 a.m.; 10/6 - 9:00 p.m.; 10/7 - 6:00 p.m.; 10/9 - 9:00 p.m.; 10/12 - 9:00 p.m.; 10/13 - 9:00 p.m., 12:00 a.m.; 10/16 - 9:00 p.m.; 10/17 - 6:00 p.m., 12:00 a.m., 3:00 a.m.; 10/27 - 12:00 a.m., 3:00 a.m.; 10/28 - 9:00 p.m., 10/29 - 9:00 p.m.; 10/30 - 12:00 p.m., 9:00 p.m.; 10/31 - 9:00 p.m. for a total 19. R20's MAR also documents that R20's order to receive Jevity 1.2 at 150 ml/hr overnight with 200 ml FWF three times a day during feedings was not started until 10/27/22 and there is no documentation of R20 receiving the overnight feeding on 10/29 or 10/30. R20's MAR (Medication Administration Record), dated 11/22, documents that R20 was to receive Jevity 1.2 for twelve hours overnight at a rate of 150 ml/hr being turned on at 8:00 p.m. and turned off at 8:00 a.m. The MAR has no documentation of R20 being administered the feeding on 11/3, 11/5, 11/6, and 11/9 as well as 11/1, 11/2, 11/7, 11/8 were circled as R20's tube feeding was not administered. In the same section that this tube feeding is signed off is a handwritten statement, On hold; pending discontinue-R20 doesn't remain still. The MAR documents that R20 was restarted on Jevity 1.5 237 ml bolus every three hours on 11/9 at 12:00 p.m. There is no documentation of R20 receiving the bolus on the following dates/times: 11/9 - 12:00 a.m. & 3:00 a.m.; 11/10 - 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/12 - 9:00 p.m.; 11/13 - 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/14 - 12:00 a.m., 3:00 a.m.; 11/15 - 9:00 p.m., 11/16 - 6:00 a.m., 12:00 a.m., 3:00 a.m., 11/17 - 6:00 p.m.; 11/18 - 6:00 a.m., 6:00 p.m.; 11/19 - 6:00 p.m., 9:00 p.m., 12:00 a.m., 3:00 a.m.; 11/20 - 6:00 p.m.; 11/21 - 6:00 p.m.; 11/22 - 6:00 a.m.; 11/24 - 6:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., 9:00 p.m.; 11/25 - 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m.; 11/26 - 3:00 p.m.; 11/27 - 6:00 a.m., 6:00 p.m.; 11/29 - 3:00 p.m., 6:00 p.m. for a total of 41. On 12/7/22 at 12:00 p.m., V11 (Registered Nurse) stated, There was an issue with the facility getting a tube feeding pump when we first got the order. So, it wasn't started right away. I actually spoke with (V40) myself to try and do something different than boluses every three hours because when it's busy it's not easy to get them done every three hours. If you missed one dose by getting sidetracked or busy by the time you were able to do it, she was due for her next one. So, she might miss a dose. R20's Nurses' notes, dated 11/9/22 at 9:00 p.m., document, Fax sent to doctor to discontinue pump feeds and continue with bolus feeds every three hours due to safety concerns related to inability to remain in bed for 12 hours. R20's Physician notification form, dated 11/9/22, documents, R20 has gastrostomy tube and was ordered for 12 hour of Jevity 1.2 at 50 ml/hr. R20 does not remain still and is constantly getting up and walking halls. Unsafe to be hooked to machine for any length of time. Please consider returning to bolus feeds of Jevity 1.5 237 ml every three hours. The form also documents the physician's order to refer to dietician for orders. On 2/7/23 at 1:20 p.m., V24 (Registered Nurse) stated, I don't work that hall too often. The facility was having difficulty getting the right equipment for (R20's) continuous feeding. We didn't have the equipment until the night of the 9th. I was the first one to hook her up for the feeding when we had the right equipment. I attempted to do the feeding and she wouldn't stay in the bed, and she was wanting to leave the room. The tubing was stretching, and it just wasn't working. So I contacted the doctor about getting them stopped and switched back to the bolus feedings. I did the bolus feedings as she previously had ordered. I mentioned it to the other nurses that nobody was signing out a bolus feed, but they were circling that the continuous feed wasn't getting done. It looks like we aren't feeding her. I don't know that all of the nurses were giving her the normal schedule of bolus feeding during that time. I know it wasn't on the MAR to give them. I was terrified to put my name in the book, so I contacted the doctor. If it's not signed off in the MAR, then you can only assume it's not done. I don't know of anyone notifying the physician prior to that evening. R20's Dietary Notes, dated 11/16/22 and signed by V40, document, CBW 161 lbs. Significant weight loss noted: 8.5% in 90 days. R20's Dietary notes, dated 12/13/22 and signed by V40, documents, CBW 157 lbs. Significant weight loss noted: 7.65% in 90 days. Weight trending down in 30 days. R20's MAR, dated 12/22, has no documentation of R20 receiving her Jevity 1.5 237 ml every three hour bolus on the following dates/times: 12/3 - 6:00 a.m., 6:00 p.m.; 12/4 - 3:00 p.m., 6:00 p.m.; 12/7 - 9:00 p.m.; 12/13 - 12:00 a.m., 3:00 a.m.; 12/17 - 6:00 a.m., 6:00 p.m., 9:00 p.m.; 12/19 - 6:00 p.m.; 12/21 - 6:00 p.m., 9:00 p.m.; 12/22 - 9:00 p.m.; 12/26 - 3:00 p.m. for a total of 15. R20's MAR, dated 1/23, documents from 1/7-1/20 R20 had an order to receive Jevity 1.2 474 ml bolus four times a day, and there is no documentation of R20 receiving the bolus on 1/11 at 6:00 a.m. and 12:00 a.m. The MAR also documents that this order was discontinued on 1/20/23 and Jevity 1.5 375 ml bolus four times a day was started. There is no documentation of R20 receiving that bolus on 1/21 at 6:00 p.m. or 1/30 at 12:00 p.m. R20's Physician's orders, dated 2/23, document that R20 has an order dated 1/20/23 to receive Jevity 1.5 375 ml bolus four times a day via gastrostomy tube. R20's MAR, dated 2/23 obtained on 2/6/22 at 3:00 p.m., documents that R20 has an order to receive Jevity 1.5 375 ml bolus four times a day. The MAR also documents that as of 2/6/23, there is no documentation that R20 received her bolus on 2/4 at 6:00 p.m. & 12:00 a.m. and 2/5 at 6:00 a.m. and 12:00 a.m. On 2/04/23 at 11:10 am, V32 (Registered Nurse) stated, (V27/Licensed Practical Nurse/LPN) was not feeding (R20), who was to get a tube feed. Several weeks ago, I came on shift and (V27) was giving me report. She was saying how (R20's) tube feeding had been infusing all night. I started to question her, because (R20) didn't have an infusion pump or continuous feeding. (V27) argued that (R20) did have an infusion pump and I just let it go. As soon as (V27) left, I went to (R20's) room. The door was closed. I was right, they didn't' start (R20) on continuous pump, she was still on bolus feedings. (R20) can't talk much, but can say 'yes' or 'no.' She was really agitated when I went in her room, needed oral care, it was obvious it hadn't been done. I asked (R20) if she got fed by the nurse before me and she indicated 'No.' So I gave her her feeding. When I went to the MAR, it was signed off by (V27) as being given. Honestly, I don't think (V27) went into her room all night. We don't even have a tube feeding pump in the building. (R20's) behaviors will increase because she is hungry. I've seen it other times. I will come in and she will be agitated, and her feedings will not be documented as given. As soon as I feed her, her agitation stops. On 2/7/23 at 12:40 p.m., V40 (Registered Dietician) stated, (R20) should not be losing weight with the amount of calories and protein that she gets on a daily basis from her tube feedings. It gets frustrating. I make recommendations and they don't get followed up with. I was not notified when they changed the tube feeding from continuous overnight back to the boluses. I didn't know about it until I came in for my monthly visits. They should have consulted with me about what to put her on. On 2/7/23 at 1:20 p.m., V24 (Registered Nurse) stated, I don't know that (R20) always gets her feedings or if she does if they are late. I don't want to assume, but her behaviors are escalated when I suspect it. It seems like she has an increase in behaviors. She complains of pain at times too. She will normally tell me she has a headache, which could be part of hunger pains. She doesn't eat, and then nurses may not be giving her all of her boluses. This breaks my heart. She can't verbalize. She can't tell us that she is hungry. On 2/7/23 at 4:10 p.m., V41 (Medical Director) stated, (R20) should not have gone without receiving her tube feedings. I agree that these issues needed to be addressed. On 2/8/22 at 10:15 a.m., V11 stated, (R20) doesn't have many behaviors. When she first got here she was exit seeking mainly. Now though she will sit on the floor; she learned that from an old roommate. Now the only thing I really notice is the yelling out occasionally. Sometimes, if you ask her, she will say she's having pain; she will shake her head 'yes.' Sometimes, I feel like her yelling out is related to her feedings. I will ask her if she's hungry and she will say 'yes' at times. The yelling out is sometimes when she's due for a feeding as well. There are times too that it's hard to understand what she wants because she will shake her head 'yes' and 'no' to respond to our questions, but sometimes 'yes' looks like 'no' and 'no' looks like 'yes,' and I can't decipher what is wrong. On 2/8/23 at 1:50 p.m., V3 (Resident Care Coordinator/Acting Director of Nursing/DON) stated, Nurses should be documenting when they administer medications or treatments on their MARs and TARs. If they don't sign it off, we don't know if it was done. The rule of thumb is if no signature, then it wasn't done. On 2/16/23 at 11:35 a.m., V48 (Director of Nursing) stated, The doctor and the dietician should have been notified prior to the 11/9 that there was no equipment to administer (R20's) continuous feeding. They should have known that we had to keep the boluses going, and then contact them letting them know when the continuous feeding was actually started. The boluses should have continued until the continuous feeding was started. I don't see where (R20) got any type of feeding from 11/1-11/9. V48 also confirmed the lack of documentation that R20 received her scheduled g-tube feedings.

Based on interview and record review, the facility failed to obtain laboratory draws as ordered by a physician for one of three residents (R1) reviewed for laboratory values in the sample of 25. This failure resulted in R1 being hospitalized with a critically low Valproic acid level. Findings include: The facility's Laboratory Tests policy, no date available, documents, Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations, and physician orders. Obtain laboratory orders upon admission, readmission, and PRN (as needed) for medication and condition monitoring per the physician's orders. R1's Physician's orders, dated 10/22, document the following orders: 10/18/22 Increase Depakote to 1125 mg by mouth three times a day. Check Depakote (Valproic Acid) level in one week. R1's most recent Valproic blood level, dated 9/30/22, documents a level of 46 low (Normal 50-100). The facility was unable to provide any Valproic acid levels after this date. R1's Hospitalist Admission History and Physical, dated 1/17/23, documents, R1 with severe schizophrenia, tardive dyskinesia, seizure disorder brought in from facility with complaints of lethargy and worsening tremors. R1 is lethargic, barely responsive, and thus unable to contribute to the history. History was obtained from emergency department records and from her mother at the bedside. The History & Physical also documents, Depakote level is subtherapeutic. R1's Hospital Progress note, dated 1/19/23, documents that R1's Valproic Acid is less than 13 (Normal 50-125). On 2/2/23 at 9:30 a.m., V1 (Administrator in Training) confirmed that R1's most recent Valproic acid level was drawn on 9/30/22. On 2/8/23 at 1:50 p.m., V3 (Resident Care Coordinator/Acting Director of Nursing) stated, The laboratory comes to our facility every Monday, Wednesday, and Friday unless it is a stat (as soon as possible) order. If it is stat, they come right away. If the physician orders for a lab to be drawn I would expect it to be done on the next scheduled lab draw day.

Based on observation, interview and record review the facility failed to ensure appropriate interventions were implemented for a resident assessed as high risk for wandering, provide supervision when a daily wandering, cognitively impaired resident exited the building and failed to recognize the incident of elopement as an elopement for one of five residents (R7), reviewed for elopement risk, in a sample of 10. These failures resulted in an immediate jeopardy. Findings include: These failures resulted in R7 not being adequately supervised and exiting from the facility on 9/10/22 at 2:30am. While the immediacy was removed on 9/15/22, the facility remains out of compliance at a Severity Level II as the facility implements the following: chart audits are completed and elopement assessments are completed, in-servicing all staff on policy and procedures, door alarm, elopement prevention, missing resident, emergency care/elopement, behavior tracking comprehensive care planning and resident monitoring policy including 1 on 1 policies are reviewed by the Quality Assurance team. The facility's Elopement Prevention policy, revised 10/06, documents that the IDT (Interdisciplinary Team) will imitate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures will be included in each high risk resident's plan of care to minimize risk factors. Interventions of personal door alarm devices and monitoring will be initiated as deemed necessary by IDT and documented in the individual resident's plan of care. This form documents that the plan of care for minimizing elopement risks will be reviewed each time the Risk Assessment is completed with initials and dating of the care plan by any member of the IDT present for review. The facility's Resident Monitoring policy, revised 12/22/2017, documents to initiate monitoring of residents as nursing measure upon the clinical decision of the Charge Nurse and/or Interdisciplinary Team to assist in providing safety to residents that are identified to be a potential threat to self or others or an elopement risk. Document all assessments, needs, interventions and resident responses in the resident's medical record. R7's Cumulative Diagnosis Log documents a closed fracture of the lateral wall of the right orbit, maxillary sinus fracture, open, seizures, trauma, sarcoidosis, bipolar disorder, suicidal ideation/attempts, anxiety, depression, falls, gastroesophageal reflux disease, anemia. R7's Elopement Risk Assessment, dated 8/12/22, documents a score of 5, indicating that R7 is a high risk for elopement. R7's care plan documents that R7 has attempted to elope from the building and is currently on one on one supervision related to her behaviors. R7's Progress notes, dated 8/13/22, documents that R7 is exit seeking and running out different doors in the facility throughout the day. R7's medical record has no documentation concerning the incident that happened on 9/10/22. On 9/13/22 at 9:00am, R7 was in the court yard with V8, Unit Aide. R7 stated that she left the building because she does not want to be here. R7 stated that she was going to buy a pack of cigarettes. R7 asked several times What time is smoke time over a period of 10 minutes. V8 verified that R7 wanders and attempts to leave the building. V8 stated that R7 has been one on one since she was admitted to the facility. On 9/14/22 at 5:25am, R7 was in her room unattended by staff. There were no staff located in the area of R7's hall. On 9/14/22 at 5:30am, V10, CNA, Certified Nursing Assistant, stated that on 9/10/22, R7 was sitting in the hall outside of her room, then would walk to the nurses station and back to room. V10 stated that when her and V9 started rounds, R7 took off out the front door. V10 stated that there were only three staff that night, V10, V9, CNA's and V11 Registered Nurse, so there is no way one on one supervision can be done. V10 verified that R7 is on one on one supervision since admission to the facility, because of her elopement risk. On 9/14/22 at 5:40am, V9 CNA, stated that when we work short staffed we are unable to do one on one supervision. V9 verified that R7 is on one on one because of exit seeking and elopement attempts. V9 stated that R7 has eloped before. V9 stated that R7 was anxious and pacing in the hall watching staff watch R7. V9 stated that she told V11 that R7 was up to something to keep an eye on R7 while we (V9, V10) do rounds. V9 stated that rounds were started at 2:00am, not long after that, R7 ran out the front door, V11 ran after her, but could not keep up. V9 verified that V11 ran back into the building, said that R7 ran towards the fields, so V9 and V10 went after R7, but could not find her. V9 stated that the police came and asked V9, V10 and V11 to search every room, which they did, R7 was not in the building. V9 stated that the police brought R7 back to the building around 3:15am. V9 stated that V14, Police Officer, stated that R7 was found sitting by a dumpster at a local restaurant about a mile away from the facility. 9/14/22 at 6:15am, V3, Assistant Director of Nursing/Licensed Practical Nurse, stated that R7 has been on one on one supervision since admission because of exit seeking and elopement attempts. V3 verified that R7 has actually got out the front door, but has come right back in. V3 stated that R7 will ask the same questions over and over, about 15 seconds apart. V3 verified that there were only three staff for the night shift on 9/9/22-9/10/22. On 9/14/22 at 9:35am, V11, Registered Nurse, verified that R7 ran out the front door on 9/10/22 around 2:30am. V11 stated that she ran after R7, but could not see her when she got outside of the building. V11 stated that she called the police when she came back into the building and the two CNA's (V9 and V10) went to search for R7. V11 stated that the police brought R7 back around 3:15am. V11 stated that she sent a message to the Boss (V3 Licensed Practical Nurse) and called V16, R7's Family, after calling the police. V11 verified that there was not enough staff to do one on ones on 9/10/22, just make sure to do checks on the residents. On 9/14/22 at 7:20pm, V14, Police Officer, stated I responded to a walkout at the facility at 2:11am. Myself and another deputy searched the bean field and cemetery east of the facility, but did not find (R7). Due to (R7's) history of elopements and suicide attempts, fire and rescue were called in on the search. (R7) was found about one mile away from the facility, sitting by a dumpster behind a restaurant, on a busy highway. I picked (R7) up and returned her to the facility. The staff at the facility wanted me to arrest (R7) because they did not have the staff to watch her. There were only three staff on duty at the facility. The call came in at 2:11am and (R7) was located at 3:11am. V14 stated that he has been called to the facility before concerning R7, leaving the building. On 9/13/22 at 2:00pm, V1, Administrator in Training, stated that the facility did not consider R7's leaving the building an elopement, because staff seen her go out the front door. V1 verified that R7 was not seen on the property, when staff searched for R7. On 9/13/22 at 2:30pm, V2, Cooperate Administrator, verified that R7's exiting the building was not considered an elopement. V2 verified that R7 was in the community at night by herself. V2 stated that staff just do the best they can, when they are short staffed. An Immediate Jeopardy situation was identified on 9/15/22. The Immediate Jeopardy began on 9/10/22 at 2:06am, when the facility failed to provide supervision to prevent a high risk elopement resident from leaving the building unattended. V1, Administrator in Training was notified of the Immediate Jeopardy on 9/15/22 at 4:20pm. The Surveyor confirmed through interview, observation and record review that the facility took the following action to remove the Immediate Jeopardy: All resident records were immediately audited for Current Elopement assessments and Risks levels on 9/16/2022 by nursing staff members. The Missing resident Binder was reviewed and all appropriate residents demographic information and photos were present. All staff were in-serviced on 9/16/2022 on all of the following policies and procedures. (Door Alarm Policy, Elopement Prevention Policy, Elopement Evaluation, Missing Resident Policy, Emergency Care/Elopement Policy, Behavior Tracking, Comprehensive Care Planning and Resident Monitoring Policy including 1 on 1) by the AIT and Resident Care Coordinator. R7's care plan was updated with interventions for elopement prevention, wandering and exit seeking. The quality assurance team will review compliance R7's daily.

Based on observation, interview, and record review, the facility failed to perform daily and/or weekly skin checks on a resident at a high risk for developing pressure ulcer and assess a resident's skin condition. This failure affected one of two residents (R41) reviewed for pressure ulcers in the sample of 31. This failure resulted in R41's pressure ulcer being discovered at a Stage 3. Findings include: The facility Pressure Sore Prevention Guidelines, dated 1/18, documents, It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as High or Moderate risk for skin breakdown as determined by Braden Scale. The nurse will complete a skin assessment on all residents upon admission then weekly for four weeks. After the weekly skin assessments are completed they must then be done with an annual, quarterly and significant change MDS or in the event a pressure ulcer develops. The following guidelines will be implemented for any resident assessed at a Moderate or High skin risk. The guidelines also document in a chart if a resident is at high risk for developing pressure ulcers daily skin checks will be performed, and if at moderate risk weekly skin checks will be completed. Also documenting, Any resident scoring a high or moderate risk for skin breakdown will have scheduled skin checks on the treatment record. Skin checks will be completed and documented by the nurse. On 8/29/22 at 11:45 a.m., R41 had an oval shaped open area with depth on his sacral area. R41's Braden Scale for Predicting Pressure Ulcer Risk assessments, dated 4/18/22 and 7/18/22, document that R41 is at a high risk for developing pressure ulcers. R41's TAR (Treatment Administration Record), dated 6/1-6/30/22, documents for the nurses to perform weekly skin care on Sundays. The TAR documents that this was completed three times during this time period on 6/5, 6/12, and 6/19/22. There is no documentation of daily skin checks being completed. R41's TAR dated 7/1-7/31/22, documents for the nurses to perform weekly skin care on Sundays. The TAR documents that this was completed once during this time period on 7/10/22. There is no documentation of daily skin checks being completed. R41's Nurses' notes, dated 8/3/22, documents, R41 has open area to buttocks. New order received apply collagen to buttocks then calcium alginate cover with border foam. R41's medical record has no documentation of an assessment being completed of R41's pressure ulcer when it was discovered on 8/3/22. R41's Wound Evaluation & Management Summary, dated 8/10/22, documents, (R41) has a Stage 3 pressure wound sacrum for at least 1 day duration. Stage 3 Pressure Wound Sacrum Full Thickness: Wound size: 2 x 0.7 x 0.2 cm (centimeters). Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Pressure Ulcer care plan, dated 8/17/22, has no documentation of revision that R41 had developed a pressure ulcer. R41's Wound Evaluation & Management Summary, dated 8/24/22, documents, (R41) has a full thickness Stage 3 pressure wound to his sacrum that measures: 0.7 x 0.5 x 0.1 cm (centimeters). On 8/31/22 at 1:00 p.m., V9 (Corporate Nurse) stated, (R41) does not have an initial wound assessment. His wound was not fully assessed until he was seen by the wound doctor. When the wound was identified an AIMs for Wellness should have been completed that would have documented the full wound assessment and notified the physician. That was not done. If a resident is a high risk for developing pressure ulcers then daily skin checks should be documented on the TAR. V9 confirmed that daily skin checks were not done for R41 nor were all weekly skin checks.

Based on observation, interview and record review, the facility failed to protect one resident from physical abuse by other residents, failed to supervise while wandering in resident Common areas, failed to supervise while wandering in and out of other resident rooms and during group smoking times for one of four residents (R1) reviewed for abuse in a sample of eight. This failure to supervise R1 while among other residents continues to leave R1 at risk for potential of abuse. Findings include: Facility Abuse policy dated 4/2021, documents As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse 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 mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis. Facility reported incident dated 2/25/21 documents On 2/21/21 an allegation of physical altercation involving (R1) and (R9) was reported. (R9) stated I asked (R1) to go to her room because (R1) was bugging me and then I pushed her. I said I was sorry afterward. Upon completion of the investigation, the facility believes that the incident did occur secondary to resident diagnosis. Facility reported incident dated 4/16/21, documents On 4/11/21, an allegation of physical altercation involving (R4) and (R1) was reported. (R6) stated I saw (R4) hit (R1) in the arm. (R4) stated (R1) is always in the way, so (R4) hit (R1). Upon completion of the investigation, the facility believes the incident did occur due to (R4) becoming upset with (R1) sitting in her chair and also secondary to resident diagnosis. Facility reported incident dated 5/21/21, documents On 5/15/21, an allegation of physical altercation between (R1) and (R2). (R2) stated I was in the doorway to get out to the courtyard for smoke pass. She (R1) was behind me while I was sitting in my wheelchair in the doorway trying to push me. She kept trying to push me out the door when I told her to stop. (R1) was continuing to push me, so I backhanded her. (V8) Activity Aide, I did witness the altercation. (R1) was trying to push (R2) outside the door to the courtyard. Then (R2) got upset with (R1) and backhanded her in the face. Upon conclusion of the investigation, the facility believes the incident did occur secondary to resident diagnosis. Activities will modify the smoking schedule so that (R2) and (R1) have different smoking times. Facility reported Incident dated 5/25/21, documents On 5/18/21, an allegation of physical altercation between (R1) and (R3). (V7) Activity Aide, stated I was conducting smoke pass and (R3) was wheeling himself out to the courtyard. (R1) was behind him and started to push him in his wheelchair. (R3) didn't like that so he backhanded her, and I separated the two residents. Upon completion of the investigation, the facility believes the incident did occur secondary to resident diagnosis. Activities will modify the smoking schedule so that (R3) and (R1) have different smoking times. R1's medical record documents R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief interview of mental status (BIMS) is undetermined due to communication deficit. On 5/26/21 at 9:03 AM, V6, Licensed Practical Nurse/Resident Care Coordinator (RCC), stated Over the last few months, (R1)'s behavior has gotten worse. We have a referral to a neurologist in because (R1) went from being able to communicate, to now not being able to really communicate. We did change (R1)'s smoking schedule to minimize her interactions with the other residents. On 5/26/21 at 8:53 AM, V2, Certified Nursing Assistant (CNA), stated I don't think there's anything in writing, but we were told to keep a close eye on her and redirect her when she goes into other resident rooms or when she was invading other resident's personal space. On 5/26/21 at 8:56 AM, V5, CNA, stated There isn't anything written in our communications sheets about (R1), but I know to keep a close eye on her and redirect her when she goes into other resident rooms or when she gets around groups of other residents. On 5/25/21, R1 observed throughout the day wandering around the facility. R1 observed walking into another resident's room, staff offices and standing with other residents congregated together. Staff did not redirect R1 out of resident's room or away from the residents that were grouped together. R1's medical record does not contain a referral for a neurologist consult. R1's current care plan does not address R1's recent change in behavior or resident to resident altercations with intervention for the facility reported incidents of 2/21/21, 4/11/21, 5/15/21, and 5/18/21. R1's behavior tracking dated February 2021 and April 2021 do not document behaviors. R1's behavior tracking dated May 2021 does not document behaviors on 5/15/21 and 5/18/21. On 5/26/21 at 11:55 AM, V3, Minimum Data Set/Care Plan Coordinator (MDS/CPC), verified the information for R1's recent change in behavior and resident to resident altercations should be in the care plan, but has not been entered. V3, MDS/CPC also stated I'll be honest with you, we had a mass exodus last month and a lot of things aren't getting done that should. I'll try and find the behavior tracking for (R1), but since we don't have Social Services right now, I'm not sure what's being done and what's not. I'm not the full time MDS/CPC coordinator. I'm at this facility more than others, but that's a couple days a week. On 5/27/21 at 2:00 PM, V10, Medical Director, stated I didn't put in a neurological consult for (R1) because I wasn't aware that she needed one.

Based on observation, interview and record review, the facility failed to evaluate and identify the risk associated with the use of a motorized wheelchair for one (R8) resident out of three reviewed for accidents out of a sample of eight. This failure resulted in R8 running her motorized wheelchair into stationary objects causing significant injury as evidence by R8 sustaining fractures to the first metatarsal base and the second through fourth metatarsal necks of the left foot and dislocation of the 1st-3rd metatarsals of the right foot. Findings include: Facility Motorized Wheelchair policy, undated, documents Each resident will be evaluated for the need and safe use of motorized wheelchairs. Conduct an Illinois Department of Healthcare and Family Services (HFS) evaluation for each new admission within 30 days of admission and then quarterly. R8's medical record documents R8 has a diagnosis of [CONDITION(S)], depression, anxiety and [CONDITION(S)] with a Brief Interview for Mental Status (BIMS) of 13. R8's medical record dated 2/17/21 documents (R8) sustained a fracture to the first metatarsal base and second through fourth metatarsal neck of the left foot. (R8) obtained the fractures as a result of running into a tote box in her closet with her motorized wheelchair. R8's hospital record dated 2/25/21 documents (R8) was driving her mechanical wheelchair, and sustained a left foot injury. Per (R8), this has happened multiple times. Pain 9/10. X-ray that was done today shows displaced first metatarsal fracture. There is minimally displaced second through fourth metatarsal fractures. R8's medical record nurse's notes dated 3/31/21 documents Resident complaining of foot pain. Stated she ran her wheelchair into her dresser earlier in the day. Her right foot is swollen and bruised down the medial side of the foot. X-ray results of right foot shows acute fractures of the first through fifth toes on right foot. X-ray results faxed to V10, Medical Director. R8's medical record dated 5/7/21 documents (R8) sustained dislocation of the first through third metatarsal of the right foot. (R8) obtained the fractures as a result of bumping into an object while operating the motorized wheelchair. (R8) will be reassessed for appropriateness of motorized wheelchair. R8's hospital records dated 5/6/21 documents (R8) noted some pain in her right foot. She states that it feels broken, similar to the previous fracture. X-ray obtained of right foot shows possible Lisfranc dislocation and malalignment of the third metatarsal with chronic base of the third metatarsals, subacute in nature with fourth metatarsal neck fractures with medial displacement along with a clinic healing first base of the first metatarsal fracture with second through fourth metatarsal neck fracture with increased callus formation with partial progression of healing. R8's hospital record dated 5/7/21 documents (V1, Administrator) calling regarding (R8) and recent X-ray findings. (R8) seen in office yesterday for follow up of left foot, but x-ray completed on right foot. (V1, Administrator) is asking if the results showed pre-existing issue or if it was as new finding. On the right foot, advised that report doesn't indicate this to be a pre-existing finding. On 5/25/21 at 11:33 am, R8 sitting in her wheelchair in front of her dresser. R8 pushed the control lever of the motorized wheelchair forward into the dresser where a cracking noise was heard. Resident stated she was trying to back up, but went forward instead. R8's room has two large holes in the wall about a foot off the ground, several scrapes along the walls and doors and a large piece of the wall missing from the corner. On 5/25/21 at 12:27 PM, V2, Certified Nursing Assistant (CNA), stated We've told them we didn't think it was safe for (R8) to be in her wheelchair. She runs into things all the time. It's been ongoing ever since she got the wheelchair. You can see what she's been doing to her room. She runs into her bed all the time. We're concerned for her safety. You can see the bathroom door as well.The bathroom door frame is broken at the bottom where the door hinge attaches and is no longer secured to the frame. The door hinge at the top of the frame has a missing screw and the remaining screws are partially pulled out. As V2, CNA, opened the door, the door was not steady and had to be held with two hands to open. On 5/25/21 at 12:33 PM, V11, Maintenance, verified the door was not in safe operating condition and stated I'll have to get some longer screws to go through the broken frame and reattach the door for now. That should hold it in place. R8's Motorized Wheelchair Assessment documents R8 was assessed for use of a motorized wheelchair on 4/7/20, 6/17/20, 7/15/20 and 10/5/20. R8's current care plan does not address resident's motorized wheelchair or incidents of injury from motorized wheelchair. R8's Physical Therapy Plan of Care dated 7/10/20, documents R8 as using a manual wheelchair at time of assessment. R8's Physical Therapy Plan of Care dated 5/24/21 documents R8 as using a motorized wheelchair at the time of assessment and documents (R8) exhibits decreased safety awareness for wheelchair mobility. On 5/25/21 at 2:12 PM, V3, Care Plan Coordinator (CPC) verified a motorized wheelchair assessment had not been completed since October 2020 and there was nothing in R8's care plan to address the motorized wheelchair. V3,CPC stated The motorized wheelchair assessments should be completed initially and then every three months or quarterly. We also should have completed another motorized wheel chair assessment back February when (R8) broke her toes using it. I just got notification today that she did it again on 5/7/21. That's why I'll be completing one today. On 5/25/21 at 3:00 PM, V1, Administrator, stated (R8) was re-assessed today for the use of a motorized wheelchair and is no longer in one due to safety concerns.

Based on interview and record review the facility failed to provide supervision for two residents (R2 and R3) of four residents reviewed for incidents and accidents in the sample of 15. This failure resulted in hospitalization after R2 and R3's suicide attempts. Findings include: 1. R2's Face Sheet, documents R2 has [CONDITION(S)] Disorder, Borderline Personality Disorder, [CONDITION(S)] (Post Traumatic Stress Disorder), and Suicide Attempts. R2's Physician Order Sheet, dated 10/1/19 through 10/31/19, documents R2 was receiving [MEDICATION(S)] 10mg (milligram) every noon, [MEDICATION(S)] 15mg twice daily, [MEDICATION(S)] 100mg twice daily, [MEDICATION(S)] 20mg daily, [MEDICATION(S)] twice daily, [MEDICATION(S)] 5mg at bedtime, and [MEDICATION(S)] 10mg at bedtime. R2's current plan of care documents, Resident has history of stating that she hears voices telling her to display inappropriate behavior and/or to harm herself. Resident has risk factors for self harm. Resident has history of self harm and [CONDITION(S)]. Place resident on 1:1 (one-on-one) supervision as needed when determined by IDT (Interdisciplinary Team). Resident has risk factors that require monitoring and intervention to reduce potential for self injury .Ambulates independently with steady gait. Resident has a history of becoming verbally aggressive/argumentative and impulsive . The facility's 5-Day Final Report, dated 10/9/19, documents On 10/01/19, (R2) ingested approximately 90cc (cubic centimeter) of cleanser containing [MEDICATION(S)]. (R1) immediately vomited. 911 contacted. Poison control contacted. Water provided as instructed. Transported to ER (emergency room ) for evaluation and treatment. This report does not contain witness statements or documentation detailing the events of the incident. On 7/21/20 at 8:50 am, V14 SSA/Social Service Assistant stated someone left the nurses station door open and R2 walked in, grabbed a spray bottle of bleach cleaner, removed the lid and drank some of it. V14 stated R2 did go to the hospital for a few days. On 7/22/20 between 10:20 am, 10:30 am, 10:44 am, and 10:46 am, V7 Medical Records/CNA (Certified Nursing Assistant), V8 CNA/Transport, V11 and V10 CNA's respectively stated R2 had drank a disinfectant and went to the hospital. On 7/23/20 at 2:57 pm, V24, former DON/Director of Nursing stated R2 reached over the nurses station and grabbed a bottle of disinfectant and drank some of it and went to the hospital. On 7/21/20 at 3:15 pm, V1 Administrator stated he did the investigation when R2 drank somekind of disinfectant and cannot recall the details of the incident. V1 was unable to provide any documentation regarding the events of this incident. The facility was unable to provide requested documentation for monitoring and supervision of R2. 2. R3's Face Sheet, documents R3 has [CONDITION(S)] Disorder and [CONDITION(S)] (Post Traumatic Stress Disorder.) R3's Physician Orders, dated 8/1/19 through 8/31/19, documents R3 is receiving the [MEDICATION(S)] 60mg (milligrams) every 12 hours and [MEDICATION(S)] 100mg twice a day. The Self Harm/Suicidal Potential Assessment for R3, dated 7/12/19 and 10/15/19 document R3 is High Risk for self-harmful behavior such as suicidal gestures: In need of structure, direction and canceling and is likely to require psycho-active medication management. The Suicidal Potential Assessment, dated 4/5/19 documents Resident has a history of [CONDITION(S)] and self harm for attention. The Suicidal Potential Assessment, dated 10/31/19, documents Resident scored 13 out of 27 on mood assessment and 13 on self harm/suicidal potential assessment upon admit. Resident has hx (history) of self harm and suicide attempts. Resident expressed SI ([CONDITION(S)]) upon admission, placed on 1:1's (one-on-ones). R3's current plan of care documents Resident has risk factors for self-harm and [CONDITION(S)] and requires assist with ADL's (activities of daily living) as necessary with staff assist of 1. R3's medical record includes an A.I.M. (Assess, Intercommunicate, and Manage) for Wellness form, dated 9/7/19, documenting Resident made an attempt of suicide on herself. Bleeding was stopped. 911 was called immediately. The Nursing Home to Hospital Transfer Form for R3, dated 10/18/19, documents R3 was transferred to the local hospital with reason for transfer as self-harm with no other documentation listed. On 7/23/20 at 2:57 pm, V24 former DON/Director of Nursing, stated in the fall, around October 2019, R3 was found lying on the shower room floor with the shower hose wrapped around her neck. V24 stated R3 had attempted to hang herself in the facility shower room with the shower hose, went to the hospital, and did not return for a awhile. On 7/23/20 at 12:30 pm, V21 SSA/Social Service Assistant stated he was in the facility at the time R3 tried to hang herself in the shower room with the shower hose. V21 stated it was her (R3's) intention to hurt herself. On 7/22/20 at 10:20 am, 10:30 am, 11:30 am and 11:45 am, V7 Medical Records/CNA (Certified Nursing Assistant), V8 CNA/Transport, V10 and V11 CNA's stated R3 did try to hang herself in the shower room. On 7/21/20 at 3:15 pm, V1 Administrator stated, I don't think I have anything on that other than what's in R3's chart. Depends on what the issues are or what was going on at that time if I would have reported or investigated it. V1 was unable to provide an investigation or any documentation for R3's attempted suicide in the facility shower room. R3's Nurses Notes do not contain documentation regarding R3 being found on the shower room floor with the shower hose wrapped around her neck. There is not an A.I.M for Wellness for R3's attempt to hang herself in the facility shower room. R3's medical record does not contain any documentation regarding R3 attempting to hang herself in the shower room. The facility was unable to provide requested documentation for monitoring and supervision of R3.

Based on record review and interview, the facility failed to properly assess the potential for self-harm, develop a plan of care for reocurring suicide attempts, effectively implement the Suicide Precautions policy and fully investigate two suicide attempts, for one of 12 residents (R4) reviewed for supervision in the sample of 20. This failure resulted in R4 cutting her wrists on 7/02/17 and cutting her neck on 8/22/17, both of which required hospitalization and sutures to repair. Findings include: The facility policy, titled Suicide Precautions (revised 10/06), documents It is the policy of Peterson Health Care to provide a safe and caring environment for all residents by identifying and meeting physical and psychological needs. Attention will be given to residents with potential behaviors associated with causing self harm. Any resident with a past history of suicide attempt or suicidal ideations or verbalize suicidal thoughts shall be assessed for precaution needs. The Nurse shall: 1. Actively observe and listen to residents for behavioral and verbal changes such as increased insomnia, anxiety, poor concentration, anorexia, etc. 2. Interview the resident by using clear, direct questions using the Suicidal Potential Assessment. 3. Should potential for self harm be identified, the Suicidal Attempt Checklist or Suicidal Threat checklist shall be completed. 4. Evaluate resident responses and discuss them with the IDT (Interdisciplinary Team) and resident for development of care plan needs. 5. Notify family or responsible party of the care plan needs based on the psychological assessment if they are unable to attend care plan conference. 6. Encourage resident to report feelings and needs to staff. If verbalizing or acting on suicidal ideation, resident room safety precautions will be implemented. 7. Implement Resident Room Reviews as IDT deems necessary to remove harmful objects from resident access (sharp objects, shoe laces, belts, plastic bags, call cords). 8. Initiate resident checks every 15 minutes or 1-1 as IDT deems necessary. 9. Notify physician of resident behavior or suicidal ideation. 10. Provide necessary medical treatment for [REDACTED]. Transport resident to hospital for immediate attention as needed. 11. Notify DON (Director of Nursing) and Administrator of any suicide attempt or residents determined to be at risk. 12. DON or Administrator shall report as necessary per regulation the proper legal and state Agency. On 9/13/17 at 10:56 a.m., E1 (Administrator) stated the facility follows the protocol in the Resident Protection Investigation Procedure to investigate incidents where residents inflict self harm or attempt suicide. The facility policy, titled Resident Protection Investigation Procedure (revised 11/18/16), advised staff, under Investigation Procedures to do the following: A review of the initial written reports; Completion of a written report on the status of the investigation of the occurrence; An interview with the person reporting the incident; Interviews with any witnesses to the incident; An interview with the resident; Where appropriate, an interview with the resident's attending physician or psychiatrist; A review of any residents involved in the occurrence; An interview with staff members having contact with the resident and accused individual during the period of the alleged incident; Where appropriate, interviews with the resident's roommate, family members, visitors or others who were in the vicinity of the incident; A review of all circumstances surrounding the incident. The Resident Protection Investigation Procedure documents a Final Investigation Report is to be made, consisting of The summary, conclusions and results of the investigation will be recorded on a final written incident report and submitted to the administrator or designee within five days of the occurrence. Hospital Medical Records document that R4 was admitted with Depression, Bipolar Disorder, Post Traumatic Stress Disorder (PTSD) and Suicidal Ideations, on 5/17/17. Hospital Medical Records documents R4 had a substance overdose suicide attempt on 6/12/17, was placed on suicide watch and hospitalized for [REDACTED]. A physician's orders [REDACTED]. The Social Service Admission Assessment, dated 6/14/17, documents that R4 was being admitted to Long Term Care due to Suicide Attempt. A Social Service Progress Review form, no date, but checked completed upon admission, documents R4 as being sad/crying, withdrawn, anxious and having suicidal ideations. A Psychosocial History form, dated 6/14/17, documents R4 as having the admitting [DIAGNOSES REDACTED]. A Self Harm/Suicidal Potential Assessment form, dated 6/14/17, documents R4's suicide potential at a 9, indicating a moderate risk for self-harmful behavior; however, the scoring was calculated incorrectly, based on R4's documented psychiatric history. The correct score on the Self Harm/Suicidal Potential Assessment should have been 15, indicating high risk for self-harmful behaviors. The Weekly Quality Assurance Review form dated 6/16/17, documents R4 was discussed in the Interdisciplinary Team Meeting as being a new admit, on psychotropic medications and having the targeted behavior of Severe Mood Disorder, PTSD and Generalized Anxiety Disorder; however, R4's history of suicide attempt (most recently on 6/12/17) was not identified as a targeted behavior. The Psychosocial Treatment Plan, dated 6/14/17, documents R1's relevant [DIAGNOSES REDACTED]. The Psychosocial Treatment Plan fails to identify Suicidal Ideations or R4's suicide attempt 6/12/17. R4's Initial Plan of Care, created 6/15/17 documents R1 has risk factors for self harm, resident has related (diagnosis) of Severe (Major Depressive Disorder), Anxiety and PTSD and instructs staff to determine past history of self harm, Assess and re-assess (as needed) for suicide risk, update (physician) and responsible party and initiate supervision and monitoring as appropriate for risk level, if resident is engaging in verbalizations of self harm or self destructive behaviors, ensure safe environment, observe and monitor for personal safety, if resident verbalizes thought of self harm, remain with resident and engage in conversation to further assess thoughts and potential for self harm, keep resident in visual observations until self harm risk can be determined, sweep room and surrounding area for sharp objects, remove objects that can be used for self harm, check room for hoarded (medications), during episodes of distress or self harm behavior, attempt to determine source of agitation by asking open-ended questions to seek to resolve. The initial Plan of Care created on 6/15/17, fails to identify that R4 has a recent history of actual suicide attempt or establish an appropriate monitoring schedule, of either every 15 minutes or 1:1, as instructed in the Suicide Precautions policy. Resident monitoring sheets document on 7/02/17, that R4 was on visual checks by staff only every 30 minutes and R4 was last observed in her room at 6:00 a.m. Nursing Notes, dated 7/02/17, document (R4) attempted self harm; bilateral cuts on wrists. (Paramedics) called and transferred to (Hospital). (Physician) notified. Administrator notified. Report given to (emergency room ) nurse. Nurse said medical staff was able to stitch up wrists and keep resident safe. Behavior Monitoring Records for July 2017, did identify Self harm/ideations as a targeted behavior; however, the 7/02/17 incident with R4 cutting her wrists was not documented on the Behavior Monitoring Record. A Final Five Day (Incident) Report, completed by E1 (Administrator) on 7/07/17, documents an investigation into an allegation of Attempted Self Harm by R4 on 7/03/17. The Final Five Day Report documents, under Summary: Report received of potential self harm. Staff interviewed and stated during visual monitored checks resident located with potential self harm. 911 immediately notified for evaluation and treatment. Resident admitted to hospital for psychiatric hospitalization . Facility notified of sutures to (R4's) wrists. (R4) recently admitted to the facility. Resident placed on frequent visual monitoring for better supervision from admittance. Conclusion: Allegation of self harm substantiated. (R4) currently hospitalized for [REDACTED]. Nursing Notes on 7/07/17 document R4 returned from the Hospital, with sutures in her bilateral wrists. R4's Plan of Care, under the Risk for Self Harm category was updated with the following approaches: 7/03/17 - Hospital for (psychiatric) evaluation and 7/07/17 - Initiate room change for better supervision. The Plan of Care failed to identify that R4 had actual self harm and a suicide attempt, the type of self harm or items used to harm herself, or specifics regarding frequency of supervision. On 7/19/17, Social Service notes document, Resident room was re-swept due to inappropriate items per her (suicidal ideations) and suicide risk concerns. Again, Behavior Monitoring Records for July 2017, did identify Self harm/ideations as a targeted behavior; however, there is not documentation related to R4 having suicidal ideations on 7/19/17. The Risk for Self Harm category on R4's plan of care does not reflect any behavior changes or new interventions. Nursing Notes on 8/22/17, document R4 was noted sitting in a chair, small bloody area noted on neck. Upon assessment, open area noted, pressure applied while 911 called. Vitals refused per (R4). Resident reported self injury. Nursing Notes document R4 returned from that hospitalization on [DATE], with sutures at the site of the neck injury. A Final Five Day (Incident) Report, completed by E1 (Administrator) on 8/28/17, documents an investigation into an allegation of Attempted Self Harm by R4 on 8/22/17. The Final Five Day Report documents, under Summary: Report received of potential self harm. Staff interviewed and stated (R4) approached staff, alert and oriented with potential self harm. Staff immediately notified 911 for evaluation and treatment and applied basic first aid to the area. Resident admitted to hospital for psychiatric hospitalization . Facility notified of sutures to neck. (R4) has a history of non-compliance with coming to staff with concerns. Resident placed on frequent visual monitoring for better supervision from admittance. Conclusion: Allegation of self harm substantiated. (R4) currently hospitalized for [REDACTED]. R4's current Plan of Care, under the Risk for Self Harm category was updated with the following approaches: Initiate 1:1 Supervision permanently upon return from hospital Again, the Plan of Care failed to identify that R4 had actual self-harm and a second suicide attempt, the type of self harm or items used to harm herself. On 9/12/17 at 2:30 p.m., E1 (Administrator) stated there were details that were not included in the Final Five Day Reports for R4's 7/02/17 and 8/22/17 suicide attempts, that should have been documented. E1 stated R4's 7/02/17 suicide attempt did occur while R4 was on only every 30 minute checks. E1 stated staff went to check on R4 at approximately 6:30 a.m. on 7/02/17, but R4 was not in her room. Staff found R4 approximately 10 minutes later hiding in a closet with her wrists slit from the broken mirror of a make-up compact. E1 stated R4 had used the broken mirror of another make-up compact to cut her neck on 8/22/17. After the 8/22/17 incident, E1 stated staff had found potentially harmful hidden items in the ceiling tile of R4's room and they are uncertain as to how R4 obtained those items. On 9/13/17 at 12:00 p.m., Z1 (Psychiatrist) stated he was familiar with R4's psychiatric history and previous suicide attempts. Z1 stated that suicidal patients do not always verbalize their intentions of self-harm and close monitoring is imperative. On 9/13/17 at 10:30 a.m., E1 stated R4 was admitted post-suicide attempt, but was uncertain as to when R4's most recent suicide attempt was. E1 stated, upon admission, R4 was placed on visual checks every 15 minutes, but after a week was decreased to every 30 minute checks due to not exhibiting any signs (anger or ideations). E1 stated rooms are checked for potentially harmful items only based on their suicidal ideations.

Based on interview and record review the facility failed to ensure floor cleaning equipment was in proper working condition to prevent falls for one resident (R1) of three reviewed for falls in a sample of three. This failure resulted in R1 sustaining a right wrist fracture. Findings include: Facility Fall Prevention policy, undated, documents: provide resident safety and minimize injuries related to falls; and all staff must observe residents for safety. R1's Nurse's Note, dated 9/19/16 at 1:00 pm, documents R1 sustaining a witnessed fall. The facility's Final Five Day Report (for the 9/19/16 fall), undated, documents, Conclusion: The cause of injury to (R1) was determined to be a slip and fall due to residual water from a housekeeping machine. (E7/Housekeeper) immediately cleaned up residual water from floor and notified (E6/Housekeeping Supervisor). (E6) determined there was a malfunctioning hose on the machine and immediately notified (E 8/Maintenance Supervisor) who then repaired the machine. (E6) inserviced all housekeeping staff on the use of the machine and what to do if malfunction occurs and how to address spills. (R1's) wrist was splinted until Xray results were obtained. After viewing Xray results MD ordered an orthopedic consult. Orthopedist ordered SA (short arm)cast. Cast is currently in place. R1's Physician order [REDACTED]. R1's Orthopedic History and Physical, dated 9/22/16, documents a mildly displaced dorsal triquetrum fracture with soft tissue swelling. The recommended plan of care for R1 is a short arm cast, pain medication (tylenol) and a two week follow-up. On 10/19/16, at 1:10 pm, R1 stated, there was water on the floor and I fell . On 10/19/16, at 10:08 am, E4 (Unit Aide) stated, I saw (R1) come around the corner and (R1's) sandal hit the water just right and (R1) fell . On 10/19/16, at 10:30 am, E7 (Housekeeper) stated, I did not know that the floor cleaner was leaking, until a staff member told me that (R1) slipped on the water and fell on the floor.