Every finding on record at Fargo Health Care Center

Based on interviews and record reviews, the facility failed to prevent a resident from being physically assaulted by another resident. This failure affected one resident (R1) of three residents reviewed for physical abuse. Findings include:On 7/21/2026 at 12:33 PM, R1 stated that R7 came straight to R1, bypassed R1's roommates and hit R1 in the face very hard while R1 was resting in bed. R1 said there was no bruise, but it hurt. R1 stated R7 caught R1 off guard so R1 did not scream but R1 said R1 screamed immediately after R7 left the room. R1 said V10 (Nurse) and a V4 (Certified Nursing Assistant/CNA) came quickly into R1's room after R1 yelled and screamed. R1 said R7 was quiet and never said a word before, during or after the assault. R1 stated R1 did not know R7, never interacted with R7 and only seen R7 in the hallway twice. R1's Face Sheet documents R1's diagnoses of diabetes, hypertension, panic disorder, paranoia schizophrenia, and osteoarthritis. R1's last quarterly Minimum Data Sheet (MDS) documents a Brief Interview for Mental Status (BIMS) score of 12 indicating some cognitive impairments. On 7/21/2026 at 3:14 PM, V10 (Licensed Practical Nurse) described R1 as laid-back, compliant with care, medication, and showers. V10 stated on the afternoon of R1's physical assault, V10 heard some noise coming from R1's room and when V10 entered, V10 saw R1 laying in the bed looking terrified. V10 said V10 saw R7, a male resident who lived on the 3rd floor coming out of R1's room. V10 said R7 looked anxious. V10 said R1 told V10 that R7 hit R1 in the face. V10 said V10 assessed R1 and R1 had no swelling or bruises on R1's face, R1 denied pain and R1 was not crying. V10 stated R1 was very alert and V10 said they notified V1 (Administrator). V10 said they sent R1 to the hospital.On 7/21/2026 at 3:30 PM, V4 (CNA) said V4 was scheduled to work that day but V4 said V4 was with another resident at the time of R1's physical assault but heard about it later. V4 said V4 visited R1 later and noticed that R1 looked scared and V4 said V4 did not ask R1 any additional questions because V10 handled the situation well. On 7/22/2026 at 3:20 PM, V1 stated they reviewed the camera footage of R1's physical assault. And they saw R7 at the corner of the front receptionist area and there R7 waited, peaked, walked pass staff and then immediately ran into R1's room. V1 stated the assault was unprovoked and when V1 asked R7 why you do it, V1 said R7 responded I just do not like her. V1 said it is their expectation that such an event does not happen again by having CNAs monitor residents' rooms every 2 hours and hire more security staff.Review of R1's care plan dated 8/8/2024 documented R1 Will remain safe, will be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect) through next review.Review of R1's hospital records dated 7/5/2026 documented no visible redness, no bruising and contusion. Review of R1's police dated 7/26/2026 record showed Battery as the incident. The facility failed to follow their Abuse and Retaliation Policy Prevention Program dated January 2026 that documents residents to be free from abuse and neglect.

Based on interviews and record review, the facility failed to ensure that a resident (R2) remains free from verbal and physical abuse/assault and free from injury (fracture) from another resident (R3) and failed to follow their abuse policy. These failures caused physical harm to R2, having a fracture and the need for emergency treatment and surgical intervention (sutures). These failures affected one resident (R2) out of three residents reviewed for verbal and physical abuse/assault.Findings include:Facility's Reported Final Incident Investigation Report (1/29/2026), showed in part that on 1/26/2026 approximately around 3:45 PM, verbal altercation occurred between R2 and R3 over a cigarette lighter when returning from independent pass and standing on the facility's smoking patio. Verbal altercation and name calling occurred between the two residents and R3 became agitated and hit R2 on the right cheek area, which resulted from R2's bleeding and needing emergency care treatment. R2 returned from hospital with diagnosis of closed fracture of right maxillary sinus and R3 was discharged to behavioral hospital with Involuntary petition. Facility's reported Final Incident Investigation based on medical records review and interview a conclusion of abuse was founded.On 3/23/2026 at 9:25 AM, observed few residents on the smoking patio, smoking without any staff supervision.On 3/23/2026 at 10:40 AM facility's presented census sheet showed a census of 96 residents.On 3/23/2026 at 12:58 PM, R2 stated that on 1/26/2026 after returning from the outside pass, R2 was sitting on the smoking patio with R5 and talking when R3 came by and kept asking for a lighter. R2 said that R2 got upset and told R3 to shut up and don't start with me and that R3 and R2 were verbally arguing and were name calling each with derogatory remarks and that R2 told R3 to get a lighter from inside the facility and to leave R2 alone. R3 got upset and hit R2 several times on the right cheek, causing R2's bleeding from nose and having a laceration on the right cheek. R2 said that R2 did not return punch, because R2 was worried about R5 getting hurt. R2 said that R2 suffered a bone fracture under the right eye and had to have stitches. R2 affirmed that at the time of verbal altercation, derogatory name calling and then the actual physical abuse, there was no staff member, or other residents besides R5 present on the patio and that no staff came outside to help, R2 ran into the facility's building, called police and reported to V1 (Administrator) and V3 (Psychiatric Rehabilitation Services Director/ PRSD). R2 said that someone from staff should have been monitoring and supervising residents outside on the smoking patio and could help deescalate the situation and prevent R2's injury. R2 said that R2 spoke to police and was going to press charges but then changed R2's mind and R2 did not press charges on R3.On 3/24/2026 at 11:34 AM, R5 said that R5 was present during the incident between R2 and R3 at the smoking patio and was a witness to the physical abuse. R5 said that on 1/26/2026 in the afternoon, R5 was sitting in the chair on the smoking patio with R2 sitting next to R5, smoking and conversing. R3 approached R5 and R2 and kept asking for lighter. R5 and R2 said that they do not have a lighter and R2 suggested for R3 to use the light up cigarette bud that R5 was using. When R3 took the cigarette bud from R5, R2 said to R3 to not forget giving the cigarette bud back to R5 and R3 got upset and started calling R2 names and was threatening and verbally abusing R2. R5 said that R3 returned the cigarette bud to R5 and walked away and R2 and R5 thought that was the end of confrontation. R5 said that R3 then walked behind and to the side of R2 and all of sudden started punching R2 in the face. R5 said that R3 stroked R2 more than once and that R2 had a bloody nose and face. R5 said that there was no staff or security member present outside at the patio during the time of the verbal altercation and escalation to physical abuse. R5 also said that nobody from staff members came outside and helped, that R2 and R5 returned to the facility together and that then R2 and R5 told V1 (Administrator). R5 said that R2 got sent to the hospital via ambulance and that R2 called police. On 3/24/2026 at 12:07 PM, V4 (Licensed Practical Nurse/LPN) stated that R2's incident happened at the smoking patio and that V4 found out from V3 (PRSD) what happened, because V4 was on the break. V4 said that R2 was bleeding from nose and right cheek and that V4 provided first aid and then R2 was sent to the hospital for evaluation and treatment. V4 affirmed that R2 was struck in the face by R3 but V4 did not witness the abuse. V4 said that R3 was sent to the hospital for behavior evaluation and then was discharged and did not return to the facility. V4 said that security should be monitoring residents when smoking and that usually the security is present outside on the smoking patio and was not sure why nobody was present at the time of verbal and physical altercation. V4 said that if there were an altercation on the unit between residents, the staff should try to resolve the conflict and interfere before the altercation escalates.On 3/24/2026 at 12:34 PM, V5 (Certified Nursing Assistant/CNA), stated that V5 is aware of the incident that happened between R2 and R3, but V5 did not witness the incident. V5 said that V5 is not sure if someone is supervising the smoking breaks on the smoking patio, but security is usually nearby and should be present at the patio to supervise residents to prevent incidents.On 3/25/2026 at 09:20 AM, four residents were observed smoking on the patio, and no supervision staff was present on the patio to monitor smoking residents. On 3/25/2026 at 10:26 AM, observed V11 (Security Guard), sitting at the nurse's station, on the first floor by the front entrance, looking at the camera monitors, but when a resident came to ask V11 a question, if V11 could buy some chips, V11 turned away from the cameras for few minutes to speak with resident and V11 was not looking at the camera monitors. V11 said that that V11 's role is to monitor the front door and provide security if needed. V11 stated that the smoking patio and the smoking area should be monitored and that on 1/26/2026 when R2's physical abuse occurred, V11 was on vacation and was not present in the facility and is not sure who covered V11's shift. V11 also said that the facility has two smoker's lists, unsupervised smokers and supervised smokers. V11 stated that the supervised smokers should always have a staff member present at the patio, and that they should never be alone. V11 said that unsupervised smokers are independent residents with a community pass and are not always as closely supervised during their smoke breaks. V11 said that the camera monitors display video footage only and that V11 is not sure if audio function is working and that V11 could not hear what residents are saying when outside. V11 said that if a couple residents start verbally abusing each other, V11 would not be able to hear the altercation. V11 also said that if any argument or altercation were in progress during the smoke break, a resident would come inside the facility and ask V11 to come outside and interfere, but said that is not the resident's responsibility to notify staff, the staff should be supervising the residents and immediately try to de-escalate altercations. V11 also said that the residents with an independent community pass do not need to be supervised in person at all times. V11 said that if the supervised smokers have the smoking break, V11 would be outside with the residents, but V11 would not be with the unsupervised residents during their smoke break, V11 would monitor from the video cameras instead. V11 stated that V11 would not have enough time to go outside and prevent an altercation or physical abuse between residents when in progress, because the abuse could happen very quickly. V11 thinks that a smoke monitor should be present with residents during designated smoking times at all times to prevent altercations and prevent possible injury.On 3/25/2026 at 10:39 AM, V6 (LPN) said that some residents have behavioral issues and could be aggressive or noncompliant with the rules and should be supervised because of unpredictability. V6 said that residents with independent community access passes were assessed for risk and should not be causing problems, but sometimes the residents argue and have an altercation and that is when staff intervenes to prevent future escalation. V6 stated that all residents have the right for safety and that V11 (Security Guard) should be outside with the supervised smokers. V6 thinks that the facility should have a better policy and provide safe smoking arrangements for all residents. V6 said that it is possible for the unsupervised residents get in the argument and staff should ensure all resident's safety.On 3/25/2026 at 10:59 AM, V12 (CNA), said that if any residents would be getting aggressive, the staff should separate the residents before an altercation escalates, so someone should be supervising the residents at all times, but do not always. V12 said that the cameras do not have audio and the staff watching the cameras could not hear somebody arguing and that is why a staff member should be always present out on the smoking patio with the residents to prevent confrontation and possible physical abuse. On 3/25/2026 at 11:44 AM, V3 (Psychiatric Rehabilitation Services Director/ PRSD) stated that on 1/26/2026, at the time when R2's incident occurred, (after 3pm), V3 was notified of an incident and V3 said that there was no supervising staff outside on the smoking patio with the residents. V3 did not witness the abuse, and no other staff witnessed the abuse happening. V3 said that after the incident, R2 came inside of the facility with R5 and V3 observed R2 having blood on the face and R2 was calling the police. V3 said that R2 was taken to the Emergency department for treatment and when R2 returned to the facility, R2 had diagnosis of fracture on the right cheek bone and had stitches. V3 understood that both residents signed out for pass and while at the smoking patio, R3 was asking R2 for a lighter and that R2 told R3 to get a lighter from inside of the facility and both residents were verbally abusive and calling each other names and R3 punched R2 in the right cheek several times. V3 said that the security should be supervising all smokers not just the ones on restrictions and the security should be periodically checking on the residents outside. V3 stated that the facility does not currently have a designated smoking monitor and that the security supervises restricted residents during smoke times. V3 affirmed that R2 and R3 were smokers with independent passes and were not on the supervised smoker's list. V3 said that to prevent future incidents, the facility should make sure that the smoking policy rules are strictly enforced and all residents are closely monitored and supervised during smoke breaks at all times. V3 said that somebody should be at the smoking patio at all times, including the managers, and step in to de-escalate potential arguments and to make sure that residents are properly monitored. V3 affirmed that R2 was physically and verbally abused on the smoking patio on 1/26/2026 and stated that the incident could have been prevented if a staff member was present out at the smoking patio with the residents. V3 stated that the facility is responsible for residents while the residents are on the facility's property such as the smoking patio.On 3/25/2026 at 1:20 PM, V2 (DON/Director of Nursing) stated that V2 was on vacation when R2's incident happened and that V2 was informed when returned. V2 stated that if there is nobody to supervise the residents, it is hard to prevent altercations and possible abuse. V2 said that the facility should provide residents' safety and that something should have been done to prevent future physical abuse.On 3/25/2026 at 2:39 PM, V1 (Administrator) said that V11 (Security Guard) was on vacation when R2's incident happened and that V13 (Activity Director) was monitoring the front door and the smoking patio. V1 said that supposedly R2 and R3 were out on pass and collided at the smoking patio. V1 stated that normally V1 would schedule another security guard, but not sure why, V13 was used to monitor the cameras and front door. V1 said that R2 told V1 that R3 was asking R2 for a lighter and started to argue. R2 said to V1 that R3 then punched R2. V1 said that V1 is not sure if anybody from the staff knew that R2 and R3 were on the smoking patio since they both signed out on pass. V1 said that V1 performed the investigation. V1 said that R2 said that R2 got hit by R3 and then R2 was sent to emergency room for treatment. V1 said that R5 was also on the smoking patio during the incident. V1 stated that the smoke patio should be monitored at all times, even between the smoke break times. V1 said that the staff should be present on the patio with the residents and that the camera video monitoring does not provide audio, so the monitoring staff could not hear what was said. V1 affirmed that calling another person names, is considered verbal abuse. V1 affirmed that if staff was present at the time of the verbal abuse, the staff member could de-escalate the situation and prevent R2' physical abuse. V1 affirmed that every resident should be supervised and that during smoke breaks on the patio, staff should be physically present and supervise residents for safety. V1 affirmed that R2's incident was considered verbal and physical abuse and that the physical abuse caused harm for R2 as evidence by R2's suffering injury in the form of fracture of the maxilla bone and the need for sutures. On 3/25/2026 at 3:57 PM, V7 (Activity Director), stated that V7 was working the day of R2's incident and that V7 remembers that both residents signed out to go out on pass, but stayed at the patio to smoke. V7 stated that V7 was standing by the glass door and checked on R2 and R3 and that they appeared to be talking at the time of V7's check and that V7 returned to the nurses station by the cameras and sat down in the chair. V7 said that V7 did not witness R3 punching R2. V7 said that a staff member should be always present and supervise residents to prevent another future incident.R2's diagnosis include but is not limited to Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus; Schizoaffective disorder, unspecified; Insomnia, unspecified; Restlessness and agitation; Anxiety disorder, unspecified; Other chronic pain; Sleep apnea, unspecified; Tinea cruris; Nicotine dependence, unspecified, uncomplicated; Vitamin deficiency, unspecified; Cough, unspecified; Influenza due to identified novel influenza A virus with other manifestations; Functional dyspepsia; Urinary tract infection, site not specified.R2's Minimal Data Sheet (MDS), (2/19/2026), in section C for Cognitive patterns showed Brief Interview of Mental Status (BIMS) score of 15 which shows intact cognition.R2's Hospital Records (1/26/2026) showed in part that R2's reason for hospital visit was assault victim and loss of consciousness and that R2 had a closed fracture of right maxillary sinus and a laceration over right cheek and that the wound was repaired with stitches. Records also showed in part that R2 had a CT head without contrast and CT of Maxillofacial bone performed on 1/26/2026 and R2 should follow up in 5 days (1/31/2026) for suture removal.R2's Progress Note (1/26/2026 at 3:32 PM) documented by V4 (LPN) showed in part that at 3:10 PM, R2 while in the patio smoking, was physically punched by R3. On assessment, Right facial area was noted with laceration with minimal amount of blood. Progress note also showed that R2 called police and was taken to the emergency room by the paramedics.R2's Progress Note (1/26/2026 at 10:28 PM) showed in part that R2 returned to the facility with discharge paperwork that showed R2's diagnosis of Closed fracture of right maxillary sinus, Facial laceration, Assault and that laceration below right eye with two sutures was observed and one scratch on right eyebrow with minimal facial redness on the right side.R2's CT of Head (1/26/2026) showed in part small layering blood products in the right maxillary sinus with a background of mild scattered mucosal thickening; Polyps versus retention cysts in the left maxillary sinus; Comminuted, mildly impacted fracture involving the right anterior maxillary wall; Soft tissue swelling overlying the right maxillary sinus fracture.R2's CT Maxillofacial Bones (1/26/2026) showed in part Mildly impacted and comminuted right anterior maxillary sinus wall fracture.R2's Abuse Risk Assessment (2/19/2026) showed in part a yes answer to denial when discussing mental health issues and is minimizing significance of mental health and psychosocial issues.R2's Care plan (1/27/2026) showed in part that R2 has a laceration below right eye with 2 sutures, and one scratch on right eyebrow and minimal facial redness.R2's Care plan (1/28/2026) showed in part that R2 has a diagnosis of closed fracture of right maxillary sinus.R2's handwritten statement (1/26/2026) showed in part that R3 was asking R2 and R5 for lighter and that R2 told R3 to get lighter from the facility and R3 started to curse out R2 and R2 told R3 to leave R2 alone and that it was not a good day. R2 started to talk with R5 and R3 was standing behind R2 and started to hit R2 several times and so R2 ran into the facility's building to tell the staff.R3's diagnosis include but is not limited to Schizophrenia, unspecified; Pain unspecified; Insomnia, unspecified; Gastro-esophageal reflux disease without esophagitis; Vitamin D deficiency, unspecified.R3's Minimal Data Sheet (MDS), (12/17/2025), in section C for Cognitive patterns showed Brief Interview of Mental Status (BIMS) score of 15 which shows intact cognition. R3's Progress Note (1/26/2026 at 3:31 pm) documented by V4 (LPN), showed in part that on 3/3/2026 at 3:10 PM, R3 was physically aggressive towards R2 during smoke break on the patio and that R3 was educated and counselled to report grievances. R3's progress note also showed in part that the police department was present and that neither of the two residents would be charged and that a physician ordered R3 to be transferred for behavioral evaluation.R3's Progress Note (1/27/2026 at 2:13 am) showed in part that social worker called hospital for follow up and that R3 was being admitted with diagnosis of Aggression and that resident would be discharged from the facility.R3's Care plan (12/13/2025) showed in part that R3 has potential to exhibit inappropriate behavioral problems and that R3 would be monitored for adjustment. R3's care plan also showed in part that R3 should be supervised while in the community and have restricted independent pass privileges.R3's Abuse Risk Assessment (12/17/2025) showed in part a yes answer to denial when discussing mental health issues and is minimizing significance of mental health and psychosocial issues.R3's document titled Petition for Involuntary/Judicial Admission (1/26/2026), filled out by V3 (PRSD) showed in part emergency inpatient admission by certificate and that R3 was involved in a physical altercation with another resident and that R3 became physically aggressive and engaged in behaviors that pose immediate risk to the safety of others.R3's handwritten statement (1/26/2026) showed in part that R3 asked for a lighter and was told by R2 to get lighter from inside of the facility and R3 said that R3 is not talking to R2 and that R3 and R2 started arguing and R3 felt threatened and hit R2 because R2 was standing too close to R3's face and R3 was defending self.Facility's document titled Security Staff Job Duty Instructions (Undated), showed in part purpose to ensure accurate monitoring, documentation and reporting of all residents to maintain safety.Facility's document titled Facility Smoking Safety Policy (Revised 2026) showed in part that objection is to provide a safe and healthy living environment with respect for the health and well-being needs of each resident and that the facility recognizes potential harm that could result from careless smoking and implemented smoking policy to maintain a safe living environment.Facility's document titled Resident's Rights Policy (Reviewed 1/2026), showed in part that the purpose is that no resident should be deprived of any rights that are guaranteed by the law and that the residents have the right to be free of abuse.Facility's document titled Rounds Policy (Revised 12/2025) showed in part that daily rounds should be conducted to ensure residents are monitored every hour or as needed depending on resident's condition and that residents should be monitored hourly during rounds.Facility's document titled Abuse Prevention Program Facility Procedures (11/18/2016), showed in part that abuse is defined as the willful infliction of injury with resulting physical harm and includes verbal abuse and physical abuse. Policy also showed in part that the facility should prevent abuse by establishing a resident sensitive and secure environment by supervising and monitoring the ability of the staff to meet resident's needs and correcting situations involving inappropriate language or insensitive handling at the time situations occur.Facility's document titled Abuse and Retaliation Policy Prevention Program (1/2026), showed in part that the facility confirms the right or residents to be free from abuse and that facility prohibits abuse of residents by attempting to establish a resident-secure environment and ensuring that the facility is doing everything to prevent occurrences of abuse and should be immediately protecting residents involved in possible abuse. Policy showed in part that physical abuse is infliction of injury to a resident that occurs other than by accidental means and requires medical attention and includes but not limited to hitting and that verbal abuse is using oral or gestured language that deliberately includes derogatory term to residents and that facility should tall every step needed to ensure that residents are safe.

Based on interview and record review, the facility failed to ensure that an involuntary discharge was not based on the residents' condition at the time of transfer to acute care and failed to provide physician's documentation of the reasons a resident was involuntarily discharged from the facility in the resident's medical record. These deficient practices affected two of three residents (R1 and R4) reviewed for involuntary discharge. 1. R1 was admitted to the facility on [DATE] and was discharged to the hospital on 9/28/2025 and was not allowed to return to the facility. R1 was petitioned for involuntary discharge and was also served a 30-day notice for involuntary transfer and discharge. Progress notes dated 9/28/2025 2:39 a.m. document R1 stated am depressed because my sister died and want to go to the hospital. R1 also stated that R1 cut herself with scissors and was observed with bleeding on R1's right wrist. R1 was sent to the hospital via 911 and returned the same day with stitches to her right wrist, was placed on 1:1 and was petitioned for involuntary discharge to another hospital for psychiatric evaluation. R1 was also issued an Involuntary Discharge and was not allowed to return to the facility. Minimum Data Sheet dated 8/1/2025 under Section E: Behaviors did not document any physical behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; verbal behavioral symptoms directed toward others such as threatening others, screaming at others, cursing at others; and other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). On 2/6/2026 at 11:23 am. V4, R1's Legal Guardian, stated the facility called her on 9/28/2025 to let her know that R1 had wanted to kill herself because she found out that R1's sister passed away untimely. They also let her know that R1 cannot return to the facility anymore because R1 needed 24-hour care because she would take scissors and stab herself. V4 stated V4 was happy with R1's stay in the facility because she had friends in the facility and that the facility takes good care of R1 and she would have liked for R1 to return to the facility instead of being transferred to a different facility. On 2/6/2026 at 1:48 p.m. V2, Director of Nursing, stated R1 has a diagnosis of depression, R1 doesn't have any behavior, R1 is not aggressive to other residents, does not engage fights with other residents. R1 is not a threat to the other residents in this facility. To my knowledge, the nurse and Certified Nursing Assistant/CNA made rounds that day on 9/28/2025, the resident pulled her call light and R1 had scissors and hurt her wrist using the scissors. R1 is not allowed to have scissors in her room. This was previously investigated already. This was more like a cry for help from R1. On 2/6/2026 at 2:12 p.m., V1, Administrator, stated R1 was served the Notice for Involuntary Transfer and Discharge because R1 harmed herself and how can I protect her if she conceals scissors and she can harm herself again. I don't feel she's a danger to other residents. I think she is a harm to herself. Facility presented a document titled Notice of Involuntary Transfer or Discharge and Opportunity for Hearing dated 9/29/2025; addressed to R1 and V4, R1's Legal Guardian; signed by the previous social services director who is not employed by the facility anymore. The form documents that the reason for this proposed transfer or discharge is the safety of individuals in this facility is endangered, 483.15 (c)(1)(i)(C). R1's electronic health records exclude any documentation from the physician regarding the reason for involuntary discharge and how the safety of individuals in this facility is endangered because of R1. It also excludes any behavior that endangers the safety of other residents in the facility.2. R4 was admitted to the facility on [DATE] and was discharged to the hospital on 1/27/2026 and was not allowed to return to the facility. R4 was petitioned for involuntary discharge and was also served a 30-day notice for involuntary transfer and discharge.Progress notes dated 1/27/2026 4:21 p.m. document: Staff observed R4 smoking in a non-designated area. When staff addressed the behavior, he became verbally aggressive and refuse(sic) to be redirected, he presents as a threat and harmful to self and others. This behavior may be influenced by symptoms associated with her diagnosis of paranoid schizophrenia, including impaired judgment and difficulty with impulse control. Due to concerns regarding a decline in his mental and physical status, nursing staff contacted his physician, who recommended further evaluation. R4 was subsequently petitioned, with IVD (Involuntary Transfer and Discharge) initiated and bed-hold policy notification completed. He was transported to the local hospital for further assessment and treatment.Review of R4's electronic health record affirms that R4 has been observed to be smoking in non-designated areas for smoking multiple times and has a behavior contract addressing this behavior. R4 also exhibits profanity towards staff and aggressive behaviors toward staff and peers.On 2/6/2026 at 11:45 a.m., V5, Social Services Director, stated R4 was presented with the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing, which V5 completed and signed, because the facility cannot accommodate the smoking times that R4 needs. R4 needs supervision when smoking because of mobility and safety and has violated the facility smoking policy at least three times during his stay. V5 stated she filled out the form and then gives it to the nursing department to notify the physician and hospital for necessary paperwork and documentation.On 2/6/2026 at 2:12 p.m. V1, Administrator, stated R4 is very non-compliant, is very bold, will tell you right in the face that he loves using marijuana and will not stop smoking. The reason he is being served the Involuntary Transfer and Discharge Notice is because R4 on multiple times has been caught smoking inside the facility and even engages other residents with him in his room to join him to smoke. V1 cannot provide physician documentation regarding reason for the proposed discharge of R4.Facility presented a document titled Notice of Involuntary Transfer or Discharge and Opportunity for Hearing dated 1/27/2026; addressed to R4 and R4's Representative; signed by V5, Social Services Director. The form documents that the reason for this proposed transfer or discharge is your welfare and needs cannot be met by the facility, as documented in your clinical record by your physician, 483.15 (c)(1)(i)(A). R4's electronic health records exclude any documentation from the physician regarding the reason for involuntary discharge, what services the facility was unable to provide to meet the needs of R4 and what the facility attempted to meet the R4's needs aside from the Smoking Behavior Contract.

Based on interview and record review, the facility failed to implement care plan for psychosocial and mental well being and failed to provide the necessary services for the behavioral health needs of a resident. This applies to one (R1) of 4 residents reviewed for behaviors. As a result, R1 harmed self requiring psychiatric hospitalization. Findings include: According to the Electronic Health Record (EHR) R1 had diagnoses including Other seizures; Bipolar disorder, current episode depressed, Gastro-esophageal reflux disease without esophagitis; Unspecified asthma, Major depressive disorder, single episode, Other chronic pain; Restlessness and agitation; Hypo-osmolality and hyponatremia; Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus; Pain in unspecified knee; Type 2 diabetes mellitus with other diabetic kidney complication; Cough, unspecified; and Tinea pedisR1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE].The Minimum Data Set (MDS) dated [DATE] showed cognition was intact with a fifteen out of fifteen points requires on the Brief Interview for Mental Status (BIMS).A care plan on Mental and Psychosocial Well being showed R1 is in need of specialized rehabilitation, support, counseling and/or psychotherapeutic services secondary to mental illness diagnosis and a need to develop community integration skills. Care Plan goals include: The resident will engage in the following service(s): Mental health (i.e., psychotherapy, life skill training, substance abuse services). Intervention include: Obtain proper consent prior to making any referrals. Assist the resident in locating an appropriate treatment provider and making the initial appointment. Arrange transportation, as necessary. R1's records indicate that client centered therapy sessions were conducted on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No other therapy sessions were documented after the [DATE] session which documents in part: The therapist will continue meeting with the client for an individualized biweekly therapy for the next six months. On [DATE] at 11:45 a.m., V5, Social Service Director, facility has an outside provider that comes to the facility twice a week to conduct support group sessions and 1:1 sessions with the residents and another outside provider that provides Intensive Outpatient therapy that provides group therapy sessions outside of the facility to address their mental health needs. V5 stated she is not aware that R1 participates in either of these services and was not able to provide documentation that R1 had an ongoing structured group or individualized sessions to address her mental health needs. V5 also stated that the Social Services Department in the facility does not conduct any therapy group session or individualized sessions to address the mental health needs of the residents with behavioral and mental health needs of the residents in the facility. V5 confirmed that no other therapy sessions with R1 were conducted after [DATE] and confirmed that R1 did not participate in any psychosocial groups or 1:1 session for psychosocial well-being. Progress notes dated [DATE] 2:39 a.m. document R1 stated am depressed because my sister died (sic) and want to go to the hospital. R1 also stated that R1 cut herself with scissors and was observed with bleeding on R1's right wrist. R1 was sent to the hospital via 911 and returned the same day with stitches to her right wrist, was placed on 1:1 and was petitioned for involuntary discharge to another hospital for psychiatric evaluation. R1 was also issued an Involuntary Discharge and was not allowed to return to the facility. R1's Screening Assessment for Evaluating Self-Harm/Suicide dated [DATE] document under section Recommendation and Outcome (check the category corresponding with the resident's score): Expected to integreate (sic) with structure, direction and supportive counseling. Presents with a low to moderate risk for self-harmful behavior (score 6-10)Social Services policy with review date of 9/25 under Philosophy and Policy documents in part: It is the philosophy of this organization to treat each resident as a unique individual with specific physical, psychological and spiritual needs. It is our policy to provide a competent variety of psychological programming and therapeutic recreation opportunities designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psycho-social well-being needs of each individual resident.

Based on interview and record review, the facility failed to ensure residents environment was free from accident hazards. This failure affected 2 (R1 and R9) residents reviewed for accident hazards in the total sample of 9 residents. This failure resulted in R1 having access to scissors and used the scissors to cut her wrist and received 2 stitches as treatment. Findings include: 1. R1's ([DATE]) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact. R1's ([DATE]) Standing Order documented, in part Resident may have independent pass privileges. R1's census list documented that R1 was admitted at the facility on [DATE], was sent out to a hospital on [DATE] and readmitted on [DATE]. R1's ([DATE]) Resident Inventory Record did not include scissors. R1's ([DATE]) Accident/Incident documented, in part at 2:35am resident pulled call light, staff responded and entered the room, asked what happened resident stated, I am depressed because my sister died and want to go to hospital. head to toe assessment done and noted resident a laceration on resident's Right wrist with minimal bleeding. When on (sic) asked what resident used, resident stated I cut myself with scissors. this writer asked where the scissors was (were) and resident handed it over. Outcome: Resident sustained 2 stitches from Hospital. R1's ([DATE]) final reportable documented, in part Diagnosis: Major Depressive disorder. Type of Incident: Injury. Date [DATE]. Time: 2:35pm. Around 2:35 am, resident pulled the call light, staff responded and observed resident bleeding from her right wrist. First aid rendered to stop bleeding. When asked what happened, resident stated that she felt depressed because her sister died recently. 911 activated. Resident asked if she had shared this with anybody and she said no. Head to toe assessment done with no other injury noted. Denied any pain. Resident placed on 1:1 monitoring for safety. 911 crew arrived at (sic) transfer resident to took (take to) hospital for evaluation. Resident returned from Hospital the same day, in stable condition. Head to toe assessment done, noted with two sutures to right wrist. On [DATE] at 9:30am, R1 stated she got pairs of scissors from the previous facility she was admitted prior to (facility name), and she kept the scissors in her bag during her admissions to (facility name). R1 stated staff checked her belongings and apparently did not see her scissors. R1 stated while at (facility name) she stored her scissors in a locked drawer. On the night of the incident, she was on a phone and was made aware that her sister died, she got depressed and took the scissors in the drawer and cut her wrist. R1 stated she pulled the call light and (V16- LPN/Licensed Practical Nurse) came and rendered first aid. (V16) asked her what happened. R1 stated she told her that she got the scissors from her previous facility. R1 stated that she had an episode of depression and refused to eat in [DATE] and was sent out to the hospital.On [DATE] at 3:04pm, V18 (CNA-Certified Nursing Assistant) stated she could not really remember what she did with her (R1). But she (V18) knew she did the inventory. The purpose of the inventory was for resident to be aware what they brought with them when they came in at the facility and for the facility to know if anything was missing. Secondly, to check if they have sharp objects on them, including scissors, so they would not be able to use to harm themselves and others. On [DATE] at 11:12am, V16 stated it was around 2am-3am when she (R1) pulled the call light. She (V16) went inside, and her hands were covered in blanket all the way to her shoulder covered. She (R1) said she was not feeling good and wanted to go to the hospital. V16 stated she opened the blanket to check her blood pressure that was when she saw the dried blood on her right hand. She asked what happened and she said she cut herself. She saw blood and put her on 1:1 supervision. She (V16) asked her (R1) what she used, and she said she used scissors. (V17-Security) got the scissors and put it in the office. She did not have the time to ask the resident where she got the scissors because 911 came. When she came back from the hospital, she got 2 stitches. V16 stated when a new resident is admitted , the staff would do inventory of the resident's belongings and enter it in the computer and check whatever she brought to know what she had. Anything that is dangerous to self and others, or anything that they are not supposed to have with them is removed. The purpose is to know what they brought. The resident was admitted to the facility because they have a problem, it is not expected for a resident to have scissors with them. Residents with history of depression should not have scissors with them. On [DATE] at 12:15pm, V17 (security) stated he got the scissors and put the scissors in a rubber glove. The scissors had blood on them and were sharp enough that if you would really try to cut yourself, you would. The incident should not happen. Staff should search belongings and see what they have, like scissors, knives, and stuff like that. On [DATE] at 4:07pm, V2 (Director of Nursing) stated the expectation is not to have any type of sharp objects that could potentially harm themselves, staff, and another resident. On [DATE] at 4:17 V2 stated the cut on her wrist was a serious injury because she (R1) received 2 stitches to treat the cut. On [DATE] at 5:24pm, V1 (Administrator) stated it was absolutely necessary for the resident's environment to be free of accident hazards to ensure residents were safe at all times. Residents should still be safe if they have mental issues. V1 stated it was not expected of residents to have access to any hazardous materials including guns, drugs, scissors, and needles. 2. On [DATE] at 3:33pm, R9 stated she has been at the facility since [DATE] and stated she had scissors from another facility and staff took the scissors from her a month ago and she did not know why staff took her scissors. R9 stated she used the scissors to cut her hair. R9 stated honestly, she did not remember if facility did an inventory of her belongings. On [DATE] at 4:24pm, V5 (Psychiatric Rehabilitation Services Coordinator/PRSD) stated (V4 - PRSD) instructed her to go with (V6-Activity Director) to search her (R9's) room because she has been hiding medications. They did a room search and saw a pair of scissors and a box full of medications. On [DATE] at 3:37pm, V6 (Activity Director) stated she (R9) showed her medications to her Primary and the Primary informed the nurse about it. Then (V4) told them (V5 and V6) to do a search in her room. V6 stated she found the scissors in a plastic bag, and she (R9) said she got it from her previous nursing home. V6 also stated she (R9) had a candle and a lot of medications in plastic box, more than 50 but less than 100 medications of different colors and different sizes. V6 stated she showed the medications to (V2), and she (V6) kept the scissors and candle in the Activity storage room. V6 stated she (R9) did not say where she got the medications. On [DATE] at 4:31pm, V19 (Licensed Practice Nurse/Restorative Nurse) stated he worked double shifts on [DATE]. During the morning shift, he gave her (R9) 2 capsules of Duloxetine 20mg (milligrams). Then on evening shift, (V20 -R9'S Primary Care Physician) came. He was passing medications, and he (V20) came to talk to him with the resident and ask what medications the two capsules in her (R9)'s hand were. He told him it was her psych meds, Duloxetine. He (V19) showed (V20) the medication dispensing card (BINGO card) of her (R9)'s Duloxetine and it was the same medication when compared. V19 stated she did not want psych meds anymore and asked her why she just told him. V19 assumed she hid the medications under her tongue. V19 stated he checked her mouth, but he was not going to lie, he did not check under her tongue. V19 stated when giving medication, the expectation was to stay until the medications were swallowed. To check under the tongue to make sure she swallowed her medications. V19 stated Duloxetine was a psych med and it could lead to a behavior symptoms if not taken. V19 stated he did a random check of her room, not a thorough check and stated he should have done a thorough check of her room to ensure there are no other medications in her room because she could potentially overdose. V19 stated he was sure he informed (V2) the day the incident happened. On [DATE] at 3:52pm, V2 stated the incident happened on [DATE] and the search happened on [DATE] and found medications without labels. V2 stated the expectation was to do the room search immediately on [DATE] because she could be harmed as well as other residents in the room. V2 stated he (V19) did not tell her about the incident on [DATE]. On [DATE] at 4:05pm, V2 stated the nurse had to follow the rights of medication administration and to make sure the resident swallows the medication to ensure the resident was receiving the therapeutic benefits of the medication. If a resident had certain behaviors of holding on to the medications and took all of them at once, the resident could overdose and that was going to be a problem because the resident could die. On [DATE] at 4:07pm, V2 stated all information should have been shared with her sooner, not to put resident at harm, the expectation is not to have sharp objects that could potentially harm themselves, staff, and another resident. Initial inventory checks are done on the items a resident has on admission. There are house rules and the resident signs a contract agreeing to the rules. On [DATE] at 5:24pm, V1 (Administrator) stated it was absolutely necessary for the resident's environment to be free of accident hazards to ensure residents were safe at all times. Resident should still be safe if they have mental issues. V1 stated it was not expected of residents to have access to any hazardous materials including guns, drugs, scissors, and needles. R9's ([DATE]) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R9's mental status as cognitively intact. R9's ([DATE]) Standing Order documented, in part Resident May have independent pass privileges. R9's (10/2025) MAR (Medication Administration Record) documented, in part Cymbalta 20 mg capsule. Delayed release. Dispensed: duloxetine 20 mg capsule, delayed release. Give 2 capsules (40mg) by oral route once daily. Start date: [DATE]. Of note, last given on [DATE] by V19 (Licensed Practice Nurse/Restorative Aide). R9's ([DATE]) Progress Notes documented, in part Resident was given her duloxetine 20mg 2 caps QD (every day) in the morning, resident apparently hid the medication under her tongue, took the meds out of her mouth and kept it. During resident's PCP (Primary Care Physician) rounds later in the day, resident brought out the meds and showed it to him that she doesn't want to take the medication anymore. (PCP) then asked writer what she was talking about, writer took the pills from resident and explained to the Doctor that those are psych meds that were given to her in the morning. Writer then asked resident if she told any staff she does not want the meds anymore, she confirmed she is yet to inform any nurse about her decision. Furthermore, writer asked why she is refusing the medication, she said I don't want it anymore, I'm fine this was said in the presence of her PCP. Psych MD notified of resident's decision and gave a new order for medication to be discontinued. Order noted and carried out. Entered By: V19 (Licensed Practice Nurse/Restorative Nurse. R9's ([DATE]) care plan documented, in part The resident exhibits the symptom of resisting care which is related to: (x) Psychiatric illness, severe mental illness. (X) Hiding, hoarding medications and other non-allowed items at bedside or other places within the room. The ([DATE]) email correspondence with V1 (Administrator) and V2 (Director of Nursing) documented, in part No residents are allowed to have any hazardous items, for example scissors in their possession while in our facility. Such items could potentially cause harm if they are handled inappropriately or used without supervision. The (undated) House Rules and Behavior Expectation documented in part Residents of Fargo Health Care Center are expected to conduct themselves in accordance with the facility philosophy which promotes personal responsibility and dignified behavior. 3. All residents are asked to come to the nursing station for medications at the prescribed times, if physically able. Medications must be consumed in the nurses' presence while at the nursing station. 9. The following items are considered contraband and are not allowed in resident rooms: medication of any type, any sharp or dangerous object (knives, razors, needles, letter openers, box cutters, certain nail clippers, pins, tacks, etc.) cleaning agents, certain shaving cremes, weapons, and drug paraphernalia. 15. This nursing facility reserves the right to check/search all bags and personal belongings of all residents, staff, and visitors upon entering and exit from the building to prevent anyone from bringing in contraband or weapons. This is to ensure all our residents, staff and visitors are safe at all times. Resident rooms may also be checked/searched at the discretion of staff. Two staff members and resident must be present for this procedure. It is our desire to maintain a safe environment for all parties. The (undated) Routine Resident Checks, Safety Room Checks, and Outdoor Area (Patio) documented, in part Policy Statement. Routine resident checks shall be made to assure that the resident's safety and well-being are maintained. On occasion it may be required for facility staff to check a resident's room for contraband or other items not safe in this environment. Policy Interpretation and Implementation. 4. To provide safety to all residents, Resident Room, Dining Rooms, and outside areas will be checked for any concerns related to unsafe items (contraband such as Alcohol, Medications, drug paraphernalia, and/or items that may be used by resident or others to cause harm). Resident upon entering the facility from independent pass, the facility reserves the rights to check bags or resident coat/jacket and pockets. If resident is observed with unapproved items, appears to be under the influence, and/or has a history of safety concerns such as alcohol, illegal substances, etc., the facility will conduct search, with resident present to ensure the resident and other residents in the facility are safe and free from harm. 5. If facility staff identify and safety concerns related to the environment or items or substances that pose risks to residents' health and safety and are in plain view, they will be confiscated, and all concerns will be addressed to the Administrator immediately. The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must provide services to keep your physical and mental health at their highest practicable levels. Your facility must be safe. The (07/2024) Medication Administration Policy documented, in part Policy: All medications must be administered safely and effectively. Remain with resident until all medications have been fully swallowed.

Based on observation, interviews and review of records the facility failed to provide admission contract/agreement packets in a timely manner to 5 out of 5 residents (R1, R6, R7, R8 and R9). Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1 medical diagnosis includes hypertension, major depression (single episode), bipolar disorder, anxiety disorder. Per MDS assessment of R1 dated 06/20/2025, R1 has a BIMS (Brief Interview of Mental Status) score of 15 or cognition is intact. On 08/26/2025 at 10:12 AM, R1 stated that facility let him sign a contract for services recently. R1 presented a Resident admission Packet. R1 stated that it is a contract for services and terms and condition for resident to be in the facility. R1 stated that he dislikes the contract because there are blank areas and missing pages. R1 stated that facility did not give him enough time to review the contract. R1 stated that V1 (Administrator) called him to a meeting. In that meeting, V1 told him that he told other residents not to sign the contract which was not true. V1 stated that he was upset because the contract may change his living arrangement. R1 said, I have been living for two (2) and a half year and I don't want to change what I can and cannot do because of the contract. On 08/26/2025 at 12:36 PM, V6 (MDS Coordinator/Licensed Practical Nurse) stated that the only time she encountered R1 about admission contract was when there was a meeting on the conference room. R1 came in saying don't force me to sign. V1 (Administrator) told R1 to talk in her office. On 08/26/2025 at 01:01 PM V3 (Director of Social Services/PRSD) stated that admission contract includes policies and regulation, resident rights, position and payment. Facility is three (3) years behind in providing resident admission contracts to residents already in the facility. For that reason, facility hired a consultant (V5). V3 stated that admission contract packet needs to be provided during admission. V3 stated that admission contract is important because it provides information about living in a nursing home. V3 stated that R1 was provided admission contract about a month ago. Per R1's record (face sheet), R1 has been a resident in the facility since 01/10/2023. On 08/26/2025 at 01:29 PM, V1 (Administrator) stated that every resident coming in the facility needs admission contract. V1 stated that about seven (7) months ago when she did an audit there are residents that was not offered an admission contract. V1 stated that V5 (Social Service Consultant/Outside Vendor) was hired to address this issue by offering admission contracts to residents. V1 stated that admission contracts need to be given to residents upon admission. V1 stated that R1 did not sign the admission contract. V1 provided list of five (5) residents that does not have admission contracts based on facility's audit. Five (5) residents are as follows: R1 first admission date 01/10/2023, R6 first admission date 10/05/2023, R7 first admission date 02/11/2025, R8 first admission date 10/03/2023 and R9 first admission date 06/03/2024. Majority of residents (R1, R6, R8 and R9) were without admission contracts for more than a year after admitted in the facility. Facility was requested to provide policy and procedure to address concerns related to residents not provided Resident Admissions Packet / Contract during or at the time of admission. Facility presented admission Policies dated 01/2025 that does not include providing residents admission Packet / Contract during or at the time of admission. Per facility's Resident admission Packet (by Health Care Council of Illinois) dated 12/2022. The admission packet is a contract that defines the relationship between resident and facility. It provides the following: Facility's rights and obligations, resident's rights and obligations, financial agreement between facility and residents, term and termination of the contract with automatic renewal every year and other stipulations that will affect both residents and facility.

Based on observation, interview, and record review the facility failed to follow menus, spreadsheets, and recipes. These failures have the potential to affect all 93 residents receiving food prepared in the facility's kitchen. Findings Include:On 08/12/2025 at 11:52 AM, R63 said, I don't get enough to eat and I'm always hungry. On 08/12/2025 at 12:22 PM, observed R63 eating lunch in unit dining room. R63 received ground turkey with gravy, sweet potato, peas, yellow cake, and juice. R63 did not received any bread or a substitution for bread.On 08/12/2025 at 12:30 PM, observed R7's lunch tray. R7 received turkey, sweet potatoes, peas, cake, nectar thick water and juice. R7 did not received any bread or substitution for bread.On 08/12/2025 at 12:45 PM, observed R21's lunch tray. R21 received pureed turkey, pureed sweet potatoes, pureed peas, pureed cake, and honey thickened water and juice. R21 did not receive pureed bread or substitution for pureed bread. On 08/13/25 at 11:47 AM, observed lunch tray line in progress. Residents on regular and mechanical soft diet received spaghetti with sauce and meatballs, mixed vegetables, and lemon glaze cake. The resident on a pureed diet received pureed spaghetti with meatballs, pureed mixed vegetables and pureed lemon glaze cake. There was no Garlic Texas Toast or pureed bread on the tray line.On 08/13/2025 at 12:18 PM, observed R21's lunch tray. R21 was served pureed pasta with meatballs, pureed vegetables, pureed cake, honey thickened juice and milk. R21 did not receive any pureed bread or substitution for pureed bread. On 08/13/2025 at 12:36 PM, observed R7 eating lunch. R7 received spaghetti with meatballs, mixed vegetables, cake and nectar thick juice and milk. R7 did not receive Garlic Texas Toast or an equivalent bread substitution. R7 said, I'd like a piece of Texas Toast! Of course, I would! R7 stated he would like to eat Texas Toast because he bet it would taste good and give him some variety in his meals. On 08/13/2025 at 12:39 PM, observed R93 eating lunch in the dining room. R93 received spaghetti with meatballs, mixed vegetables, cake, and juice. R93 stated that he would have liked to receive Texas Toast with this meal because it would go well with the spaghetti and meatballs. R93 stated, I'd eat it! On 08/13/2025 at 12:42 PM, R63 stated he ate 100% of his lunch meal and it was tasty. R63 stated he would have eaten Texas Toast if he was given it. R63 stated he does not get enough to eat; the portions are small, and he is always hungry. R63 stated he would take any extra food he could get. On 08/13/25 at 12:18 PM, in the kitchen observed in the recipe binder a recipe for pureed bread for Tuesday and Wednesday lunch and a recipe for Garlic Texas Toast for Wednesday lunch. On 08/13/25 at 12:19 PM, V16 (Cook) stated he follows the posted menus, so he knows what food to prepare, the recipes so he knows how to prepare the menu items and the spreadsheets to tell him the items to be served, the portion sizes to be served, the consistency of the item and any special adjustments needed for the specialized diets. V16 stated if an item is not available, he would notify the dietary manager who would tell him what item to substitute the missing item with. V16 stated yesterday he did not serve bread to the regular diets and did not prepare pureed bread for the resident on a pureed diet. V16 stated today he did not serve Garlic Texas Toast to the regular and mechanical soft diets, and he did not prepare pureed bread for the resident on a pureed diet. V16 stated the menu already has a lot of starch in it.On 08/13/25 at 12:23 PM, V14 (Dietary Manager) stated the cook should be following the menus and spreadsheets to make sure the kitchen is providing the right nutrition to the residents. V14 stated if an item is not available the kitchen would look for a substitute of similar value. V14 stated it is important to serve all the items listed on the menu spreadsheet to make sure the residents are getting enough calories. V14 stated the kitchen does not serve bread or rolls or Texas Toast to the residents at lunch even if it is listed on the menu spreadsheet. V14 said, I think the bread is optional and the kitchen stopped sending bread to the residents at lunch about one year ago because the residents were collecting the bread and giving it to the birds outside the building. V14 stated it was not discussed as far as she knows at Resident Council Meeting, but she was told by the previous administrator to stop serving the bread and that the Registered Dietitian consultant is aware they are not serving bread at lunch to the residents. V14 reviewed the menu spreadsheets and stated it does not list the bread as optional so that means it is not optional and the kitchen should be serving it. V14 stated the kitchen is not providing a menu substitute for the bread, roll, Garlic Texas Toast not being served. V14 stated she did not know why the cook did not prepare pureed bread because it is listed on the menu spreadsheet and that the cook should have made it.On 08/13/25 at 1:40 PM, via telephone interview V22 (Registered Dietitian) stated the cooks should be preparing and providing all the food listed on the menu unless an item is not available in which case a substitute should be provided. V22 stated the menus have been put together and approved by a Registered Dietitian to ensure nutritional adequacy and therefore the menus should be followed as posted. V22 stated if the menus are not being followed and residents are not being provided with all the food, they should be receiving they may be receiving reduced calories and there may be reduction in resident satisfaction with the menus. V22 stated if the kitchen is not serving the bread item at lunch than a menu alternative should have been provided in its place. V22 stated she was not aware that bread was not being served at lunch every day. V22 stated she was not aware of that and if she was told about it she would have discussed it with the kitchen and explained to them that they cannot just cut out a serving of something and then not provide something in its place because the menus are designed to provide specific amount protein and carbohydrates to meet nutrition standards. V22 stated if the kitchen is routinely not serving bread or bread equivalents (roll, Texas Toast) they may not be receiving enough starch/bread servings per day.R7's Physician Orders dated 08/14/25 documents in part, regular diet with nectar thick liquids. R21's Physician Orders dated 08/14/25 documents in part, pureed with honey thick liquids.R63's Physician Orders dated 08/14/25 documents in part, mechanical soft with thin liquids. R63's Minimum Data Set (MDS) dated [DATE] documents cognitive status as intact.R93's Physician Orders dated 08/14/25 documents in part, regular diet with thin liquids. R93's Minimum Data Set (MDS) dated [DATE] documents cognitive status has being intact.Facility provided Diet Tally dated 08/12/25 which documents 93 residents in total with no NPO (Nothing by Mouth) orders.Facility provided document titled, Client List Report dated 08/12/25 which indicates R21 is the only resident on a pureed diet.Facility provided kitchen policy titled, Standardized Recipes dated 2021 which documents in part, foods will be prepared according to standardized recipes provided by the menu source. Facility provided policy titled Cycle Menu dated 2017 which documents in part, menus will be planned in accordance with the Illinois Administrative Code Section 300.2050 for bread, cereal, rice, and pasta group: six or more servings of whole grain, enriched or restored products. Facility provided Weekly Menu for Spring/Summer 2025 Week 2 which lists in part, for bread to be served on Tuesday at lunch and Garlic Texas Toast to be served on Wednesday at lunch.Facility provided Daily Spreadsheet Week 2 Tuesday lunch which documents in part, to serve one slice of bread for general and mechanical soft diet textures and pureed bread (1 slice = #16 scoop) for pureed diet. Facility provided Daily Spreadsheet Week 2 Wednesday lunch which documents in part, to serve 1/2 slice Garlic Texas Toast for general and mechanical soft diet textures (except for low fat/low cholesterol diet to receive bread in place of Garlic Texas Toast) and pureed bread (1 slice = #16 scoop) for pureed diet. Facility provided recipe for Pureed Bread and Garlic Texas Toast (1/2 slice to provide 1 grain serving). Facility provided job description of [NAME] dated 2017 which documents in part, duties to prepare all food as planned on the cycle menu for the clients and staff and follow standardized recipes in food preparation to ensure quality of foods prepared.

Based on observations, interviews, and record reviews the facility failed to a.) ensure kitchen staff wearing appropriate hair covering; b.) food items were properly labeled and dated; c.) food items stored according to manufacturer's guidelines. These failures have the potential to affect all 93 residents receiving food prepared in the facility's kitchen. Findings include:On 08/12/25 at 9:13 AM, during initial kitchen tour observed V15 (Dietary Aide) by the food prep area. V15 had a beard and mustache and was not wearing any type of covering over his beard and mustache. On 08/12/25 at 9:16 AM, V14 (Dietary Manager) observed V15 and said that his beard and mustache should be covered with a hair net and that he should have put it on as soon as he entered the kitchen. V14 stated the kitchen has an adequate supply of beard protectors and then showed surveyor a plastic bag full of beard protectors by the kitchen front door, next to a bag of hairnets. V14 stated any facial hair an employee has should be covered with a beard protector. On 08/12/25 at 9:19 AM, V14 stated any opened food item must be labeled with a use by date. V14 stated the kitchen does not label items with an open or prepared date, only a use by date. V14 stated most items need to be used within seven days of being opened however some items have longer shelf life depending on what the item is. V14 stated the kitchen follows manufacturer guidelines printed on the item for use by dates and storage directions. V14 stated it is important to use the item or discard the item by the expiration date and follow manufacturer guidelines for use by dates and storage because the facility does not want people to get sick and potentially causing them to get diarrhea and/or give them stomach problems. On 08/12/25 at 9:28 AM, observed in the walk-in refrigerator the following items:1.) Opened 46-ounce carton Honey Thick Cranberry Juice. There was no opened date or use by date written by staff on the container. The manufacturer had printed on the carton best if used by date 12/11/25.2.) Opened 46-ounce carton Nectar Thick Lemon-Flavored Water. There was no opened date or use by date written by staff on the container. The manufacturer had printed on the carton best if used by date 12/08/25.3.) Opened 32-ounce carton Nectar Thick Milk. There was no opened date or use by date written by staff on the container. The manufacturer had printed on the carton best if used by date 12/17/25.4.) Opened 32-ounce carton Honey Thick Milk. There was no opened date or use by date written by staff on the container. The manufacturer had printed on the carton best if used by date 09/04/25.5.) Opened 46-ounce carton Nectar Thick Apple Juice. There was no opened date or use by date written by staff on the container. The manufacturer had printed on the carton best if used by date 01/12/26.6.) Large supply of sliced loaves of bread. On 08/12/25 at 9:35 AM, V14 stated there are residents in the facility who are on nectar and honey thickened liquids, and they are served pre-thickened juice and milk which come in as a shelf stable item and are then refrigerated once they are opened. V14 stated she could not tell when the items were opened because there was no opened date written on any of the containers however, they follow the manufacturer's use by date printed on the containers. V14 stated the kitchen can use those products opened pre-thickened juice and milk until the manufacturer use by date which is printed on the containers. Surveyor pointed out to V14 that on the honey thickened cranberry juice, the nectar thickened lemon-flavored water, the nectar and honey thickened milk and nectar thickened apple juice containers the manufacturer had printed on the label After opening may be kept up to 7 days under refrigeration. V14 stated she had not noticed that before and since they do not label items with an open date there is no way of knowing how long the opened pre-thickened liquids had been in the refrigerator and based on the manufacturer instructions printed on the containers the items should be discarded or used by within seven days after they are opened. On 08/12/25 at 9:44 AM. observed opened 16-ounce plastic bottle of ground cloves labeled with a manufacturer's best by date of 07/31/24. V14 stated that means that is expired and should not be used. V14 stated she will throw it out. On 08/12/25 at 9:46 AM, observed opened 1-gallon plastic container of soy sauce 75% full. On the manufacturer's label of the soy sauce container, it read Refrigerate After Opening. V14 stated the kitchen is supposed to follow manufacturer's guidelines for storage. V14 stated based on the manufacturer's guidelines the soy sauce should have been stored in the refrigerator after opening. V14 stated, we didn't but we should have. On 08/12/25 at 9:58 AM, V14 stated the facility does not have any residents who are receiving NPO (Nothing by Mouth).On 08/12/25 at 10:46 AM, during pureed food preparation observed V15 (Dietary Aide) prepping lunch trays by putting silverware wrapped in napkins onto the tray and adding meal tickets to the lunch trays. V15 was wearing a beard protector which was pulled down, so his beard was covered but his mustache was not covered. On 08/13/25 at 1:50 PM, via telephone interview V22 (Registered Dietitian) stated all items should be labeled with an opened and use by date so that the staff knows when to discard food. V22 stated the potential problem of not labeling items with an opened and accurate use by date is that it could potentially cause a food infection if the item was to be served to a resident. V22 stated manufacturer guidelines should be followed for use by dates and food storage. V22 stated if the pre-thickened juice and milk products had manufacturing guidelines printed on the containers indicating the items should be used within seven days of being opened than that is what should be followed. V22 stated if a product says on it that it should be refrigerated after opening than the kitchen should be doing. V22 stated hair restraints should be worn by everyone in the kitchen and all facial hair should be covered. V22 stated nobody wants to find a hair in their food or on their meal tray. On 08/12/25, V14 provided typed up list of diet orders for all residents in the facility. The diet order list indicates there are no residents receiving nothing by mouth (NPO). Facility provided kitchen policy titled, Hair Restraints/Jewelry/Nail Polish dated 2017 documents in part, food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated. Facility provided kitchen policy titled, Labeling & Dating Food dated 2017 which documents in part, to decrease the risk of food borne illness and to provide the highest quality, food(s) is labeled with the date received, the date opened and the date by which the item should be discarded. Bulk condiments with a best if used by date . are shelf stable for longer periods as indicated by the best if used by date once opened these items are refrigerated and labeled with the opened and with discard or use by date.

Based on observations, interviews, and record reviews, the facility failed to practice infection control and prevention measures to ensure staff wore appropriate personal protective equipment (PPE) for one (R5) resident on enhanced barrier precautions and appropriately handle and transport linen to prevent potential contamination. The facility also failed to track and register to report possible XDROs (Extensively Drug-Resistant Organisms) to the registry. These failures have the potential to affect all 93 residents residing in the facility.Findings include:On 8/12/2025 at 11:20 AM, surveyor did laundry service walk-through with V8 (Laundry Attendant). When asked about facility's laundry chute, V8 opened a door labeled 'Storage.' There was a large, gray bin filled with linen and resident clothing. Some of the linens and resident clothing were not contained in bags. When V8 opened the chute's door, multiple loose linen and resident clothing fell onto the bin. V8 stated staff are supposed to bag all linen and resident clothing but staff don't always do so. V8 also stated that sometimes staff don't always secure the bags so linen and clothing become loose while going down the chute. On 8/12/2025 at 12:21 PM, V8 was on the second floor delivering clean resident clothing and linen in an uncovered cart. On 8/13/2025 at 10:01 AM, V3 (Infection Preventionist / Assistant Director of Nursing) went over facility's infection control practices. V3 stated all linens are supposed to be secured in bags during transport and when sent down the chute. V3 also stated staff are supposed to deliver clean linen and resident clothing covered during transport. During the same interview, V3 stated facility does not track XDROs (Extremely Drug-Resistant Organisms). V3 stated [V3] been the facility's Infection Preventionist for the past three years and has not tracked XDROs. V3 stated [V3] is also not registered to report XDROs to the registry. V3 stated V2 (Director of Nursing) possibly has done it but V3 has not been doing it. On 8/13/2025 at 10:27 AM, V2 stated [V2] has not been tracking or reporting XDROs. V2 stated V3 should have been doing it. Facility's 'Handling Soiled Linen' policy documents in part that the purposes of the policy and procedures are to prevent contamination of Health Care Workers handling soiled linen and contamination of surfaces and clean linen. One of the important points listed include: Soiled laundry/linen should be bagged or contained where collected. Facility's 'Laundry Policy and Procedures' documents in part: Laundry is either bagged or covered during transport. Clean clothing is hung and placed into carts according to room number. Carts are to be covered on all sides during transport to rooms, clothing is transported to room by [evening] shift. Clean linens are all covered. Facility's 'Laundry and Linen Policies' document in part: Linens are handled, stored and processed to control the spread of infections. Illinois Administrative Code Title 77: Public Health, Chapter I: Department of Public Health, Subchapter k: Notifiable Diseases and Conditions Control and Immunizations, Part 690 Control of Notifiable Disease and Conditions Code, Section 690.1510 Entities Required to Submit and Query Information documents in part that the Department requires long-term care facilities to report patient incident information regarding XDROs. It also requires skilled nursing and intermediate care facilities to query or implement alert notification with the XDRO Registry in order to identify new admissions with XDROs. On 08/12/2025 at 11:46AM, surveyor located on the second floor of the facility and observes a sign posted on R5's door that reads in part Enhanced Barrier Precautions Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting. Do not wear the same gown and gloves for the care of more than one person. On 08/12/2025 at 11:47AM, V10 (Certified Nursing Assistant/CNA) and V11 (CNA) observed inside of R5's room transferring R5 from the bed to a wheelchair without wearing appropriate PPE/personal protective equipment. V10 and V11 observed not wearing a gown or gloves. On 08/12/2025 at 11:50AM, V10 and V11 observed exiting R5's room and transporting R5 to the dining room via wheelchair. On 08/12/2025 at 11:52AM, V5 (Licensed Practical Nurse/LPN) states R5 is on EBP due to R5 having an indwelling urinary catheter. V5 states all staff should don gloves and gown when providing care for R5, including when transferring R5. On 08/12/2025 at 11:56AM, surveyor makes V10 and V11 aware of the EBP sign posted on R5's door. V10 and V11 observed reading the EBP sign posted on R5's door and surveyor inquires to V10 and V11 about the appropriate PPE that should be worn while providing care for R5. V10 and V11 state they should have worn a gown and gloves while transferring R5 to his wheelchair because R5 is on EBP for his urinary catheter. V10 and V11 states enhance barrier precautions are put into place to minimize cross contamination and infections to the residents. V10 and V11 state there is a potential for residents to develop an infection if they do not wear the appropriate PPE and practice infection prevention protocols. On 08/14/2025 at 12:10PM, V3 (Infection Prevention Nurse) states all staff caring for residents on enhanced barrier precautions/EBP are supposed to wear a gown and gloves. V3 states this PPE is required for staff to wear to prevent cross contamination and prevent the spread of infection. V3 states residents who have a urinary catheter are at risk for UTIs/urinary tract infections and other bacteria entering their urinary catheter. V3 states if the proper PPE is not worn when caring for residents, then the staff can spread bacteria from one resident to another and cause an infection. R5's Physician order sheet/POS documents the following order: R5 placed on Enhanced Barrier Precaution due to Suprapubic Cath placement dated 03/01/2024. R5's care plan dated 06/30/2025 documents that R5 is on Enhanced Barrier Precautions due to the use of indwelling suprapubic catheter. Review of facility provided list titled Enhanced Barrier Precautions does not list R5 as a resident who is currently on enhanced barrier precautions for his urinary catheter. Facility policy dated 12/19/2024 titled Enhance Barrier Precautions documents in part, Procedure: 3. Gloves and gowns must be worn for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting.Device Care or Use: An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection.

Based on observations, interviews and record reviews, the facility failed to ensure a medication error rate of less than 5% for 4 (R2, R34, R56, R60) of 4 residents with 9 errors for 30 medication administration opportunities. This resulted in a medication error rate of 30%. The findings include: On 8/12/2025 9:31 AM Medication administration observation conducted with V4 (Registered Nurse / RN). Observed V4 prepared and administered the following medications to R2: Xcopri 50mg 1 tabletLevetiracetam 750MG 1 tabletValproic acid 250mg/5ml oral solution 10MLAptiom 400mg 1 tabletSodium chloride 1 GRAM 1 tabletFluoxetine 20 MG Oral 1 CapsuleLamotrigine 25MG 1 tablet Loratadine 10mg 1 tablet Observed R2 took prepared medications by mouth.R2's POS (Physician Order Sheet and MAR (Medication Administration Record) showed order not limited: Levetiracetam 750mg 1 tablet by mouth twice a day scheduled at 8am and 4pm. Valproic acid 250mg/5ml oral solution give 10ml (500mg) by oral route 3 times per day scheduled at 8am, 1pm and 6pm. Lamotrigine 25mg give 1 tablet by oral route 2 times per day scheduled at 8am and 4pm.Observed medication errors for the following medications Levetiracetam, Valproic acid and Lamotrigine due to wrong time. V4 administered medications at 9:31 AM to R2 not following physician's ordered time at 8AM. On 8/12/2025 9:41 AM Observed V4 (RN) prepared and administered the following medications to R60:Spiriva handihaler 18mcg 1 capsule by inhalation. Meloxicam 7.5mg 1 tablet Gabapentin 300mg give 1 capsule Folic acid 100MCG 1 tablet Ferrous Sulfate 325mg 1 tablet Pantoprazole 40mg 1 tablet Cetirizine 10mg 1 tablet PRN (as needed)Observed R60 took all prepared medications by mouth. R60's POS and MAR showed order not limited: Gabapentin 300mg give 1 capsule three times daily scheduled at 8AM, 1PM AND 6PM. Observed medication error for Gabapentin due to wrong time. V4 administered medications at 9:41 AM to R60 not following physician's ordered time at 8AM. On 8/12/2025 9:50 AM Medication administration observation conducted with V6 (Licensed Practical Nurse / LPN). Observed V6 prepared and administered the following medications to R34:Apixaban 5 MG [Eliquis] 1 tabletDiltiazem 90mg give 1 tablet OMEGA-3 1000MG 1 tabletVitamin D3 25mcg 1000 IU 1 tabletMetformin 1000mg 1 tabletAspirin 81mg 1 tabletGlipizide 5mg 1 tabletNamenda 10mg 1 tabletSeroquel 100mg 1 tablet Observed R34 took all prepared medications orally. R34's POS and MAR showed order not limited:Eliquis 5mg 1 tablet by oral route 2 times per day at 8am and 4pm.Diltiazem 90mg give 1 tablet by oral route 2 times per day at 8am and 4pmGlucophage (Metformin) 1000mg 1 tablet by oral route 2 times per day at 8am and 4pmNamenda 10mg give 1 tablet by oral route every 12 hours at 8am and 8pmObserved medication error for Eliquis, Diltiazem, Glucophage, Namenda due to wrong time. V6 administered medications to R34 at 9:50 AM not following physician's ordered time at 8AM. On 8/12/2025 10:03 AM Observed V6 prepared and administered the following medications to R56:Docusate sodium 100mg 1 tabletSenna plus 1 tabletVitamin D 25mcg 1000IU 1 tablet Lamotrigine 25mg 2 tabletsDepakote 500mg 1 tabletPolyethylene 1 capful powder mixed with water in a cup. Observed R56 took all prepared medications by mouth. R56's POS and MAR showed order not limited: Depakote 500mg delayed release give 1 tablet by oral route every 12 hours at 8AM and 8PM.Observed medication error for Depakote due to wrong time. V6 administered medications to R56 at 10:03 AM not following physician's ordered time at 8AM. On 8/14/25 at 11:13AM V2 (DIRECTOR OF NURSING / DON) stated she has been working in the facility for 3 years. Stated nurses are expected to administer medications at the correct time as ordered by physician and follow 5 rights in giving meds (right time, right resident, right medication, right route, right dose). V2 said standard nursing practice and facility protocol is to give medications one hour before and after the ordered time. Stated if medication ordered time is at 8am, medication should be given between 7am to 9am. V2 said if it was given after 9am, it is considered late and not following doctor's order. She said if medication was not given according to physician ordered time, there could be some reactions to the medications. V2 further stated, if it is blood pressure (BP) medication, BP could potentially go up, if it is for blood sugar medication, Blood sugar could spike up and time gap between medication could be shorter and could potentially harm the resident due to some reactions. Facility's medication administration policy dated January 2024 showed in part: Drugs will be administered in accordance with orders of licensed medical practitioners of the state in which the facility operates. Medications shall be administered one (1) hour before / after of the medication schedule unless specifically ordered otherwise.

Based on observation, interview and record review, the facility failed to (a) properly date opened multi-dose inhaler for 2 (R18, R103) residents, (b) ensure that house stock medication (multidose Tubersol solution) was stored properly at appropriate temperature from 2 of 3 medication carts and 2 of 3 medication rooms inspected for medication storage and labeling. The findings include:On [DATE] at 10:13 AM 2nd floor medication cart inspected with V5 (LPN / LICENSED PRACTICAL NURSE) and found the following: Tubersol solution 1 vial kept in clear zip lock and showed house stock, pharmacy label indicated keep in refrigerator. Tubersol solution was found inside the medication cart not properly stored at appropriate temperature. R103's Trelegy ellipta 100mcg inhaler opened no date. 3 same inhalers were opened with no date. Pharmacy label indicated discard 42 days after opening. R18's Albuterol sulfate HFA 90mcg inhaler opened with no date.V5 said Tubersol solution is a House stock ordered from the pharmacy, not sure when it was delivered. She said Tubersol solution or TB (Tuberculosis) test is given to newly admitted resident and due for TB test. V5 said inhalers once opened should be dated to know when to discard. On [DATE] at 11:13AM V2 (DIRECTOR OF NURSING / DON) stated Nurses are expected to date and label the medication once opened so staff would be able to know when it was opened and when to discard as some medications is good for certain days only once opened. V2 said inhalers once opened should be dated. Stated if there is no label of date opened, medication could not be effective or could be expired don't know if it is effective, could be outdated. V2 said Tuberculin solution should be refrigerated to keep potency of the medication. she said tuberculin solution is a house stock delivered by pharmacy, and it is given for newly admitted resident 1st and 2nd step on admission then yearly. V2 said If tuberculin solution was not kept on appropriate temperature, potency of the medication is affected and could not be effective it could result to false positive or false negative result. R18's POS (physician order sheet) showed order not limited to: Albuterol sulfate HFA 90mcg inhaler inhale 2 puffs by inhalation route every 6 hours as needed. R103's POS showed order not limited to: Trelegy Ellipta 100mcg -62.5mcg-25mcg powder inhale 1 puff by inhalation route once daily. Facility's medication storage policy dated [DATE] showed in part: To ensure proper storage, labeling and expiration dates of medications, biologicals. Once any medication or biological package is opened, facility should follow manufacturer / supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States pharmacopeia guidelines for temperature ranges. Refrigeration: 36-46F.Facility's 2nd floor census dated [DATE] showed 33 residents. Facility's inhaler storage recommendations beyond use date policy dated 10/2020 showed in part: Trelege Ellipta Discard 6 weeks after opening the foil tray. Facility's medication storage information policy (undated) showed in part: PPD (Tubersol): Refrigerator (unopened / opened). Facility's medication administration and storage policy dated 7/23 showed in part: To ensure medications are administered and stored in accordance with standard of practice.

Based on observation, interview, and record review, the facility failed to a.) ensure the rights of the resident to receive effective and accessible means of communication and b.) ensure the residents were treated with respect and dignity by not passing out meals to residents sitting together at the same time. These failures affected two residents (R55 and R59) in a total sample of 19 residents reviewed for resident rights.Findings include: On 08/12/2025 at 12:03PM, surveyor located on the second floor of the facility located in the dining room. Surveyor observes meal trays being dispersed to residents sitting in the dining room. R72 and R55 observed seated at the same table in the dining room awaiting their lunch meal. R72 was served his lunch meal at 12:04PM and began eating his lunch meal. R55 did not have a meal tray and was not actively eating. V7 (CNA), V9 (CNA), V10 (CNA), and V11 (CNA) observed passing meal trays to other residents in the facility as they removed their tray off the meal cart. At 12:11PM, R55 still observed without a meal tray and not eating. R55 observed watching R72 eat his lunch meal and inquired to V9 (Certified Nursing Assistant/CNA) about where his lunch tray was asking Hey, what about me? V9 states to R5 that he will get him his tray momentarily. V9 continues passing meal trays to other residents and is observed serving R5's lunch meal tray to him at 12:13PM. At this time, R72 had finished eating his lunch meal. On 08/14/2025 at 12:14PM, V2 (Director of Nursing/DON) states the facility has an assigned seating chart for residents when they are eating their meals in the dining room. V2 states the resident's meals should be served according to the table they are sitting at. V2 states residents sitting at the same table should be served their meal tray at the approximate same time. V2 states this ensures a homelike environment and reserves the resident's dignity. V2 states the staff are aware of the dining room seating and meal tray service because there was an in-service recently conducted on the topic. V2 states if residents have to wait to be served their meals, then there is a potential for their meals to be served cold and residents can get upset. V2 states residents can become upset and not want to eat or they can develop a behavior and grab food off of other resident's meal trays. V2 states this behavior can cause resident-to-resident interactions or fights. V2 states this can be avoided if the staff follow the seating chart and serve residents their meals according to their assigned table. On 08/14/2025 at 12:28PM, V2 (DON) provides surveyor a list of resident dining room table seating charts. Second floor seating chart documents that R55 and R72 are assigned to sit at the same table. R55's Facesheet documents that R55 has diagnoses not limited to: Malignant neoplasm of unspecified part of unspecified bronchus or lung; Chronic obstructive pulmonary disease, Schizophrenia, Vitamin deficiency, Iron deficiency anemia, hyperlipidemia, Essential (primary) hypertension, Bipolar disorder, Unspecified protein-calorie malnutrition, hypoosmolality and hyponatremia, and abnormal weight loss. R55's MDS/Minimum Data Set, dated [DATE] documents that R55 has a BIMS/Brief Interview for Mental Status of 15/15, indicating that R55 is cognitively intact. R55's diet order is documented as follows: Supplement, 8 ounces QID/4 times a day, Give Ice cream with lunch and dinner, High Fiber Diet, Regular NAS/no added salt diet with thin liquids. Facility In-services dated 04/04/2025 titled Dining room seating/Trays documents that V7 (CNA), V9 (CNA), and V10 (CNA) were in-serviced on seating and table arrangements when serving meal trays. Facility policy dated 2017, titled The Dining Experience documents in part, Policy: Meals served will respect the client's dignity as an individual. Meals are served at approximately the same time to all the clients sitting at a table. Facility policy dated 03/2024, titled Resident's Rights documents in part, 1. The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect; R59's MDS (minimum data set) assessment reference date of 6/09/2025 section B documents that R59's hearing is highly impaired- absence; no speech- absence of spoken words. On 08/12/2025 at 11:30 AM R59 observed sitting on the chair, pointing to his ears when surveyor introduced self, observed communication board hung on the wall, unable to be detached from the wall to be utilized. No cue cards observed at the bedside or anywhere in the room. Per R59's care plan, items should be available to communicate with R59. On 08/12/2025 at 11: 45 AM V4 (Registered Nurse/ RN) states she has worked in this facility for 1 year. V4 states she does not know sign language, nor received training on sign language and usually communicates with gestures, or states R59 simply understands the day-to-day routine. On 8/13/2025 at 11:15 AM V20 (Certified Nursing Assistant/ CNA) stats he has been working at the facility for 2 years. When communicating with R59, V20 states he uses hand or facial gestures but does not know how to use sign language or received training on sign language. V20 states, he does not know what cue cards look like and has never used them since the time he started working in the facility. On 8/13/2025 at 11:20 AM V21 (License Practical Nurse/ LPN) sates he has been working at the facility for 6 years and regularly works on the first floor. V21 stated he communicates with R59 when caring for him using sign language, but very minimal. V21 states he can know when R59 is in pain by pointing out to the body part. V21 states, he is familiar with R59 and will usually be able to determine if he has a change of condition by facial grimace. V21 stated he does not use the communication board or any cue cards, but it would be helpful if utilized, and he did not receive training on sign language. On 08/14/2025 at 10:14 AM V4 affirmed cue cards and communication board are not being utilized with R59. V4 does not know sign language at all. On 08/14/2025 at 10:23 AM V12 (PRSD/ Psychiatric Rehabilitation Services Director) has been working in the facility since March 2025. V12 stated she completes her assessment with R59 by using hand gestures, cues or nonverbal communication, and has not received training in sign language. On 08/14/2025 at 10:41 AM V2 (Director of Nursing/ DON) stated she communicates with R59 by using hand gestures or using the application on her telephone. V2stated her expectations for her staff are to use the communication board, gestures, and if they are not able to understand R59, then they should let her know and she will call the case manager who is trained for signed language. V2 stated there is no one in the facility who is trained to speak sign language. V2 stated it would be helpful if there were staff members available who are trained to speak sign language. On 08/14/2025 at 10:49 AM V2 attempts to take out the communication board but was unable to detach it from the wall. V2 was also unable to find the cue cards in R59 room, there were not available or accessible. Using a note pad to ask R59 if he ever used the communication board, R59 stated he does not use the communication board or cue cards. Facility Policy titled Resident Rights with review date of 3/24 documents The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. The right to receive the services specified in the service plan, to review and renegotiate the plan at any time, and to be informed of the cost of the changes. Facility Policy titled Communication and Language Assistance Services Policy with review date of June 2016 documents Language assistance services are important at this healthcare organization. The facility strives to ensure access to healthcare information and serviced for limited-English- speaking or non-English-speaking resident or hearing-impaired residents. To address these responsibilities this facility emphasizes: Communication Board Cards: The organization shall make appropriate communication illustrations available to the resident for use, as appropriate depending on the resident's functional ability including the ability to point to letters, words and pictures.

Based on observation, interview and record review the facility failed to ensure splints were applied as ordered by physician for 2 (R6 and R78) of 3 residents reviewed for limited range of motion in a sample of 19. The findings include: On 8/12/2025 at 11:17AM Observed R6 sitting up on wheelchair in her room, alert and oriented x 3, verbally responsive with limited ROM (range of motion) on Right arm no device in place. R6 said she broke her wrist due to fall incident. She said staff used to apply splint on her right hand but lately it was not applied. R6 said unable to recall the last time it was applied. Multiple observations conducted with R6 on 8/12/25 between 11AM to 2PM and on 8/13/25 between 10AM to 11:30AM, R6 was not wearing Right hand splint. R6's face sheet showed admission date on 6/8/23 with diagnoses not limited to Paroxysmal atrial fibrillation; Unspecified fracture of upper end of right radius; Essential (primary) hypertension; Age-related osteoporosis; Bilateral primary osteoarthritis of knee.MDS ([NAME] Data Set) dated 6/10/25 showed R6's cognition was intact. She needed Substantial / maximal assistance with oral and personal hygiene, shower / bathe self, upper and lower body dressing; Partial / moderate assistance with eating and toileting hygiene. MDS showed R6 received splint or brace assistance. R6's POS (Physician Order Sheet) showed order not limited to: Apply splint to the right wrist at 7am. R arm splint due to Hx (history) distal radius fracture. Remove splint to the right wrist at 8pm. Splint may be removed for sleeping, bathing, writing. Please remove the splint daily for bathing. Splint may be removed to work with physical therapy on range of motion exercises. Splint may be removed if patient is sedentary. Please have splint in place when patient is ambulating utilizing platform weightbearing, splint in place for sleeping.R6's Care plan dated 7/23/25 showed in part: Splint or Brace Assistance. R6 has a Right arm splint due to history of distal radius fracture. Splint to be remove daily for bathing. Splint may be removed to work with physical therapy on range of motion exercises and when resident is sedentary. Splint in place when patient is ambulating utilizing platform weightbearing and when sleeping. Resident will keep splint on as scheduled. On 8/12/2025 at 11:30 AM R78 observed lying on low bed, with floor pad, alert and verbally responsive, left hand with contracture, fist closed with no device. He said not able to move left arm. Multiple observations conducted with R78 on 8/12/25 between 11:30AM to 3PM, no splint applied on R78's left arm / hand. R78's face sheet showed admission date on 05/01/2018 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side; Unspecified dementia, Essential (primary) hypertension; Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity. MDS dated [DATE] showed R78 was never or rarely understood. He needed partial / moderate assistance with eating; Dependent with oral, toileting and personal hygiene, shower / bathe self, lower body dressing; Substantial / maximal assistance with upper body dressing. MDS showed R78 received splint or brace assistance. R78's POS showed order not limited to: Apply splint to left lower arm every day and remove at hs (bedtime), as tolerated, inspect skin for any s/s of irritation R78's Care plan dated 6/6/25 showed in part: Splint or Brace assistance. R78 uses splint on Left hand due to diagnosis of left side hemiplegia to prevent further contracture, Splint is applied in the morning and taken off in the evening, skin check is done before application. R78 will keep splint on. R78 will be placed into the Restorative Splint/Brace Assistance Program. On 8/13/25 at 3:01PM V21 (Restorative Nurse, LPN / Licensed Practical Nurse) stated R6 has an order for splint on right arm due to fracture of right wrist. He said splint should be applied everyday all the time except shower and sleeping or ADL (activities of daily living) care. V21 said R78 has left hand contracture with limited range of motion on left arm. Stated resident has an order for splint on left hand and should be applied every day all the time except for ADL care. V21 said if Splint is not applied as ordered by physician it could potentially lead to contracture or further contractures.On 8/14/25 at 11:13AM V2 (Director of Nursing / DON) said splint use is assessed to ensure it is appropriate for the resident to prevent contractures / further contractures, alleviate pain, support the limb or wrist. Stated splint is supposed to be applied by restorative aide, nurse, or CNA and should be monitored for placement. V2 said splint is applied according to doctor's order. Facility's contracture prevention policy dated 11/2024 showed in part: Resident assessed at risk for contracture will have contracture prevention appliance applied as ordered, and a PROM (passive range of motion) program implemented as per physician's orders.V1 (Administrator) said facility does not have policy for splint use.

Based on observation, interview, and record review the facility failed to (a) ensure cigarette was kept safely to prevent an avoidable accident from occurring in the resident's environment for one (R55) of one resident reviewed for smoking, and (b) monitor and follow-up with a resident (R102) who went out on independent community pass for one of two records reviewed for discharge in a sample of 19. The findings include: On 8/12/2025 at 11:33 AM R55 observed sitting on the side of the bed, alert and oriented x 3, verbally responsive. Stated has been residing in the facility for over a year. R55 said he is a smoker, and he is keeping his lighter and cigarette with him. Stated he lost his lighter and could not find it. Observed one (1) cigarette stick on top of nightstand bedside table accessible to another resident. On 8/12/2025 at 11:35 AM Requested V7 (Certified Nursing Assistant / CNA) in R55's room and said R55 is a smoker and saw one (1) stick of cigarette on top of nightstand bedside table. On 8/12/2025 at 11:48 AM V17 (Security) stated she has been working in the facility for 4 years and is supervising residents during smoking time. Stated staff is keeping smoking materials including lighter and cigarettes. She said residents are not allowed to keep lighter or cigarette with them for their safety. On 8/13/25 AT 3:22 PM V12 (Psychiatric Rehabilitation Services Director / PRSD) stated residents who smoke are not supposed to share smoking materials with other resident and should be put away or stored properly inside the room, not accessible to another resident. V12 said R55 is a smoker, cigarette is not supposed to be on top of the bedside table as it may go to the wrong hand like resident who are not smoking or not safe to smoke. V12 said smoking materials should be stored properly for safety of all residents in the facility. On 8/14/25 at 11:13AM V2 (Director of Nursing / DON) stated cigarette should not be kept on top of the night stand bedside table as someone can go and pick it up. She said there are residents in the facility who wander and can pick up the cigarette who were not assessed to safely smoke or not a smoker. She said smoking materials should be kept safely to avoid accident or hazard. V2 said smoking material / cigarette should not be accessible to other residents for their safety. R55's face sheet showed admission date on 11/20/23 with diagnoses not limited to Malignant neoplasm of unspecified part of unspecified bronchus or lung; Chronic obstructive pulmonary disease, unspecified; Schizophrenia; Essential (primary) hypertension; Bipolar disorder; Solitary pulmonary nodule. MDS (Minimum Data Set) dated 7/14/25 showed R55's cognition was intact. He needed supervision or touching assistance with eating, oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing Care plan dated 4/15/25 showed in part: Psychosocial history reveals that resident is a known smoker. Facility's smoking safety policy dated12/23 showed in part: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member, and visitor. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Independent smokers who are able to hold their own smoking materials in a secure location or on their person. R102's 'Physician's Orders' include an order from 1/15/2025: Resident may have independent pass privileges. R102's 'Care Plan Activity Report' did not have a focus for R102's independent pass privileges. R102's 'Progress Notes' from 5/20/2025 do not document a planned out on pass. It also does not document when R102 left the facility. 5/20/2025 10:30 PM progress note documents in part that R102 remained out on pass. No progress notes from night shift staff about attempts to contact or locate R102 or whether R102 returned. Facility discharged R102 from the facility with last date of stay being 5/20/2025. On 8/13/2025 at 3:18 PM, V13 (Business Office Manager) stated the facility's front door is always manned by security including at nighttime. V13 stated the front door is alarmed and only security and staff know the code. V13 stated all other exits are alarmed and the residents are not supposed to use them. V13 stated residents are supposed to sign out in the book by security's post and sign back in when they return. V13 went over the facility's 'Release of Responsibility for Leave of Absence' papers from 5/20/2025 with surveyor. V13 stated they do not document a sign out or return time for R102 on 5/20/2025. On 8/13/2025 at 3:40 PM, V12 (Psychiatric Rehabilitation Services Director) stated [V12] did not know when R102 left the faciity on 5/20/2025. On 8/13/2025 at 3:48 PM, V6 (Nurse) stated working the morning shift on 5/20/2025 on R102's unit. V6 stated administering R102's morning medications but R102 was not at the facility for lunch. V6 did not know when R102 left the facility. V6 stated when a resident with an independent pass wants to leave, they are to go through the front door and sign out with security. V6 stated only staff know the front door codes. V6 stated that if a resident with an independent pass does not return to the facility, the staff are to notify the on-call supervisor. V6 stated after 24-hours, the facility is to file a missing person report. R102's progress notes do not document that evening or night staff notified the on-call supervisor. No mention of a police report. R102's May 'Resident Medication Administration Record' documents in part that R102 received the morning medications (7:00 AM – 3:00 PM) but did not receive the evening shift (3:00 PM – 11:00 PM) or night shift (11:00 PM – 7:00 AM) medications on 5/20/2025. On 8/13/2025 at 3:58 PM, V26 (Security) stated working the evening shift on 5/20/2025. V26 did not recall R102 leaving on 5/20/2025. V26 stated residents are supposed to sign out when leaving the building and sign back in but don't always do that. V26 stated that sometimes the residents say they will only go for a smoke but will leave out for independent pass. When asked what the procedures are for residents who do not sign out, V26 did not have an answer. On 8/14/2025 at 8:54 AM, V17 (Security) stated working on 5/20/2025 morning shift. V17 did not recall when R102 left the building. V17 stated residents are supposed to sign out anytime they leave the building even for a smoke break. V17 stated no resident knows the door code so only staff can let them out. When asked what the procedures are for residents who do not sign out, V17 did not have an answer. During a joint interview on 8/14/2025 at 11:37 AM, V1 (Administrator) and V2 (Director of Nursing) stated they do not know when R102 left the building on 5/20/2025. V2 stated residents are supposed to sign out of the facility before leaving the building. At 11:48 AM, V12 joined the interview and stated there were house rules and behavior contracts to maintain independent pass privileges. V12 stated rules include to sign in and out with security and to follow curfew. V12 stated if a resident refuses to sign out with security, then staff should not allow resident to leave the building. R102 signed the facility's 'House Rules and Behavior Expectations' document on 3/13/2025. It documents in part: Residents who have been granted a pass privilege must sign in and out when leaving and returning to the facility. It does not explain staff procedures when the resident fails to do so. The form also documents in part: Evening curfew is at 9:00 p.m. 7-days a week. It does not explain staff procedures when a resident fails to return on time. When asked about the facility's policies and procedure for out on pass, the facility provided 'Out on Pass' and 'Out on Pass Medication' policies. On 8/14/2025 at approximately 12:15 PM, V12 stated the policies were specific to residents going out on pass with medications for prolonged community stays. The policies did not contain procedures for out on pass privileges without medications or short leaves in the community. They did not go into procedures on what staff should do when a resident does not sign out in the book or when a resident does not return before curfew. V12 stated the facility presents the residents with the 'House Rules and Behavior Expectations' form and the Behavior Contract but the facility didn't have a general out on pass guideline or procedure for short community leaves.

Based on observation, interview, and record review, the facility failed to provide restorative toileting program to maintain bladder functioning for one (R2) resident in a total sample of 19 residents reviewed for bowel and bladder continence. Findings include:R2's face sheet documents that R2 has diagnosis not limited to major depressive disorder, bipolar disorder, asthma, seizure.R2's MDS (minimum data set) section H dated 05/02/2025, documents R2 is frequently incontinent. R2's MDS assessment dated [DATE] documents that R2 is continent of bladder functions.On 08/12/2025 at 11:15 AM, V2 stated she uses pullups and gets up to use the restroom when needed and does not receive any bladder toilet restorative program.On 08/14/2025 at 11:23 AM, V23 (Minimum Data Set Nurse) states R2 is sometimes continent to bladder. V23 stated the facility does not have a bladder toilet restorative program. V23 stated the certified nursing assistants are expected to encourage R2 to use the bathroom, and to ask for help if needed.On 08/14/2025 at 2:28 PM, V21 (Licensed Practical Nurse/ Restorative Nurse) is made aware that R2 is not in any bladder toileting restorative program. Policy titled Bowel and Bladder Policy review date of June 2024 documents To help residents establish a pattern of control of bowel and bladder functioning. An initial assessment of the resident's bowel and bladder function, mental status, and physician status will be conducted. Resident demonstrating incontinence of bowel and/or bladder or exhibiting a history of constipation and fecal impaction will have a comprehensive assessment and subsequent placement into: Incontinence toileting program.

Based on observation, interview and record review, the facility failed to ensure nebulizer mask and tubing were properly stored for one (R55) of one resident reviewed for respiratory care in a sample of 19. The findings include:On 8/12/2025 11:33 AM R55 Observed sitting on the side of the bed, alert and oriented x 3, verbally responsive. Stated has been residing in the facility for over a year. Observed nebulizer machine at bedside and R55 stated he has been using nebulization treatment periodically. Observed nebulizer mask and tubing not properly stored, dated and mixed with personal items inside the nightstand bedside drawer. On 8/12/25 at 11:38AM V5 (Licensed Practical Nurse / LPN) requested to R55's room and saw nebulizer mask and tubing inside the drawer mixed with personal items. V5 said it should be stored properly. On 8/14/25 at 11:13AM V2 (Director of Nursing / DON) stated nebulizer mask, and tubing is changed at least every 3 days and as needed, should be dated when changed to know when to discard. She said nebulizer mask and tubing should be stored properly when not in used in a clear plastic bag for infection control to prevent contamination. R55's face sheet showed admission date on 11/20/23 with diagnoses not limited to Malignant neoplasm of unspecified part of unspecified bronchus or lung; Chronic obstructive pulmonary disease; Solitary pulmonary nodule.MDS (Minimum Data Set) dated 7/14/25 showed R55's cognition was intact. He needed supervision or touching assistance with eating, oral, toileting and personal hygiene, shower / bathe self, upper and lower body dressing. R55's POS (physician order sheet) dated 8/13/25 with order not limited to: Albuterol sulfate 2.5 mg/3 mL (0.083 %) solution give 3 milliliters by nebulization route every 12 hours. Albuterol sulfate 2.5 mg/3 mL (0.083 %) solution give 3 milliliters by nebulization route every 6 hours as needed. R55's MAR (medication administration record) for the month of August 2025 showed / documented Albuterol nebulization was signed as given every 12 hours. Facility's nebulizer treatment / cleaning procedure policy dated 1/2025 showed in part: Cleaning and storage purpose to prevent contamination and / or cross contamination. Store respirator in a clean and clear storage bag.

Based on interview and record review, the facility failed to protect the residents' rights to be free from physical and verbal abuse by other residents. This failure affected 3 (R1, R3, and R5) residents out of 7 residents reviewed for resident to resident abuse. Findings include: 1. On 06/16/2025 at 11:20am, R1 stated, He (R2) hit me on the side of my head. He was high to the roof, and I told him to calm down. Then he swung his hand and he hit me on the left side of my head. I did not expect to be hit by someone when I decided to live at the facility. On 06/16/2025 at 2:10pm, (R2) stated, He (R1) came to my face and told me to shut the f**k up and I slapped him on the face. That was after breakfast. Yes, I hit somebody. I do remember. On 06/16/2025 at 11:46am, V4 (Licensed Practice Nurse) stated, He's (R2) a type of person if he wanted something, he has to have it immediately. He said he needed his remote. I told him to relax, I would ask the maintenance. He stood by the door. He was talking loudly a little. (R1) was in the dining room, he walked out of the dining room and stood in front of him (R2). And told him 'Why are you making noise, you are shouting.' And in seconds, he (R2) slapped (R1) on the right cheek. On 06/16/2025 at 12:15pm, V4 stated it is not expected of resident to be slapped by another resident. When a resident put his hand on another resident, it is considered physical abuse. On 06/18/2025 at 1:23pm, V1 (Administrator) stated the physical abuse between (R1) and (R2) was founded. The physical abuse did happen. I was informed immediately by (V4). The argument started with (R2) about his tv remote. He was persistent and kept yelling. (R1) overheard him talking loud back forth and came in close to (R2) and told (R2) to shut up and he (R2) got up and hit him (R1) on the left side of his face. R1's Face Sheet documented that R1's Diagnoses: (include but not limited to) hypertension, hemiplegia and hemiparesis, and cerebral infarction affecting the right dominant side. R1's (05/06/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact. R1's (06/03/2025) Progress note documented, in part Resident was slapped by co-peer. R2's Facesheet documented that R2's Diagnoses: (include but not limited to) hypertension, anxiety disorder, schizophrenia, and bipolar disorder. R2's (04/04/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R2's mental status as moderately impaired. R2's (06/03/2025) progress note documented, in part a co-resident came to talk to him but he slapped him. Authored by: V4 (Licensed Practice Nurse). R2's (06/03/2025) progress note documented, in part Resident states that a co-peer approached him telling him to be quiet, resident became triggered and struck co-peer. Authored by: V11 (Psychiatric Rehabilitation Services Director). R2's (06/03/2025) Petition for Involuntary/Judicial admission documented, in part Resident presents as a threat to others at this time. Resident stood up from his wheelchair and struck another resident in the face. The (06/03/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Physical Abuse. Name of person allegedly abused: (R1). On 06/03/2025 at approximately 9:45am, resident (R2) raise his hands and slapped resident (R1) on the left side of his face. The (06/06/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R1). Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). 2. On 06/16/2025 at 11:36am, R3 stated, I don't remember who. Somebody was attacking me, somebody in the dining room. Somebody pushed me at the same time. No, I don't expect somebody to push me. I would like that not to happen again. I don't remember how. I was just sitting down. On 06/18/2025 at 10:22am, R4 stated, I was warming food and watching TV on the 3rd floor day room. He (R3) was seated on one of the chairs and he (R3) said something that threw me off. I (R4) told him to leave me alone and he kept talking. I told him (R3) if he wanted to fight me and then he looked at me smugly. I went to the other side of the room, and he went charging at me, swinging his hands. I tried pushing him towards the door and the door closed. I tried to avoid his punches and I pushed him. On 06/18/2025 at 1:12pm, V1 stated I was notified by the nurse (V9-Licensed Practice Nurse) there was altercation between them (R3 and R4). I asked if there was a contact; physical contact between the residents and he said 'yes'. There was a small pinpoint scratch on (R3). The same day I sent the initial reportable. At the end of the investigation, the result is the physical abuse between (R3) and (R4) did occur. (R4) said he was in the dining room, heating up his food in the microwave. (R3) walked in the dining room. He (R3) could not tell me what happened. (R4) said he pushed him because 'he just kept on bothering me.' R3's Facesheet documented that R3's Diagnoses: (include but not limited to) extrapyramidal and movement disorder, and schizophrenia. R3's (05/17/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R3's mental status as cognitively intact. R3's (06/06/2025) progress note documented, in part resident stated he was pushed by a co resident without provocation and that he fell on his buttocks. Resident noted with a scratch at the back of his head with minimal bleeding. Authored by: V9 (Licensed Practice Nurse). R4's Facesheet documented that R4's Diagnoses: (include but not limited to) schizoaffective disorder, bipolar type, chronic pain, and restlessness and agitation. R4's (05/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R4's mental status as cognitively intact. R4's (06/11/2025) Progress note documented, in part Type: Correction. Resident stated he pushed the co resident. R4's (06/06/2025) Petition for Involuntary/Judicial admission documented, in part Resident noted to be physically aggressive to co-resident. Resident poses danger to other residents. The (06/05/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Physical Abuse. Name of person allegedly abused: (R3). On 06/06/2025 at approximately 8:45pm, resident (R4) stated he became very agitated with (R3). (R4) punched (R3). (R3) lost his balance fell backward hitting the left side of his head sustaining a superficial cut to her left side of his head. The (06/10/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R3). (R4) became very agitated with (R3) when he got very close in his personal space. (R4) stated I (R4) pushed him away from my face. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). 3. On 06/16/2025 at 2:45pm, R5 stated she (R6) was a former roommate. She was in the washroom, and I told (R7) that (R6) is always in the washroom when I needed to be there. She took a long time washing her hair in the sink every morning. She'd be there a half hour. I also added it is not exactly her fault. Then we (R5 and R7) went out in the porch to smoke. Five minutes later, she (R6) stalked out to the porch where we were siting and made a vicious verbal assault; loud and nasty verbal assault; right on my face about 2 inches off my face. She (R6) said 'you could have been in the washroom when I am not there'. She started to walk away a little and she said to me 'I'll beat your mother f*****g a**.' It was totally unprovoked and unnecessary. I was not happy about her saying that to me. I did not expect another resident to verbally assault me. On 06/16/2025 at 2:21pm, R6 stated I have a problem with her cussing and screaming. You don't get to holler at me. After the second smoke, I went to brush my teeth and she said you're always going in the bathroom. Saturday morning, I was going out to smoke. I got the feeling on how she was screaming at me. I saw her and I told her I will beat your f*****g a** up. Stop hollering at me. I am not a child. I know I should have not said what I said. But I got tired of her hollering at me all the time. I just reacted. I know it was wrong to say what I said. I was angry. On 06/18/2025 at 1:09pm, V1 stated the outcome for (R5 and R6) is allegation of verbal abuse that it did occur. (R5) said that (R6) told her 'I'll beat your mother f*****g a**.' It Did occur. Neither one of them denied it. The (06/02/2025) Email correspondence between V1 (Administrator) and the State Agency documented, in part Sent: 06/02/2025 7:16pm. Subject: Preliminary Incident Investigation Report - (R5 and R6). The (06/02/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Verbal or Mental Abuse. Name of person allegedly abused: (R5). On 06/02/2025 at approximately 5pm, (R5) approached (V1) and stated (R6) followed (R5) to the smoke patio to confront her (R5). (R6) got into (R5) face and stated I will beat the fuck out of you. The (06/06/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R5). (R6) got into (R5) face and stated I will beat the fuck out of you. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). The (18 - Nov - 16) Abuse Prevention Program Facility Procedures documented, in part Abuse is defined as the willful infliction of injury, and reasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of 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. V. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse they observe or hear about or suspect to the administrator immediately. The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually.

Based on interview and record review, the facility failed to ensure initial reportable for allegation of verbal abuse was reported within the mandated timeframe. This failure affected 1 (R5) resident reviewed for reporting of abuse in the total sample of 7 residents. Findings include: On 06/16/2025 at 2:45pm, R5 stated, She (R6) was a former roommate. She was in the washroom, and I told (R7) that (R6) is always in the washroom when I needed to be there. She took a long time washing her hair in the sink every morning. She'd be there a half hour. I also added it is not exactly her fault. Then we (R5 and R7) went out in the porch to smoke. Five minutes later, she (R6) stalked out to the porch where we were siting and made a vicious verbal assault; loud and nasty verbal assault; right on my face about 2 inches off my face. She (R6) said 'you could have been in the washroom when I am not there'. She started to walk away a little and she said to me 'I'll beat your mother f*****g a**.' It was totally unprovoked and unnecessary. I was not happy about her saying that to me. I did not expect another resident to verbally assault me. I told (V6 -Security Guard). I said to him (V6) what she (R6) told me, and he wrote it in their report. On 06/17/2025 at 9:42am, V6 (Security) stated, It was 2-3 weeks ago; I think it happened on a Saturday. I was sitting on my post; (R5) came up to me. She (R5) approached me. From her behavior she seemed worried and have anxiety that something could happen. She looked worried. Her expression, I cannot describe it, but I just can tell that she was worried. She said she was telling me in case something happened. And she told me her roommate (R6) was threatening her. She said 'I just want to let you know that she is threatening to kick me on my butt.' I called her (V1-Administrator) first; then I wrote, what she (R5) told me, in the Security Report. I informed the nurse on the first floor. I saw the nurse assessed (R5). The (05/31/2025) Daily Schedule documented that V7 (Licensed Practice Nurse) and V8 (Certified Nursing Assistant) were working on the first floor on first shift. On 06/17/2025 at 12:01pm, V7 stated I don't have any unusual event that happened on that day. He (V6) never approached me about (R5) in regard to allegation of verbal abuse. I don't have any knowledge of the allegation of abuse. Yes, 'I am going to beat the mother f****r a**' is a verbal abuse. On 06/17/2025 at 12:14pm, V8 confirmed she worked on 5/31/2025. V8 stated I don't remember unusual things that happened in the morning shift. Nobody reported to me there was an allegation of verbal abuse between them (R5 and R6). The (05/31/2025) Security Report Form documented, in part At 8:06am (R5) told me (V6) that her roommate (R6) told her I'm gonna beat your mother f*****g a**. (R5) told me that she (R6) made ferocious verbal assault towards her (R5). (R5) walked away while (R6) promised to beat her up. On 06/17/2025 at 12:28pm, V1 stated I got a call from (V6). He (V6) reported it to me with no urgency. I did not think he was reporting a verbal abuse. I did the reportable on 06/02/2025 when I got the information in real time. At this point, V1 was requested to read the security report dated 5/31/25. This surveyor also read the security report within earshot of V1 I'm gonna beat your mother f*****g a**. V1 stated that is verbal abuse. The initial reportable should have been reported on 5/31/2025. R5's Face sheet documented that R5's Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus, hypertension, and restlessness and agitation. R5's (06/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R5's mental status as cognitively intact. R6's Face sheet documented that R6's Diagnoses: (include but not limited to) restlessness and agitation, bipolar disorder, and schizophrenia. R6's (05/03/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15 indicating R6's mental status as cognitively intact. R6's (06/02/2025) progress note documented, in part resident verbally threatened her roommate. R6's (06/02/2025) Petition for Involuntary/Judicial admission documented, in part resident presents as a threat to others at this time. Resident threatened to beat up her roommate stating I will beat your motherf*****g a** (while in their face and gesturing within close range). The (06/02/2025) Email correspondence between V1 (Administrator) and the State Agency documented, in part Sent: 06/02/2025 7:16pm. Subject: Preliminary Incident Investigation Report - (R5 and R6). The (06/02/2025) Preliminary State Agency Incident Investigation Report documented, in part Person Completing The Form: (V1 - Administrator). We have received an allegation that may involve one of the following reportable offenses: (x) Verbal or Mental Abuse. Name of person allegedly abused: (R5). On 06/02/2025 at approximately 5pm, (R5) approached (V1) and stated (R6) followed (R5) to the smoke patio to confront her (R5). (R6) got into (R5) face and stated I will beat the f**k out of you. The (06/06/2025) Final Incident Investigation Report documented, in part Name of Resident Abused or Neglected: (R5). (R6) got into (R5) face and stated I will beat the fuck out of you. Based on the known facts from medical record review and interviews, the following conclusions have been determined about the allegation: (X) Abuse IS (X) FOUNDED. Person Completing the Form: V1 (Administrator). The (18 - Nov - 16) Abuse Prevention Program Facility Procedures documented, in part Abuse is defined as the willful infliction of injury, and reasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation of 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. V. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse they observe or hear about or suspect to the administrator immediately. External Reporting. 1. Initial Reporting of Allegations - When an allegation of abuse has occurred, the Department of Public Health regional Office shall be informed. Public Health shall be informed that an occurrence of potential abuse has been reported and is being investigated. This report shall be made immediately not less than 24 hours.

Based on observation, interviews and record review, the facility failed to ensure that one resident (R2) was free from abuse from her roommate (R3). This failure resulted in R2 being struck by R3 and sustaining a broken nose. Findings include: R2 is an [AGE] year old with diagnosis including but not limited to: unspecified dementia, unspecified severe protein-calorie malnutrition, age - related osteoporosis without chronic pathological fracture, chronic pain and cognitive communication deficit. R3 is a [AGE] year old with diagnosis including but not limited to: bipolar disorder, generalized anxiety disorder, major depressive disorder, type 2 diabetes mellitus, restlessness and agitation. R7 is a [AGE] year old with diagnosis including but not limited to: essential hypertension, chronic obstructive pulmonary disease with acute exacerbation, pain in left leg, major depressive disorder and anxiety disorder. R7 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. On 01/06/2025 at 10:15 AM, V1 (Administrator) said that R2 had been transferred out of the facility per family's wishes after R2 was hit by another resident. On 01/06/2025 at 12:39 PM, V2 (DON/Director of Nursing) said that R3 was no longer in the facility and that she was sent out for aggressive behavior and allegedly punching R2 in the nose. On 01/06/2025 at 3:12 PM, R7 (R2 and R3's former roommate) was observed lying in her bed. R7 was asked about the incident involving R2 and R3. On 01/06/2025 at 3:14 PM, R7 said, The night that R2 was hit, I was asleep, but I heard her (R2) yell out and when I woke up, R3 was wide awake and walking around the room. R3 would always yell at and intimidate R2. She (R3) once told R2 that she wished that she (R2) would die. R2 would cry out a lot and the nurse would come in and check on R2 then leave. R3 was abusive to everyone and the staff knew it. She (R3) would cuss at staff and was always angry and demanding. At night, R2 would talk a lot and that would set R3 off. R3 would become very upset with R2. I didn't say anything because I was afraid of R3 retaliating against me. One night, I opened my eyes and R3 was standing near my bed. R3 was very unpredictable and always targeted R2. On 01/06/2025 at 1:10 PM, V8 (CNA/Certified Nurse Assistant) said, I saw R2 at around 7:30 AM during breakfast, I went in to feed her. Her face was covered with a blanket and when I removed the blanket, she was bloody and her face was bruised. R2 had told me that the little lady hit her but did not say a name. R3 had recently moved from the first floor and was one of R2's roommates. R3 does not talk but she is a mean person. When R2 yells out, R3 yells and tells her to shut her mouth. R7 had told me that R3 was standing over her two months ago in the middle of the night. On 01/06/2025 at 1:26 PM, V9 (CNA) said that she was assigned to R2 on 12/16/24 and that the previous CNA did not mention anything about any injuries. On 01/07/2025 at 12:15 PM, V2 (DON) said that she was not aware of R3 allegedly targeting or being mean to R2 in the past and that she (V2) would expect for any possible signs of abuse to be reported. Surveyor inquired about the purpose of staff members reporting possible signs of abuse. On 01/07/2025 at 1:30 PM, V1 (Administrator) said that the purpose of the staff reporting any signs of possible abuse is to prevent the abuse from occurring. Resident statement by R2 on 12/16/24 documents, the little lady hit me. Resident statement by R7 on 12/16/24 documents, I heard her (R2) scream three times and my curtain was pulled. I did not see any individual come in my room. I didn't pull the call light because I've pulled the call light before and the nurse would come in to see and check on her (R2) and then say she's ok, so I didn't think that pulling the call light would make a difference. However last night was a different type of scream. Employee statement by V8 (CNA/Certified Nurse Assistant) on 12/16/24 documents, V8 was preparing to feed R2 and saw R2's right eye bruised and swollen; R2 said the lady hit me. Employee statement by V15 (Housekeeping Supervisor) on 12/18/24 documents the following: V15 was told by R7 that R3 physically abused R2 and that the CNA was notified; the CNA would come and check on R2, then would say that there are no bruises and would leave the room; R3 also verbally abused R2 and wished that she would die. Facility document titled Preliminary Incident Investigation Report dated 12/16/24 documents, R2 was found by staff at approximately 7:50 AM in bed with swelling, discoloration and a laceration to her left eye. Facility document titled Final Incident Investigation Report dated 12/18/24 documents the following: R2 identified as the abused; on 12/16/24, R2 was found by V8 (CNA) with laceration and visible blood on her right eye; R2 said, the little lady hit me; physical abuse was founded. Facility Census report dated 01/06/2025 excludes R2 and R3 as residents in the facility. Facility Abuse policy documents the following: Staff obligations to prevent and report abuse; Employees are required to report any incident, allegation or suspicion of potential abuse; any incidents or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation; residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation.

Based on interview and record review, the facility failed to ensure that a resident (R3) was free from physical abuse. This failure resulted in R3 sustaining a bruise and skin tear to the left arm that required a dressing twice a day and R3 being afraid at the facility. Findings include: The facility's Preliminary Incident Investigation Report to the local state agency dated 11/22/24 completed by V1 (Administrator) shows a report of physical abuse with alleged individual V11 (CNA/Certified Nursing Assistant) and R3. The facility's Completed Incident Investigation Report to the local state agency dated 11/27/24 competed by V1 documents, in part On 11/24/24 (should be 11/22/24) at approximately 11:45 am, R3's CNA (V14) was making rounds. V14 stated, I (V14) saw bleeding on the left arm. I (V14) asked what happen and R3 said the night CNA did that to me. Based on the known facts, medical record review, and interviews, the following conclusion have (sic) been determined about the allegation: Abuse-Neglect Founded. Based on statements from R3 and staff an investigation was conducted by V1, and incident noted to be founded. R3 stated that V11 (CNA) was turning him over hard. R3's Brief Interview for Mental Status (BIMS) dated 11/22/24 shows that R3 has a BIMS of 15 which indicates that R3 is cognitively intact. On 12/16/24 at 11:52 am, V3 (Licensed Practical Nurse, LPN) stated that V3 is familiar with R3 at the facility. When V3 was asked regarding the event with R3 on 11/22/24, V3 stated that V3 recalls on 11/22/24 at around 7:15 am, V14 (Certified Nursing Assistant, CNA) informed V3 that R3 wanted to see V3 regarding R3's arm. V3 stated that when she (V3) went to R3's room, V3 observed R3's left forearm with ecchymosis (bruising), red and, bleeding. V3 then stated that V3 asked R3 what happened to R3's left arm and R3 stated that the 11:00 pm - 7:00 am, CNA (who has been identified as V11 [CNA]) pulled R3's arm roughly bruising and tearing the skin to R3's left forearm. V3 explained that V3 assessed R3's left forearm and informed V2 (Director of Nursing/DON) regarding R3's left forearm injury. V3 then stated that V2 asked R3 additional questions and V3 left R3's room to inform R3's physician and family of the event. V3 further explained that R3's physician gave treatment orders for R3's bleeding left forearm injury and for an X ray of R3's left forearm. On 12/16/24 at 12:02 pm, V5 (Certified Nursing Assistant, CNA) was asked regarding the event with R3 on 11/22/24, V5 stated that V5 recalled the event with R3 on 11/22/24. V5 explained that R3 told V5 that V11 (Certified Nursing Assistant, CNA) held R3 very hardly by R3's arm and caused bruising to R3's left arm. V5 stated that V5 observed R3's left arm with bruising. V5 stated that V5 did not recall the color of R3's left arm bruising on 11/22/24. V5 stated that V5 then reported R3's concern and injury regarding R3's left arm to V3 (Licensed Practical Nurse, LPN) (R3's nurse) on 11/22/24. On 12/17/24 at 11:04 am, V17 (Registered Nurse, RN) stated that V17 is familiar with R3 at the facility. V17 then stated that R3 is alert , oriented and able to make R3's needs known at the facility. V17 stated that V17 was R3's 11:00 pm to 7:00 am nurse on 11/22/24 and that V17 recalled being phoned and questioned by V2 (Director of Nursing, DON) and asked if V11 (CNA); (R3's CNA on 11/22/24) made any reports to V17 regarding R3 during V17 shift on 11/22/24. V17 stated that V17 informed V2 that V17 was not made aware of any incidents or reports with R3 during V17's shift on 11/22/24. V17 stated that R3 slept during V17's shift on 11/22/24 and that V17 last saw R3 in bed sleeping around 5:30 am, when V17 was administering medication to R3's roommate. V17 denied witnessing any neglect, abuse, or injury to R3 at the facility. On 12/17/24 at 11:36 am, V11 (Certified Nursing Assistant, CNA) stated that V11 has worked at the facility for over 1 year and is scheduled to work at the facility on Monday's, Tuesdays, Thursdays, and every other weekend. V11 also stated that V11 recalls R3 at the facility and that V11 hasn't worked with R3 since 11/22/24. V11 stated that on 11/22/24 V11 provided incontinence care to R3 around 6:20 am and left R3's room. V11 then explained that around 6:30 am, R3 pulled the call light for V11 to come back into R3's room. V11 further explained when V11 went back into R3's room, R3 showed V11 a skin tear to R3's left inner arm, that needed to be covered up. V11 then explained that R3 stated that the skin tear to R3's left arm happened while V11 provided care to R3 around 6:20 am on 11/22/24. V11 denied causing injury to R3's left arm. When V11 was asked to describe how V11 last saw R3's left arm, V11 described R3's left arm at 6:30 am on 11/22/24 as opened with skin pulled back that looked tender, bruise and red, but not bleeding. V11 further explained that V11 informed R3 that V11 did not see the injury to R3's left arm when V11 provided care to R3 at 6:20 am. When V11 was asked when was the last time V11 provided care to R3 prior to 6:20 am and V11 stated that V11 did not provide any incontinence care to R3 prior to 6:20 am and that V11 only completed the round book to check to make sure R3 was ok and breathing well. V11 stated that V11 did not see bruising to R3's left arm until R3 pointed out R3's injury at 6:30 am. When V11 was asked if V11 reported R3's injury to R3's nurse V11 stated that R3's nurse left the first-floor unit and went to the third-floor unit prior to V11 providing care to R3 and that V11 did not report R3's injury to R3's nurse or any other nurse at the facility. V11 further explained that around 7:00 am, V11 informed V14 (CNA) for the 7:00 am to 3:00 pm CNA, that R3 needed the nurse and to let the nurse who comes in for the morning shift know. When V11 was asked regarding when V11 was scheduled to return to work at the facility V11 stated, They have not put me on the schedule yet, I am still suspended. On 12/17/24 at 1:48 pm, V14 (Certified Nursing Assistant, CNA) stated that V14 provides care to R3 daily on the 7:00 am to 3:00 pm shift at the facility. When V14 was asked regarding R3's event on 11/22/24, V14 stated that on 11/22/24 around 7:00 am, V14 began rounding for V14's 7:00 am to 3:00 pm shift on the first-floor unit at the facility when R3 stated to V14 Look at what the night CNA (referring to V11) did to my (R3) left arm. V14 stated that V14 observed R3's left arm red, bruising and with visible red blood from R3's left lower arm extending to above R3's left elbow. V14 then explained that V11 (CNA) was still in the facility and, V14 went to V11 and asked V11 if she knew what R3 was saying about R3's left arm injury. V14 further explained that V11 stated that V11 didn't know how R3's left arm injury happen and that V11 then left the facility for the day. V14 then explained that the day shift nurse V3 (Licensed Practical Nurse, LPN) arrived at the facility around 7:15 am, and V14 reported to the day shift nurse V3 that R3 had left arm bruising that R3 stated V11 (CNA) caused. On 12/17/24 at 2:04 pm, Surveyor observed R3 in R3's room, in bed, awake, alert and oriented times four. Surveyor observed R3's left arm area with pink discoloration, and the skin intact. R3 stated that a few weeks ago around 6:15 am, a night shift CNA intentionally caused an injury to R3's left arm. R3 explained that on 11/22/24 the CNA from the night shift (referring to V11) came into to R3's room to assist R3 with changing R3's incontinent brief. R3 further explained that V11 dug V11's fingers into R3's left arm to reposition R3 onto R3's right side. R3 then stated that R3's left arm began to bleed. R3 further stated that R3 told V11 that R3's arm was bleeding and asked V11 to get the nurse. However, V11 didn't. R3 stated that R3 waited until a staff member from the morning shift placed a bandage onto R3's left arm. R3 stated that R3 felt that V11 purposely injured R3's left arm because V11 would often speak meanly to R3 at the facility. R3 finally explained that V2 (Director of Nursing, DON) questioned R3 regarding the incident with R3 and V11 and informed R3 that V11 would not be allowed to work on the first floor with R3 again. When R3 was asked if R3 felt safe at the facility R3 stated, No! I (R3) am afraid that she (V11) will come back during the night from another floor and hurt me again. On 12/18/24 at 9:46 am, V2 (Director of Nursing, DON) stated V2 is familiar with R3 and that R3 is an alert and oriented times 3-4 resident at the facility. When V2 was asked regarding R3's event on 11/22/24, V2 explained that on 11/22/24 around 9:00 am, V2 recalls V3 (Licensed Practical Nurse, LPN ) informing V2 that R3 had an injury to R3's left arm that was bleeding. V2 stated that V2 then went to assess R3's left arm and observed a skin tear that was approximately 4.0 cm (centimeters) in length by 4.0 cm width, red, open skin, and slightly bleeding. V2 then stated that V2 asked R3 what happened to R3's left arm and R3 stated The nightshift CNA (referring to V11) was cleaning me (R3) up, grabbed my arm and dug into it. Then she (V11) flipped me over to change me and when I (R3) looked at my (R3) arm it was all bloody. V2 further explained that R3 stated that R3 asked V11 if she would tell the nurse and V11 said that she would. R3 then stated that V11 had been mean to R3 for a while and that R3 didn't tell anyone because R3 thought V11 was going to change. V2 then stated that V2 immediately reported R3's allegations against V11 to V1 (Administrator) and that V1 immediately started an investigation. V2 further explained that V1 and V2 phoned V11 and informed V11 of R3's statement regarding V11 injuring R3's left arm. V2 stated that when V2 initially spoke with V11, V11 stated that nothing happened to R3's left arm, then after V2 told V11 that R3 had a skin tear to R3's left arm and asked V11 if V11 knew anything regarding R3's left arm injury again, V11 was quiet and denied R3's arm was bleeding and refused to acknowledge seeing R3's left arm injury during V11's shift. V2 further explained that V11 did not acknowledge R3's left arm injury until V2 explained to V11 that V2 had spoken with V14 (CNA) who stated that he (V14) spoke with V11 regarding R3's left arm injury on 11/22/24 prior to V11 leaving the facility. V2 then stated that V11 finally acknowledged R3's left arm injury and stated I (V11) saw it, but it wasn't bleeding. I (V11) couldn't tell the nurse because the nurse was working another floor, but I told CNA (referring to V14). V2 stated after V11 changed her (V11's) story she (V11) was suspended until further investigation and then terminated by V1 (Administrator) and V2, after V1 concluded V1's investigation regarding R3's left arm injury. V2 then stated that V2 informed R3 that V11 would not be working with R3 anymore at the facility. When V2 was asked regarding what could happen if a staff grabs a residents' arm, digs into the resident's arm, and flips the resident over and V2 stated, They (referring to staff) can cause an injury, break the skin, cause a sore or an infection to the resident. Residents who have fragile skin can be harmed, possibly have psychological problems, and not feel safe. On 12/18/24 at 10:43 am, V18 (R3's physician) stated that V18 is familiar with R3. V18 explained that R3 is alert, oriented, able to make needs known, and ambulatory with the use of a cane with a history of falls. V18 explained that V18 last saw R3 a few weeks ago after R3 was sent out to the local hospital for something that happened to R3 at the facility (V18 could not recall). When V18 was asked regarding R3's incident on 11/22/24, V18 stated that V18 received a call from R3's nurse at the facility who stated that the staff was changing R3 when R3 acquired a skin tear on the arm that was superficial. V18 stated that V18 could not remember what orders were given regarding the incident. When V18 was asked regarding what could happen if a staff member digs their nail in R3's arm and flips R3 over onto R3's side and V18 stated that staff should not dig into a resident arm and flip a resident over because the staff can scratch and injure the skin. V18 then explained that R3 has fragile skin from receiving chemotherapy and staff should not be using their nails to reposition R3 or any resident because it can cause a nail mark or abrasion or injury to the resident. V18 stated, Repositioning should not be done with someone using their nails. Who is doing that? I (V18) was not informed that happened. On 12/18/24 at 11:19 am, V1 (Administrator) stated that V1 is the facility's abuse coordinator. V1 stated that V1 has been the Administrator at the facility for about one month. V1 then stated that V1 is familiar with R3 at the facility. V1 stated that V1 is alert, oriented, articulate, and able to make needs known. V1 explained on 11/22/24 V1 was called to R3's room and observed a reddish skin tear to R3's left forearm area that looked fresh and had a little blood to it. V1 explained that V1 asked R3 what happened and R3 stated that (the night shift CNA on 11/22/24) (referring to V11 (CNA)), had been treating R3 roughly for a long time and that R3 did not say anything because R3 thought It would get better. V1 further explained that R3 did not identify the CNA by name however, R3 stated that he was referring to the overnight CNA that had left the morning of 11/22/24. V1 then explained that V1 looked at the nursing schedule to identify the night shift CNA that left the morning of 11/22/24 and determine the CNA was V11. V1 further stated that V1 immediately suspended and removed V11 from schedule and notified the police. V11 then explained that the Police came to the facility, interviewed R3, observed R3's arm, gave a report number and left the facility. V1 stated that during V1's investigation, V1 found that V11 did not report R3's injury to the nurse on 11/22/24. V1 further explained that V11 stated, that V11 informed V14 (CNA) regarding R3's left arm on 11/22/24. V1 then explained that V1 suspended V11 then terminated V11 for improper reporting of abuse and resident injury. V1 stated that V11 denied ever abusing R3 and that V11 was not aware that R3 had a skin tear to R3's arm when V1 asked V11 regarding R3's left arm injury on 11/22/24. V1 stated that V11 was suspected of abusing R3 because R3 stated that V11 was the staff who injured R3's arm. When V1 was asked regarding what can happen if a staff handles a resident roughly and dig their nails into the residents skin and V1 stated, That is physical abuse. That is not tolerated by the facility. R3's progress note dated 11/22/24 at 12:59 pm, authored by V3 (Licensed Practical Nurse, LPN) documents, in part: Resident received alert and oriented at the beginning of the shift. At about 8.00 am the CNA notified the writer that the resident was found with ecchymosis in the lower left forearm. R3 said he got the bruises early in the morning when the CNA was cleaning him. The wound was cleaned with normal saline, and bacitracin was applied and properly dressed. He (R3) voiced no pain at that time and all due medication was administered and he is stable. V/S (vital signs) b/p (blood pressure) -130/69, PR (pulse rate)-75, RR (respiratory rate)-18, 02 Sat -(oxygen saturation) 97%, T (temperature)-96.9*F (Fahrenheit). R3's physician was notified with the order to carry out x-ray to rule out fracture's. The administrator and DON made aware. The resident was notified. R3's Physician Order Sheet (POS) dated 11/22/2024 shows an order for R3 to cleanse left arm with normal saline and apply bacitracin ointment and cover with dry gauze BID (twice a day) till (until) healed. R3's X-ray report dated 11/22/24 at 3:39 pm and titled Left Forearm 2V (view) documents, in part: left radius and ulna have normal ossification pattern. No fracture or dislocation reviewed. The facility's document titled Employee Report documents, in part: The above stated employee after an investigation was done allegedly caused an injury to a resident R3 and failed to report it properly as a result the employee is terminated. The facility's document dated 11/22/2024 and titled Victim Information Notice/Police Department documents, in part: Incident number JH517396: Incident: Aggravated (aff) Battery ([NAME]) Senior Citizen. Name of victim/complainant R3. The facility document dated 18 November 16 and titled Abuse Prevention Program Facility Procedure documents, in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . III Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics: . Staff obligation to prevent and report abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.

Based on observation, interview, and record review the facility failed to protect the residents' right to be free from physical abuse for 3 (R5, R2, and R3) of 4 residents reviewed for abuse. These failures resulted in R5, getting hit on the top of the head by V9 (Certified Nurse Assistant/CNA), as well as R2 and R3 engaging in a verbal and physical altercation while unsupervised that resulted in injuries (scratch wounds). This failure resulted in R5, who is cognitively impaired, as a reasonable person that would not expect to be harmed in their own home or health care facility, causing them to feel fear, anxiety, and anger. Findings include: 1. R5 is [AGE] years old, initially admitted in the facility on 5/1/2018. R5's medical diagnosis includes hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, convulsion, schizophrenia, dementia, mood disturbance, and anxiety. R5 has a BIMS (Brief Interview of Mental Status) of 0 dated 6/3/2024 that means R5 rarely or never understood. Per facility incident report involving R5 and V9 (former Certified Nursing Assistant), it documents as follows: On 8/29/2024, approximately 11:30 AM, another resident (R6) reported that she witnessed V9 smack R5 in his head. V9 denies the allegation. R5 was not able to provide statement due to impaired cognition. R7 who is R6's roommate reported that she did not directly observe the incident, but she heard R6 yell, she just hit him on the head. Per R6's written statement dated 8/29/2024, R5 entered my room and started to go towards the bathroom. I (R6) pulled the call light for CNA (certified nursing assistant) assistance. V9 entered the room and got behind the wheelchair and smacked R5 on the head. After final investigation by the facility, the incident that happened on 8/29/2024 between V9 hitting R5 on the head was substantiated. On 9/3/2024 at 1:10 PM, R5 was seen sitting in his wheelchair with his family that introduced to be his mother and his niece. R5 was not able to make conversation when asked, does not elaborate, or make complete statement within topic. On R5's right side of his head, a dent can be seen 3 to 4 inches in size. R5 was able to move around by wheeling his wheelchair. On 9/3/2024 at 1:19 PM, R6 stated that she remembers V9 came in her (R6) room, got behind the wheelchair of R5, and smacked R5 on the head. Per R6 it happened after R5 came inside the room heading to the bathroom. R6 pointed to the bathroom door about 4 to 5 feet away on the right side of R6's bed. When she (R6) pulled the call light, V9 went in and without saying a word hit R5 on the side of his head where there is a caved in area on R5's head. R6 said, Did you see R5? One side of his head has a caved in. R6 stated, Oh my! What had just happened she just smack him on the head. R7 who was R6's roommate was laying on her bed which was located on the right side of R6. R7 stated that she heard R6 saying, Oh my XXXX what had just happened she just smack him on the face. R7 stated that she was laying on the bed and heard R6 stated those words, that V9 hit R5 on the face. Per MDS (Minimum Data Set) assessment: R6 has a BIMS (Brief Interview of Mental Status) dated 6/2/2024 of 15. R7 has a BIMS (Brief Interview of Mental Status) dated 7/3/2024 of 14. Both R6 and R7 cognitions were intact. On 9/4/2024 at 9:44 AM, V9 (former Certified Nursing Assistant) stated that R5 was confused when he went inside the room of R6 and R7. V9 stated, When I get there, I said let's go. It's not like I hit him. If you see his head, do you think I will hit his head. V9 stated that she had a good relationship with R6 and R7. She (V9) does not know why they (R6 and R7) say that I hit R5. V9 was asked if there were other staff or residents that can verify that she did not hit R5. V9 stated that no one can verify her statement because it was only her (V9), R5, R6 and R7. V9 stated that she understands that she is in a bad position because R6's statement is backed up by R7. On 9/5/2024 at 9:34 AM, V2 stated that she was in the dining room feeding a resident when R6 told her that V9 hit R5. R6 told her that R5 went inside R6's room, so R6 pulled the call light. V9 went inside the room and hit R5. V9 was brought downstairs to V1 (Administrator) and was informed about the allegation of abuse and was told that V9 will be suspended pending investigation. V9 did not report to anyone about the incident and it was the same day the incident was reported to her by R6 before lunch. On 9/5/2024 at 10:03 AM, V10 (Licensed Practical Nurse) stated that she was in-charge of R5 when the incident happened. R6 reported to V2, then V2 reported to her (V10) that was when she knew about the incident. V9 did not report to her (V10) about anything related to the incident. V10 said that R5 was assessed and V1 (Administrator) was notified. Due to the result of the final investigation conducted by the facility, V9 was terminated. Facility submitted employee report documents that read, V9 was suspended on 8/29/2024 and terminated on 8/30/2024. Per facility employee report, V9 was on 90-day (PIP) performance improvement plan on 7/9/2024 due to discourteous behavior. On 9/4/2024 at 1:34 PM, V11 (Business Manager) verified employee report dated 8/29/2024 and 8/30/2024. V11 stated that it was V2 (Director of Nursing) who did the write up of V9 for discourteous behavior on 7/9/2024. On 9/4/2024 at 1:44 PM V2 (Director of Nursing) stated that on 7/9/2024 V9 was tasked to escort a resident to an appointment. That resident was in a wheelchair with shortness of breath (SOB) and has an order for oxygen as needed. V9 was informed the resident needed a wheelchair, despite being informed that the resident needed a wheelchair, V9 brought the resident to an appointment ambulating without using a wheelchair and the resident has shortness of breath. 2. R2 is [AGE] years old, initially admitted on [DATE], with medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Schizoaffective Disorder, Bipolar Type. R2's Brief Interview for Mental Status (BIMS) dated 7/17/2024 scored 15 that means R2 is cognitively intact. R3 is [AGE] years old, initially admitted on [DATE], with medical diagnosis of Major Depressive Behavior, Restlessness and Agitation, Drug Induced Movement Disorder, Schizoaffective disorder, Bipolar, Schizophrenia, Anxiety Disorder. R3's Brief Interview for Mental Status (BIMS) dated 7/4/2024 scored 13 that means R3 is cognitively intact. Final Incident Investigation Report documents that on 8/18/2024 R3 and R2 allegedly engaged in both a verbal and physical altercation while on the patio/smoking area. R3 sustained a superficial scratch to his nose which was treated immediately. R3 asked R2 for cigarette. R2 declined to provide R3 cigarette. R3 struck R2 in the face. R2 scratched R3 on the nose. This incident was substantiated that it did occur. Immediate Incident Investigation Report by V5 (Licensed Practical Nurse) documents: 8/18/2024, 1:30 PM at the facility patio. R3 sustained superficial injury to his nose. Residents written statements attach in facility's investigation are the following: R2's statement: R3 asked me for cigarettes. I (R2) told R3 she does not have cigarettes. R3 yelled at me (R2), I (R2) told R3 to stop, and chairs got tangled. R3 hit me (R2) to my head. I (R2) scratched him (R3) to his face. R3's statement: I (R3) and R2 on the 1st floor got into a verbal argument over cigarette at the patio. I (R3) accidentally got scratched on the face. R8's statement: R3 hit R2 in the head and R2 scratched R3. R9's statement: R2 was leaving the patio, R3 came out and sat by the end. R2 was trying to get by R3 to get inside the building. R2 told R3 to move and R3 would not move. Then R2 and R3 had some words. R3 hit R2 on the back of her head and smushed her face. R2 then hit R3 in the face and scratched R3's face. R2 and R3 were arguing prior to the fight. Written statements attached in facility's investigation by facility staff: V6 (Registered Nurse) documented R4 called his (V6) attention that there was an altercation outside between 2 residents. They (R2 and R3) got into verbal arguments and later led to physical aggression over cigarette. V7 (Certified Nursing Assistant) documented that R4 called his attention outside that there is altercation between R3 and R2. I (V7) and the nurse (V6) went outside immediately and asked what happened. R2 said that R3 hit her first because she refused to give R3 cigarette. All of this transpired around 1:40 PM. V5 (Licensed Practical Nurse) documents that V6 brought R3 to her. I (V5) saw him (R3) with superficial scratch to his nose. At this point R3 was bleeding. I (V5) immediately stopped the bleeding and asked R3 what happened? R3 said, himself (R3) and R2 got into a verbal argument that later led to physical aggression over a cigarette. V12 (Assistant Director of Nursing/Quality Assurance/Infection Prevention) documents R4 is not writing a statement. He does not want to get involved. On 9/3/2024 at 1:03 PM, R2 stated it happened in the patio smoking area that R3 asked for a cigarette. When I (R2) said no, R3 tried to take the cigarette in my mouth. Then R3 started swinging hitting me (R2) on the face and head. I went under R3 and scratched R3. There were no staff present during that time. R2 stated that during scheduled cigarette break it is often that no staff is around. R2 stated that both (R2 and R3) was sent out to the hospital. On 9/3/2024 at 2:01 PM, R3 when asked if he knew R2. R3 stated, I got in a fight, we had an argument and I don't want to talk about it anymore. R3 was asked if he can elaborate what happened. R3 replied, I don't want to talk about it anymore! R3 seems agitated, being asked about the incident. No more question about the incident was asked to avoid R3 becoming upset. On 9/3/2024 at 2:07 PM, R4 was asked about the incident between R2 and R3. R4 stated, I was told even if I see something, I saw nothing. R4 then stated, R3 know what he did, he knows he was wrong. What am I supposed to do seeing him keep on hitting her (R2). She (R2) did the right thing fighting him (R3) back. R4 further stated that it was not right to send R2 out to the hospital, but the rule was if one goes the other also needs to go. R4 said, I don't put up for a man beating up a woman. On 9/3/2024 at 2:15 PM, V13 (Security Staff) stated that she was not working when the incident between R2 and R3 happened because it happened on a weekend. On 9/4/2024 at 10:52 AM, V6 (Registered Nurse) stated that during the incident both her (V6) and V7 (Certified Nursing Assistant/Security) were in the building while R2 and R3 were out at the patio which is the smoking area. Then R4 called their attention that there was fighting outside. V6 stated that she went outside and saw R3 had blood on his nose. Then she (V6) went to take care of R3's bleeding nose. V6 said that she then took R3 to the 3rd Floor because R3 is a resident of that floor. She (V6) delivered R3 to V5 (Licensed Practical Nurse) to be taken care. R2 told her (V6) that R3 asked for cigarettes and R2 told R3 that she does not have any cigarettes. R2 and R3's wheelchair tangled and R3 started hitting R2, so R2 scratched R3. V6 said, She (R2) has nails, so it starts bleeding. Both R2 and R3 were sent to the hospital. V6 stated that when the incident happened there was no staff present. On 9/4/2024 at 11:10 AM, V5 (Licensed Practical Nurse/Restorative Nurse) stated that he was the nurse on the 3rd Floor taking care of R3. On the day of the incident between R2 and R3, R6 brought R3 to him on the 3rd Floor. R3 was covering his nose, it was bleeding. V5 asked R3 what happened and R3 stated that he had physical aggression with R2. V6 said, R3 has anger issue he gets upset quick. On 9/5/2024 at 10:14 AM, V8 (Social Service Director) stated that R3 had an incident in the past. R3 called her (V8) attention that in the elevator he (R3) bumped another resident. R3 told her (V8) I did not hit him. V8 stated that R3 said that after he (R3) bumped another resident that resident told R3 that he (R3) hit him. V8 stated that the problem was due to maneuvering of R3's wheelchair. V8 stated that R3 has aggressive behavior often and that is his usual mood and behavior. V8 stated that per assessment of V14, R1 needs supervised smoking. V8 said that supervised smoking means, R3 needs security to stay outside while R3 smokes. Progress notes of V8 dated 8/16/2024, document that R3 approached V8 stating, I didn't hit him! R3 was redirected not to yell and to talk to V8. V8 then reviewed R3's care plan. Per R3's care plan it documents as follows: R3 is non-compliant with safe smoking that includes begging, borrowing, stealing, selling and/or trading for smoking materials. Under behavior symptoms, R3 exhibits verbally abusive behavior towards staff as evidenced by yelling at peers and staff when he is not getting his way or the answer he wants. Intervention includes, to provide assistance when smoking in the designated area. On 9/5/2024 at 11:01 AM, V2 stated that during that time when R3 and R2 had verbal and physical aggression it was not the usual smoking time. R3 has an order to be independent out on pass. V2 was asked if staff are monitoring residents in the patio or smoking area when they are out smoking, and it is not smoking time. V2 said, Yes, but at that time no staff was present. V2 was asked would it help to prevent the incident if staff was present prior to or during R2 and R3's incident. V2 did not answer. On 9/5/2024 at 1:12 PM, V1 (Administrator) was made aware of the two (2) incidents that are abuse concerns. Abuse Prevention Program dated 10/2022, reads: Per policy, the facility affirms the right of residents to be free from abuse. The facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, or any other individuals. Abuse means any physical or mental injury upon a resident other than accidental means. Abuse is the willful infliction of injury resulting to physical harm, pain to a resident. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Under Establishing a Resident Sensitive Environment - This facility desires to prevent abuse by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive qualify management involving the following: Resident assessment: Staff will identify residents with increased vulnerability for abuse, who have needs, triggers and behaviors that may lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which may reduce the chances of abuse. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Staff Supervision: Supervisors will monitor the ability of staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situation such as insensitive handling, or impersonal care will be corrected as they occur.

Based on interview and record review, the facility failed to prevent a resident's fall from the bed to the floor, who was assessed as a two person assist for bed mobility. This failure affected 1 (R44) of 28 residents reviewed for falls. R44 was emergently transferred to the hospital with increased pain and experiences psychosocial harm, feeling scared and afraid while being turned in bed by staff. Findings include: On 5/20/24 at 11:13am, R44 stated that R44 has been in the facility for almost 2 years, and I (R44) don't walk. R44 stated, I fell out of bed about 2 months ago. I had moved to (another floor) because they needed my room as an isolation room. R44 stated that in R44's current room, R44's bed is up against the wall and that the room on the other floor (where R44 had been temporarily transferred on 2/13/24) didn't have a wall next to R44's bed, so R44's bed was open on both sides. R44 stated, (V20 Certified Nursing Assistant/CNA) was on the same (one) side and pushed me over to change me. I was holding onto the end table. When (V20) pushed my (incontinence brief), (V20) pushed it under my buttock, and I fell face first on the floor. I had bruises on my right knee and feet and my toes and elbow hurt. There was no side rail. When asked if one or two CNAs assisted R44 with turning in bed for incontinence or activities of daily living (ADL) care, R44 stated that there was one CNA, but now, a majority of the time, there's 2 people. When asked if the staff move the bed away from the wall to stand on one side (with other CNA on the other side), R44 stated, No. I roll to the side and hang onto the wall. My body hits against the wall to keep me propped up. R44 said that both CNAs stay on the one side for R44's care. R44 stated, I am not over it. I still have issues of getting too close to the side. When asked how does this make R44 feel, R44 stated, I feel afraid on the inside. I talked to my psychiatrist (V24) about it. R44 said that R44 even asked V24 if it was R44's fault that R44 fell , and V24 said, You have nothing to do with it. It's not your fault. They had one aide there. It was their mistake. R44 stated that V24 said to get it out of R44's head and to not think about it. R44 stated that R44 talked to V24 shortly after the fall happened on 2/23/24 with V2 (Director of Nursing/DON). On 5/22/24 at 9:38 am, R44 was reinterviewed and stated that it was at 8:30pm on 2/23/24 when R44 fell from the bed to the floor. When asked if R44 has expressed R44's feelings after R44's fall, R44 stated, I told (V2), and I had talked to (V24) after I had fallen. I still have a phobia to falling off the side of my bed. R44 stated, (V2) was in the room with (V24) when I said that I am scared about rolling off the bed. I told (V2) the other day too. R44 stated that before this fall on 2/23/24, I have never fallen before. When asked about a fall mat as a fall precaution, R44 stated that there was one in the room but that there was problem with the bedside table not rolling on it. R44 stated, I rely on that table. I tried it, and it wouldn't roll at all. R44 stated, since I am larger, it's harder for me to move in bed. I can't move my legs. I have so much pain. R44 stated, I can pull with my arms. They had even talked about a trapeze, but that didn't come to be. R44's Face Sheet documents, in part, diagnoses of idiopathic peripheral autonomic neuropathy; chronic obstructive pulmonary disease with (acute) exacerbation; asthma, uncomplicated; acute embolism and thrombosis of other specified deep vein of right lower extremity; pain in left leg; anxiety disorder due to known physiological condition; arthropathy; obesity; essential (primary) hypertension; heart failure, unspecified; cramp and spasm; hypoparathyroidism; localized edema; major depressive disorder; hyperlipidemia; presence of left artificial knee joint; non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin; body mass index [BMI] 34.0-34.9, adult; and bacterial pneumonia. R44's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R44 is cognitively intact. R44's bed mobility of rolling left and right is indicated as substantial/maximal assistance. R44's MDS, dated [DATE] and 4/17/24, indicate no side rails in use. R44's Care Plan, active effective date of 1/13/24, documents, in part, a focus of (R44) is at risk for falls related to impaired mobility, pain on right lower extremity, unable to stand without staff assistance, use of psychotropic medication with a goal of R44 being free from falls until next review and interventions of anticipate resident needs in relation to present ADL function and provide education on safety techniques. R44's Fall Risk Assessment, dated 1/12/24, documents, in part, a score of 10 which is a high fall risk. R44's Census Activity, documents, in part, that R44 was transferred to another room on another floor on 2/13/24. On 5/22/24 at 2:43pm, V20 (CNA) stated that R44 is alert, and (R44) is bed bound. When asked about R44's fall incident on 2/23/24, V20 stated that V20 was taking care of R44 in R44's new room on the 3:00pm to 11:00pm shift, and it was about 8:30pm. V20 stated, I (V20) was changing (R44's) (incontinence brief), cleaning (R44) on the bed. There's no bed rail. (R44's) bed was not against the wall. I turned (R44) by myself. (R44) usually holds onto the side of the bed frame with (R44's) hand on that side. I was just ready to bring (R44) back to me when I realized that (R44) fell . I hollered help. No one came. I had to come out the room. I said to (V27, Security), 'Please call the nurse (V18, Registered Nurse/RN). I need help'. V20 stated that V18 then came into R44's room, assessed R44, and then 911 emergency services were called. When asking V20 about what action in R44's care was V20 performing when R44 fell off the bed, V20 stated, I was putting (incontinence brief) on (R44). I (V20) had rolled (R44) away from me. I was behind (R44), and I pull (R44) back to put clean (incontinence brief) under (R44's) hip. I just slid it (clean incontinence brief) under hips, and R44 fall out of bed. When asked how high the bed was during R44's care on 2/23/24 at 8:30pm, V20 stated that V20 had raised to the height of R44's bed to about V20's waist for V20 to provide R44's care. When asked if R44 was in the middle of the bed when turning R44, V20 said that V20 usually makes sure that residents are in the middle but didn't with R44. V20 stated that R44 landed on the floor, and I run around the bed and look at (R44) on the floor. That's the first thing I did, run around and see (R44). Then I hollered for help. No one. Then I run out by the room door and holler to (V27) to send in (V18). V20 stated that after V18 responded, V18 informed V20 that two staff members usually turn R44 in bed. V20 stated that V20 told V18, I never had a problem with (R44) before, but (R44) was in a room with bed against the wall. This bed was open on both sides. I didn't think something like this was going to happen. Can (R44) have a bed rail? I cared for (R44) before with one person. Bed was against the wall, I did it before. When asked, how does V20 know how many staff persons it takes to assist residents with bed mobility, V20 stated, I look at their size. I had been able to do (R44) with one before, but I know now that I need two. If it's a large person, common sense tells you, you need two. When asked if V20 looks in the chart for assistance level, V20 stated yes, but couldn't tell where to this surveyor. On 2/23/24, V20 was asked if R44 needed two staff persons for assistance with turning, V20 stated, At that time, no. Not need two people. (sic) When asked if R44 moves R44's legs in bed, (V20 shaking V20's head no) and stated, (R44) does not move (R44) legs. On 5/21/24 at 2:19pm, V18 (RN) stated that R44 is alert, oriented, stays in the bed and is almost bed bound. When asked about R44's fall incident on 2/23/24, V18 stated that V18 was made aware of R44's fall when V20 (CNA) came to V18 and said that R44's on the floor. V18 stated that V18 went to the room, and R44 was laying, face down on the floor and that R44 said R44 fell when V20 was taking care of R44. When asked if V18 had performed incontinence care with R44 prior to the fall on 2/23/24, V18 stated that V18 had an admission that day. V18 stated that when R44 fell , I (V18) called 911. (R44) is very big (weight). There was one CNA (V20) on the floor. (V20) was elderly. (R44) stayed on the floor. When asked about R44's position, V18 stated that R44's bed was open on both side with no side rails, and R44's position on floor was face first. V18 stated that R44's body on the floor was parallel with the bed and was in between the wall and nightstand (end table) where there was a wall near R44's head. V18 stated that R44 was alert and said that R44 bumped R44's head on the wall. When asked if R44 complained of pain after the fall on 2/23/24 at 8:30pm, V18 stated, Yes, (R44) had pain. I gave (R44) pain meds a few hours before the fall. I gave (R44) all (R44's) meds. When asked about where R44 was complaining of pain, V18 stated, (R44) didn't talk much due to position (laying face down on floor). I just moved (R44's) head to put pillow and and use sheet to cover (R44). (R44) was naked. V18 stated that (R44) did have redness to right side of R44's face. V18 stated that V18 did not medicate R44 with any pain medication due to already giving R44's pain medication prior to R44's fall. V18 stated that when V18 gave R44 the medications before R44's fall, R44's bed was in the low position; however, when V18 went in with V20 (CNA) after the fall, (R44's) bed was high. (V20) was taking care of (R44). In R44's Progress Note, dated 2/23/24 at 9:09pm, V18 (RN) documents, in part, At 8:40pm, writer was informed by (V20, CNA) that resident fell off the bed while giving care. Writer immediately went to resident room and found (R44) on the floor facing down, initials assessment done, noted with redness on right-side of the face, no bleeding noted, voiced 5/10 on pain scale, resident states 'I hit my head on the wall'. R44's February 2024 MAR (Medication Administration Record) shows that on 2/23/24 from 3:00pm to 11:00pm, there is no documentation of Hydrocodone 5 milligram (mg)/Acetaminophen 325 mg tablet oral every 6 hours PRN (whenever needed) was noted. Facility document, titled CNA Assignment Sheet and dated 2/23/24 for 3:00pm to 11:00pm shift (on R44's new floor from transfer date of 2/13/24), documents, in part, that V18 is the nurse assigned, and V20 is the one CNA assigned to the floor. R44's emergency hospital records, dated 2/23/24, document, in part, that R44 was being changed at the nursing home and fell off of the bed. (R44) with head strike and pain to right arm, bilateral feet, and that R44's pain to right arm and bilateral ankles is exacerbated from baseline. On 5/22/24 at 10:16am, V4 (Restorative Nurse, Licensed Practical Nurse/LPN) stated that R44 was receiving bed mobility for restorative therapy because R44 had reached R44's maximum potential with transfers in skilled therapy. V22 stated that with standing, (R44) could not do it. (R44) can't with left leg. When asked about bed mobility for R44, V4 stated that it's how (R44) can maneuver left to right in bed and repositioning. V4 stated that it's done with the CNA staff and also with the restorative aide (V5). When asked what R44's bed mobility staff assistance level for turning left to right in bed is, V4 stated, Substantial maximum assist with 2 persons. It needs to be 2 persons. It's for safety purposes. (R44) has no side rails. One person is on one side of the bed and the other person is on the other side of the bed to avoid falls. When asked how this is done when one side of R44's bed is up against the wall, V4 stated that the aides will move the bed from the wall, so that one person is on one side and the other person is on the opposite side. When asked about side rails as an option for R44, V4 stated that it's our facility policy of no side rails. We don't have side rails. V4 stated, That's why at all times for R44's changes (incontinence care), it has to be 2 persons. When asked about R44's fall on 2/23/24, V4 stated, (V20) tried doing (R44's) care alone. It caused the fall. There was no other CNA on the floor. That was the problem. When this surveyor informed V4 that R44 stated R44 is utilizing the end table next to R44's bed for support when there is one CNA turning R44 in bed, V4 stated, That's not acceptable. (R44) should not be holding that. There should be someone there. The nightstand is used for (R44's) personal things. V4 stated, (R44) has pain all the time with legs causing decreased mobility in bed which is why R44 is a two person assist for bed mobility. R44's Restorative Program Notes, dated 1/15/24, documents, in part, that R44 is receiving bed mobility restorative therapy with (R44) is working towards set bed mobility goal of turning onto left side with substantial maximal assist from staff, goal ongoing and that R44 has presence of left artificial knee joint, weakness, other lack of coordination and pain in left leg, and has decreased ROM (range of motion) to BLE (bilateral lower extremity). R44's Restorative Functional Assessment, dated 1/17/24, documents, in part, that R44 was noted with decreased bed mobility skills, total to substantial maximal assist from staff was provided to resident when performing bed mobility maneuvering and repositioning and that R44 is non-ambulatory/wheelchair/bedbound. On 5/22/24 at 11:20am, V2 (DON) stated that V2 was notified by V18 (RN) on 2/23/24 about R44's fall. When asked if V2 inquired about details of the fall incident, V2 stated, I (V2) asked what happened and (V18) said that (V2) was repositioning (R44) and (R44) fell . I (V2) asked (V18) if (V20) asked (V18) for help because (R44) is a two person assist. (V18) said no. When asked about R44's fall on 2/23/24, V2 stated that (R44) had never fallen before, and that since R44 had surgery on left leg with a pin inserted, R44 cannot bend the left knee. V2 stated that R44 has received multiple skilled therapy sessions to strengthen R44's legs, but R44 has reached the maximum potential. V2 stated that R44 sees V24 (Psychiatrist) for depression. When asked if V2 was with V24 (Psychiatrist) on 3/7/24, when V24 was talking to R44 after the fall on 2/23/24, Yes, I did rounds with (V24) after the fall. (R44) said that (R44) was scared and apprehensive with (staff) turning her. I assured (R44) that we will make sure proper staff provide R44's care. When asked if V2 has spoken to R44 about still feeling scared with receiving care in bed, V2 said that V2 hasn't and will make sure that V2 supervises R44's care. V2 stated, I understand that (R44's) kind of scared but will have to overcome that gradually. V2 stated that two persons are there during care so R44 should not have that feeling of being scared. This surveyor informed V2 that R44 said that when staff turn R44 now, R44 uses the wall as a support device, and V2 stated, That should never be. That's inappropriate. It should be two persons. V2 stated, It's never appropriate to use the wall like that. It should never happen. V2 stated, (R44's) care planned for two people to assist. When asked if using two persons for turning R44 in bed is ensuring that R44 is feeling safe and not scared, V2 stated, Yes. On 5/23/24 at 4:46pm, V24 (Psychiatrist) stated that V24 sees R44 in the facility for depression and anxiety. This surveyor explained to V24 about the review of R44's fall incident on 2/23/24 in the facility. When asked if R44 and V24 had a conversation about R44's fall after it occurred, Yes. V24 stated, It was the caregiver (V20) turning (R44) too fast or positioning. I provided (R44) more comfort. I told (R44) not to feel anxious about this one caregiver (V20) and try not to generalize it to all staff. When asked if R44 stated to V24 that R44 was still feeling afraid and scared after the fall when R44 is having care rendered by staff, V24 stated, Correct. V24 stated that R44 has a fear of falling from this fall incident on 2/23/24. When asked if V24 has visited R44 since having this conversation, V24 stated that V24 couldn't recall but doesn't think so. In R44's Progress Notes, dated 3/14/23 at 9:03pm, V24 documents, in part, that R44's last date seen was 3/7/24. Facility policy (undated) titled Fall Prevention Policy documents, in part, It is the policy of (Facility) to identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury . Every resident will be evaluated for falls upon admission and subsequently thereafter when the resident's condition changes or at least quarterly. The care plan will state the goals, interventions and approaches to every resident who was identified as being at risk for falls. Staff will be trained to be alert to risk and hazards for falls in the environment. Facility policy (undated) titled Facility Policy Regarding Resident Falls documents, in part, Overview: This facility is committed to minimizing resident falls so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all resident falls is not possible, it is this facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. Facility policy (undated) titled Personal Care Services documents, in part, Policy: Each resident shall receive nursing care and supervision based on individual needs. Each resident shall show evidence of good personal hygiene. A patient care plan for each resident is developed based on the nature of the illness, treatment prescribed, long and short term goals, and other pertinent information. The nursing care plan is a personalized plan of care for individual residents. It indicates what nursing care is needed, how it can be accomplished for each resident, how the resident likes things done, what methods and approaches are most Successful; and what modifications are necessary t (to) insure (ensure) best results. Nursing care plans are available to all nursing personnel assigned to a resident. Procedure: . Incontinent residents: Incontinent residents shall have partial baths and clean linen each time the bed or clothing is soiled. Facility job description, dated May 2003 and titled Certified Nursing Assistant, documents, in part, Purpose of the Position: The primary purpose of the position is to provide your assigned residents with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisors. Duties and Responsibilities: . Nursing Care Functions: . 25. Perform ADL programming in accordance with each resident's individual care plan goal . Safety and Sanitation: . 8. Follow established safety precautions in the performance of all duties.

Based on interviews and review of records, the facility failed to protect the residents' right to be free from physical abuse by resident (R2) against another resident (R1). The facility failed to follow their abuse policy by not having preventative measures in place for a resident with a history of physical, verbal, and sexually inappropriate behavior. The facility failed to have preventative measures in residents (R1) care plan before and after a resident (R1) was physically abused. These failures led to a resident (R2) physically assaulting another resident (R1) causing multiple injuries. Findings include: Facility reportable dated 8/1/2023 between R1 and R2: Per report facility substantiated the incident of physical abuse between R1 and R2 did occur, and that due to the incident R1 sustained injuries. Per hospital records dated 8/2/2023 R1 sustained multiple bruises to the right side of her face, under her right eye, right upper arm and forearm, left shoulder, and scratches to her left forearm. R1 is [AGE] years old, initially admitted in the facility on 9/6/2022. R1's medical diagnosis includes atherosclerotic heart disease of native coronary artery. R1's cognition is intact with a brief interview of mental status (BIMS) dated 2/12/2024 with a score of 15. On 4/23/2024 at 12:40 PM, R1 was seen sitting on her bed inside her room. R1 was alert, verbally responsive, and able to express her thoughts during conversation. R1 stated that 8/1/2023 was the day when R2 hit her on her face. R1 stated that when R2 was first admitted it became clear that R2 has changes in behavior and becomes darker and darker, violent, and bullies her. R1 said that she is afraid that R2 will hurt another person in another facility. R1 said that R2 was very violent and that R2 was even physically aggressive with a social worker staff in the facility. R2 is [AGE] years old, initially admitted in the facility on 4/28/2023. R2's medical diagnosis includes psychosis, schizophrenia, restlessness, auditory hallucination (threatening to harm himself and others), and agitation. R2's cognition is intact with a brief interview of mental status (BIMS) dated 5/4/2023 with a score of 15. Per census record, R2 was discharged from the facility against medical advice on 8/18/2023. Identified Offender Report of R2 recorded the following: Armed habitual criminal, unlawful use of weapon, multiple aggravated battery, multiple domestic battery, multiple aggravated robbery, home invasion, resisting peace officer. Per R2's progress notes, R2 has multiple incidents of physical, verbal, and sexually inappropriate behavior to both staff and residents in the facility. Progress notes of R2 are as follows: On 5/2/2023, V22 (Activity Aide) documents: R2's diagnosis includes depression with psychosis, auditory hallucination, hearing voices, threatening to harm self and others, seeing dead bodies, non-compliant with medication. On 6/8/2023, V23 (Social Worker) documents: R2 yelling and angry said barely got sleep due to his roommate being loud and calling his name. 6/13/2023 R2 was horse playing with another resident, R2 was being too rough with that resident. On 6/13/2023, V19 (Registered Nurse) documents: R2 was raising voice towards staff and co-resident because of co-resident's complaint of disturbing his sleep due to female resident present in his room. On 6/15/2023, V9 (Registered Nurse) documents that R2 was under suspicion of drinking ETOH or alcoholic drinks. On 7/5/2023, V20 (Licensed Practical Nurse) documents: R2 started playing loud music at 10:30 PM and was verbally inappropriate toward staff and residents. On 7/2/2023, V19 (Registered Nurse) documents that R2 was agitated and verbally aggressive towards staff and refused to let female resident leave the room. 7/3/2023 documents: R2 was ordered by V16 (Psychiatrist/Physician) via involuntary petition due to aggressive behavior. Police intervention was needed prior to transfer to the hospital. On 7/27/2023, V9 (Registered Nurse) documents: R2 was reported to attempt to touch on another staff buttocks while the staff was getting the food cart. On 7/31/2023, V21 (Director of Nursing) documents: dietary staff reported that R2 touched her inappropriately by brushing against her. On 8/1/2023, V9 (Registered Nurse) documents that R2 was physically aggressive to R1 resulting in multiple injuries. On 8/2/2023, V8 (Licensed Practical Nurse) documents that R2 was admitted for aggressive behavior to the hospital. On 8/15/23, V9 (Registered Nurse) R2 was readmitted back to the facility. On 8/18/2023, V11 (Social Worker) documents: R2 assaulted writer (V11), hit her in the head three times, once in the ear and twice on the neck. On 4/24/2024 at 12:38 PM, V11 (Former Social Worker) stated that since the start of her employment in the facility around July 2023, R2's behavior was making her feel uncomfortable. R2 was very aggressive and violent. He (R2) punched another Social Worker (V10) very hard on his face. V11 stated when she saw R1's face after the incident that happened on 8/1/2023 it was hurt badly. V11 confirmed that R1 and R2 are in a relationship. V11 stated that there was no determination or assessment as to R1 and R2's safety in their relationship with R2's behavioral concerns. On 4/24/2023 at 1:08 PM, V10 (Former Social Worker) stated that R2 assaulted him and V11. R2 was abusive to staff members and also directed his abuse to residents. R2 targets certain residents, including R1 even before the incident on 8/1/2023 happened. V10 stated R1 and R2 were separated and that he told R2 that he was restricted to go to a specific floor. V10 did a care plan on his (R2) behavior. Abuse Prevention Program Facility Procedures dated November 18, 2016, reads: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain, or mental anguish. Under pre-admission screening of potential residents. The facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal conviction. While the background or fingerprint check, and/or Identified Offender Report and Recommendation are pending, the facility shall take steps necessary to ensure safety. Under resident assessment, as part of the resident social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendations Report into the identified offenders plan of care including the security measures listed. Abuse policy of the facility clearly instruct for facility staff to identify residents with increased vulnerability of abuse or who have behavior that might lead to conflict. R2's care plan does not address any of the incidents on R2's progress notes to address his physical, verbal, and sexually inappropriate behavior. No psychiatric notes or any medical notes by physician(s) were documented on R2's progress notes that addresses R2's inappropriate behavior. On 4/24/2024 at 2:48 PM, V1 (Nurse Consultant) was informed about R2's lack of documentation and that he wasn't seen by a psychiatrist or any physician on his progress notes. After V1 reviewed R2's electronic record, V1 stated that she cannot find any documentation. V1 stated that there should be a sit down and facility staff should work together to determine that residents are safe and that R2 needs to be seen by a psychiatric or medical doctor when initially admitted and readmitted within 72-hours after admission. V1 said, I don't know why there is no documentation that R2 was not seen by any doctor. As to R1's care plan, it does not address potential abuse prior to and actual abuse after the physical abuse incident happened on 8/1/2023. On 4/24/2024 at 11:45 AM, V7 (Social Service Director) stated that currently she is in-charge of the whole facility and all residents since she is the only social worker in the facility. V7 was asked about R1 being a victim of abuse and if there is a need for this to be care planned. V7 said, I am new to this position. I don't know that an abuse incident should be care planned for the resident that experienced abuse. For me, I will talk to the admin for best practices. V7 was asked if there is a need to determine safety of both residents for residents that are couple. V7 said, If both can give consent. I don't know if I need to check on the safety of residents that are a couple even when a resident has a record of domestic violence. Hypothetically, I don't really know the guidelines on how to protect the victim from the perpetrator. These are all new to me. V7 then stated that room changes and coordination of outside services for domestic violence are possible interventions. After request for behavioral services, policies, and procedures V7 said, I don't know what are those (sic) behavioral services that the facility offers. The facility's Behavioral Management Protocol and Guidelines for Handling Behavioral Emergencies and Reducing hospitalization dated January 2019, reads: Staff need to decide how likely a resident is to lose control by determine (sic) if there is a history of aggressive and /or unpredictable behavior. If a resident is the person making delusional (untrue) statements. If a resident behavior is illogical. The facility's Abuse Prevention Program Facility Procedures dated November 18, 2016, reads: Through the care planning process, staff will identify any problems, goals and approaches which would reduce the changes of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

Based on observation, interview and record review the facility failed to ensure the resident receives adequate supervision and assistance devices to prevent accidents in 1 (R1) of three residents (R1, R3 and R4) included in the sample. This failure resulted in R1 sustaining a closed fracture of phalanx of right fourth toe with laceration requiring 3 sutures. Findings include: R1 is a [AGE] year-old male with a diagnosis including COPD, Schizophrenia, and Parkinson's Disease. R1 has a Brief Interview for Mental Status of 11/15. R1 requires 1-person physical assistance for transfer and walking in room. R1 uses a wheelchair to ambulate. R1 wanders and has an electric monitoring device on ankle to help prevent elopement. Incident report sent to Illinois Department of Public Health shows on 6/11/23 at 6:45AM resident accidentally ran over by staff with his wheelchair, resulting in R1 sustaining a laceration to his right 4th toe, first aid rendered. Resident transferred to hospital and returned the same day. Received 3 sutures to his laceration on the 4th toe. Facility document titled Accident includes statement on 6/12/2023 6AM CNA observed bleeding from his socks and informed the nurse on duty. Nurse on duty assessed and notes with bleeding under the 4th toe, initiate first aid treatment by cleaning with saline and applied gauze and tape. Resident went out to hospital and returned with 3 sutures. Resident has a diagnosis of Parkinson's and he became restless during the night and was attempting to get out of the bed. Night CNA assisted him out of bed and he has tremors, she mistakenly hit his foot with the wheelchair. Hospital record dated 6/11/23 shows laceration of fourth toe of right foot, initial encounter. Closed fracture of phalanx of right fourth toe, initial encounter. On 8/7/23 at 11:00 AM R1 was observed in his room in bed. R1 was clean, odor free and appropriately dressed. Attempt was made to interview him. R1 could only respond, I don't know and I don't remember. R1's wheelchair did not have footrests attached to wheelchair during this interview. R1's footrests were not in his room when surveyor searched. A second attempt to interview R1 was made on 8/7/23 at 11:07 AM. R1 stated, I don't know how I cut my toe. I may have bumped it while in my wheelchair. The nurse saw it and I had to go to hospital. I am ok now. On 8/7/23 V4 (Physician) stated R1 could have gotten the cut injury by hitting his foot while in the wheelchair. It was not by being run over by the wheelchair. R1 is very restless and resistive to care. Due to his cognition, it is hard to interview him so we could not get him to tell us what happened himself. On 8/7/23 at 12PM R1 was observed in the dining room eating lunch. R1 was in wheelchair. R1 did not have footrest attached or in the immediate area for staff to use while transporting. R1 had on socks. R1's feet were in contact with the floor. On 8/7/23 at 12:05PM V2 (DON) stated R1's footrest are supposed to be attached to wheel chair. V2 stated, I don't know why they are not. I am also the restorative nurse. The CNA involved in this incident was identified as V3 (CNA). During interview with surveyor on 8/7/23 at 10:42AM V3 denied allegation she injured R1 per following interview. V3 (CNA) stated, That day I put (R1) in the chair. I pushed the chair to the nurse station. There was no injury at that time. I came back to (R1) ten minutes later and there was blood from his toe. I told the nurse. Nurse came and looked at it. She treated it. I had nothing to do with injury. I did not see the injury until I came back to him. He did not move from the location I pushed him to in front of the nurses station. On 8/8/23 at 1:33PM V6 (RN) stated, I was called to the floor at nurses station by the CNA (V3). (R1) was in his wheelchair. His foot was bleeding. There was a cut between the 4th and pinky toe. I assessed, cleaned and wrapped in gauze. I notified the physician and (R1) was sent out. That is all I remember. He did not say how he did it. The CNA did not say how it happened. On 8/7/23 at 11:58AM V2 (DON) stated, I was told that a (V3 CNA) ran over his foot during transfer. (R1) did not have any footrest on his wheelchair. I don't know why (R1) is missing footrest on his chair. I was told it was a mistake by (V3) herself. This was reported to Public Health. We re-educated (V3) on proper transfer to wheelchair and transport. I do not know why (V3) admitted to me running over (R1's) foot and then telling you she didn't. On the day he got hurt, (V3) told me he didn't have his footrest for his wheelchair. On 8/7/23 at 12:05PM V4 (CNA/ Restorative Aid) stated R1 is supposed to have his footrest attached to his wheelchair when being transported. On the day he was injured he did not have footrest attached. V4 stated, I do not know where his footrest are at this time. They are not on his chair or his room. He could easily hit his feet without the footrest in place on his wheelchair. On 8/7/23 at 12:15PM V4 (CNA/ Restorative Aid) stated, I was able to locate the footrest of (R1). Another CNA borrowed (R1's) footrest to use on another resident. The CNA never brought them back. On 8/10/23 at 10:09 AM V2 (DON) on inquiry as to whether there is a policy for staff transporting a resident in a wheelchair and the use of footrest, stated we do not have a specific policy on the use of footrests for wheelchair transfer and transport of resident. The CNAs are taught that when in school. Facility policy titled Lifting and Transferring Residents include statements: Standard: Residents are lifted and transferred safely in all instances. Policy: Residents are assessed and determinations made for lifting and transfer requirements and the procedure for each resident. All members of the nursing staff, nurses, nursing assistant are responsible for using good body mechanics, knowing the proper procedures, and properly operating assistive devices.

Based on observation , interview and record review the facility failed to visually monitor and check every two hours for a resident present in the facility who was at risk for elopement, failed to implement its missing residents and elopement policy regarding the use and response to electronic monitoring devices. This applies to 1 of 5 sampled residents (R1). As a result, on 2/25/2022 R1 a cognitive impaired resident eloped from the facility without the facility staff being aware the resident was missing. A local emergency medical service (EMS) found R1 in a snowbank which put the resident at risk for frostbite or hypothermia. This was identified as an immediate jeopardy situation which began on 02/25/2022 when R1 eloped from the facility. On 03/07/2022 the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 03/08/2022 based on the acceptable removal plan. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: 1. The following information was obtained from R1's medical record: R1 is a [AGE] year-old female who was originally admitted to the facility on [DATE]. R1 has a diagnosis including Essential hypertension , Anxiety Disorder , [CONDITION(S)] Disorder , Restlessness and Agitation. R1 had a BIMS score of 3 which indicated severe cognitive impairment. R1 speaks Lithuanian with some broken English. R1 is assessed as a high risk for elopement and has an electronic alarm safety device on the left wrist. According to R1's care plan dated 2/25/22 the following was identified: wandering (8/27/21) and elopement (8/27/21 ). A facility incident report dated 2/25/22 7:31PM states Resident noted not to be in the facility. A code green was called, and a search was conducted inside and outside of the facility and the resident was not located. Facility received a phone call from a neighboring nursing home facility, and they described a resident that fit the resident's description. The resident was transferred to a local hospital for evaluation. Facility called the hospital who identified the resident and stated the resident is being evaluated in the emergency room . An ongoing investigation will continue to follow. The first time the facility knew R1 was missing was at 4pm on 2/25/2022 after receiving a call from the neighboring nursing home. R1 On 3/1/22 11:40AM stated, I went for a walk to the park. When I was in the park I tripped and fell in the snow. I was lying in the snow. People came to help me. The ambulance came and took me to the hospital. I was cold that day. I got cold when I was in the snow. I am ok now. (This resident was able to be interviewed through broken English without interpreter). On 3/2/22 10:45AM surveyor inquired from interview of R1's physician if the elopement of R1 had the potential of serious injury. V15 (physician) 3/2/22 10:45AM stated I don't know anything about R1 as far as eloping from the facility. I do know R1 suffered no serious injury based on emergency room report. R1 is confused and could have suffered hypothermia or frostbite from laying in the snow outside. It is common sense. R1's hospital record dated 2/25/22 3:06PM documented: Patient (Pt.) arrives to the ED (emergency department) via EMS (emergency medical service) from the street. Per EMS patient is Russian/Lithuanian speaking. She was found face down on ice. Pt has an electronic monitoring bracelet on the left wrist. She is alert but unable to provide further history of where her nursing home is. She says she walked outside to go home to see her children. She denies having any pain at this time. She is feeling comfortable. No sign of trauma other than mild bruise to both knees. She denies having any pain there. Patient was covered in ice, so her body felt cold but temp reveals normal thermal in the ED. Patient is found to be [CONDITION(S)] down to 87% on room air . She says she is not on oxygen at baseline. HPI (history and previous illness) was obtained through Russian interpreter. Pt is a poor historian and unable to provide any further history. We later found patient's real ID (identification) and contacted PCP (primary care physician). He states patient is known to be non-compliant with medications and does not take any. The surveyor reviewed the local weather history on 3/2/22 from the Now Data-NOAA online Weather website. The website indicated the local outside temperature at time of R1's elopement was 29 degrees Fahrenheit. 2. V1 (Administrator) was interviewed regarding R1's elopement. V1 on 2/28/22 at 11 AM stated, on 2/25/22 it was reported to me, R1 left the building without any staff or residents knowing. R1 was later found at another facility. The other facility called to report they had one of our residents. The other facility called the hospital. R1 was transferred to hospital . R1 was readmitted to the facility on [DATE] at 3:30PM. R1 is now in bed on the second floor. V1 stated, V1 did not know how R1 got out of the facility at this time. According to the hospital report, R1 was not taken from this other facility but transferred from the local park to the emergency home. The EMS staff contacted the other facility to see if R1 was a resident, since the facility was close to the park. On 2/28/22 at 11:30AM V1(Administrator) notified surveyor stating now I know how R1 left the facility. At 11:30AM the facility camera video recordings was observed. The camera system was viewed by the surveyor in the administrator's office. The camera clock showed at 1:26 PM R1 was observed walking up the ramp leading from the back exit service door. R1 was fully clothed with a large sweater or coat on . The basement exit door could not be viewed since it was in the shadow. R1 walked up the ramp. The front facility camera showed R1 walking between the two buildings to the front of the facility. R1 headed east on the sidewalk for approximately 20 yards then continued to the street. R1 continued walking down the north side of the street east until no longer in view. No staff or residents were observed in the front of the building during this time. Cars were observed passing R1 within 3 feet while R1 was walking on the street . 3. The following staff interviews were conducted regarding R1's elopement on 2/25/2022 and interventions in place for monitoring the resident. On 2/28/22 12:53PM surveyor inquired on how R1 got out of the facility unnoticed and if facility elopement plan was followed . V2 Director of Nurse( DON ), On 2/28/22 12:53PM stated at 3PM we were in a meeting. At approximately 4PM I went to first floor office . The office manager told me that someone called from another facility to see if we were missing a resident. This resident had a wander guard. I called facility back and asked who was there . She said the person was Lithuanian speaking and had a wander guard on. I asked our staff and they said it must be R1. I called code green. We searched inside and out . We found R1 was missing. Another facility told me R1 was sent to the hospital . I can't tell you how R1 got from that other facility to the hospital . I assumed other facility called 911. I called hospital . I gave residents name and R1 was the resident at the hospital. She told me I should have social services come over and pick her up. Social services went there. You will have to ask him what happened after that . Right after the knowledge of the incident I in serviced staff to do immediate rounds to make sure residents are present when the staff come on shift at 3PM , 11pm and 7 am shift. I then created an incident report to send to IDPH. That is all I did . V3 (Social Service Director) On 2/28/22 1:13PM stated I was on third floor at time of the incident . I was attending a meeting. The office manager told me another facility called and said they might have one of our residents . This resident had a wander on . I notified the DON. She told me to go to hospital and retrieve the resident . I called the hospital . They stated the resident was being admitted . No further action took place. V1 (Administrator) On 2/28/22 1:19PM stated I got a call from V2( DON) on 5/25/22 . She reported she called code green after she received a call from another facility stating they believed that they had one of our residents . They sent her to the hospital. V2( DON ) called local emergency room . They were able to establish R1 was our resident. After knowledge of the incident, we began a head count every two hours. We initiated our investigation into the incident. The next day V2 talked to the hospital to get admitting diagnosis which was hypertension. R1 remains in the hospital. V6 (Laundry Person ) On 2/28/22 2PM via V4 (Spanish interpreter/maintenance director) stated, on 2/25/22 around 1:20PM I was in the bathroom near the basement back entrance. The back entrance door alarm went off. By the time I came out of the washroom the alarm was off. I did not see any staff at the exit. I did not see anyone in the area. I continued with my laundry duties. V6 did not confirm on interview any investigation done to see what caused the alarm and/or reported it to anyone else. In addition, V6 not able to report how the alarm was stopped before exiting the bathroom. V5 (Office Manager ) On 3/1/22 9:57AM stated around 4PM I received a call from someone from another nursing home stating she wanted to talk to administrator or DON . I told her the administrator was already gone for the day. I transferred the call to the DON. I have access to the computer system facility cameras. They are on the computer at my desk in the reception area . I wasn't monitoring the cameras since I was busy with tasks. I don't remember hearing any door alarms. The guard takes her break around 1:00PM to 1:30PM but I watch the door. I never saw R1 that day in the front entrance area. I have seen R1 come to the door wanting to leave. I then contact staff to intervene. R1 has never left the building while I have been watching the front entrance. I am aware that there is a procedure to follow when a resident elopes. V7 ( Security Person ) On 3/1/22 10:11AM stated I was at the front door at time of elopement on 2/25/22 . I check the front of facility and the patio for residents. I monitor the front door . I saw R1 on 2/25/22 in the morning. She was in the hallway at the front door and was trying to go outside . I stopped her and sent her back on the elevator to the 2nd floor. That was the only time I saw her . I never saw her in the afternoon . I don't remember the alarm going off around 1PM that day( 2/25/22) . I leave the facility at 3PM . There is another guard that takes over after 3PM. I am aware of the code green . I know the procedure . V8 ( LPN) On 3/1/22 10:30AM stated we have electronic monitoring devices for residents on the 2nd floor. There are 2 on my floor. I check to see the electronic monitoring device function every shift. I check by the red light flashing on the electronic monitoring device . These alarms go off when a resident wearing one goes to the 1st floor front door and the Basement back door. I was taking care of R1. There was no indication that anything was wrong. She ate breakfast. She was compliant with her medications . During lunch time R1 was in the day room. I saw her again after lunch in the dayroom. That was last time I saw her. There was no indication of agitation or anxiety. She went into a bedroom to sleep after lunch. There was no indication that R1 was gone. The nurse had a meeting in the basement until about 4PM . I then went home . The residents are checked every two hours. R1 was checked at 1PM and it was documented on the checklist. R1 tried to elope frequently. But she was always stopped at the front door and sent back. I am aware of code green and the procedure to follow when there is an elopement. V9 (C N A) On 3/1/22 10:42AM stated I take care of R1. R1 was needing redirection on 2/25/22. R1 gave no indication that she was trying to elope that day. R1 speaks some English and can communicate . She did not say she wanted to leave that day. The last time I saw R1 was 1PM. R1 went into her room from the dining room. I think she was sleeping in her bed at that time. I am not aware of anytime that she left the floor that day. The residents can go from floor to floor to do activities. They come back to the floor after they are done. When R1 leaves the floor I or the nurse goes with her. That day the only activity was on the 2nd floor. We didn't allow her to go to another floor that day. I am trained in elopement procedures when a code green is called . V10 (CNA) On 3/1/22 10:59AM stated work on the 2nd floor. I help take care of R1 . R1 always states I want to go out of the facility. I saw R1 on the floor until 1PM . R1 was in her room. That was the last time I saw her. Sometimes R1 goes on the elevator to the 1st floor. We have to follow her and redirect her to the 2nd floor. R1 is not supposed to leave the 2nd floor by herself . I am trained in elopement procedures . V11 (RN) On 3/1/22 11:18AM stated I was in facility 7AM to 3:30PM 2/25/22. I never saw R1 that day. I cannot remember the basement exit door alarm go off that day . We had the security guard at the front door that day. I am trained in code green . V12 ( LPN ) On 3/1/22 11:24 AM via phone stated I was on the 2nd floor on 2/25/22. I never saw R1 that day . I went to a meeting and went back to 2nd floor about 3:50PM. I was about to do rounds. Both CNAs told me everything was ok. I was notified by the office person to see if anyone was missing. I immediately thought about R1 . I asked again if they saw R1 . We went to the room and R1 was not there. V2 ( D O N ) called code green and searched . R1 was gone . V13 ( CNA) On 3/1/22 2:33PM stated on 2/25/22 I worked the 7-3PM shift and 3-11PM shift . I worked the 2nd floor 3-11PM on this day . I didn't see R1 when I came on my shift . I did rounds but I didn't see R1 . I assumed she was at activities on another floor . Around 4:00PM or 4:30PM they called a code green . We searched for R1 and didn't find her . That is all I know. R1 is able to speak a little English . R1 used to pack all her belongings like she was leaving. We had to redirect her at times. V14( Restorative Aid ) On 3/2/22 10:09AM stated on 2/25/22 R1 was on the 2nd floor at around 12:30PM . R1 was talking to a nurse. R1 can speak some English but she can't hold a conversation. I didn't see R1 after that. I don't know anything about a code green. I am familiar with the code green procedure. V16 (nurse) On 3/2/22 11:11AM stated I check the electronic monitoring device on the left wrist of R1 . The way I check is by looking at it and make sure a red light is blinking . I do not check the electronic monitoring device at the alarm to see if it is activated . On the day that R1 eloped I was not working . I do not know anything about her elopement . 4. The surveyor toured the facility on 2/28/22 and noted there are 3 resident floors and a basement. The following observations were made: The basement houses facility service areas ( laundry area, dietary area offices etc.) There is one exit to the outside that leads to a concrete ramp. This exit door has an alarm that can be heard from the door area and the 1st floor nurses station. There is an electronic monitoring device alarm on this door that can be heard at the door itself and no other location. When the door is opened the alarm triggers. A keypad entry deactivates the alarm. The alarm can be deactivated, and the door can be propped open. The first floor has an exit at the back from the stairwell. An external alarm is on this exit door with a keypad . There is an electronic monitoring device alarm on this door . The front entrance door has an electronic monitoring device alarm. There is a security person that is stationed at the front door . The receptionist desk is at the entrance in office with a glass window for visual of the area . This is a total of 4 exits from the building . The facility has security cameras located to provide visual control of the back basement entrance, the back 1st floor entrance, and the front entrance location . The facility has camera visual access from the reception computer and the administrator office on screen located on the office wall. There is one elevator in the facility that goes from the 3rd floor to the basement. The elevator does not have an alarm for the electronic monitoring device at the elevator entrance on the 3rd, 2nd, 1st, and basement floors. All alarms at the exits were observed in functioning condition. The three electronic monitoring device alarms at the exits were observed in functioning condition . The 2nd floor stairwell exit doors have an audible alarm with a keypad. Basement, 1st and 3rd floor stairwell doors do not have alarms. 5. Facility policy titled Facility Policy Regarding Missing Residents and Elopement ( Revised 8/20 ) states including Statement of Policy: It is a policy of this facility that all residents are afforded adequate supervision to meet each resident s nursing and personal care need . 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 care plans. Environmental Considerations for the Prevention of Missing Residents and Elopements. Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility: An electronic monitoring safety device or other similar personal safety device that will notify facility staff when the resident has left the building without supervision; and/or door alarms on facility exits; and/or Staff supervision, either by visual contact or by video camera , of facility exits. As part of the facility's Preventative Maintenance Program, all electronic monitoring safety devices, door alarms, and video camera shall be maintained and tested in accordance with the manufacturer s instructions. The regular testing of all electronic monitoring safety devices, door alarms and video cameras shall be documented and included as part of the Preventative Maintenance Program. At no time shall an electronic monitoring safety alarm or other door alarm be turned off , without the continual supervision of the appropriate exit. The person responsible for turning off or turning down an electronic monitoring safety alarm or a door alarm shall be responsible for resetting the alarm and ensuring that it is in working condition. Failure to reset and test exit alarms may result in serious employee disciplinary action. An electronic monitor device is considered a restraint and will be monitored and documented as such in the resident chart. Routine Procedures for the Prevention of Missing Residents and Elopements At the beginning of each nursing shift or medication pass or at each meal, charge nurses shall account for all at -risk residents under their respective charge. The electronic monitor should be checked every shift for placement and checked every week for functioning. The Procedures for the Response to Missing Residents and /or Elopements shall be implemented for any at -risk resident not accounted for. The incident shall be documented in the clinical record. Unless otherwise identified in a plan of care , all residents who are at risk for safety concerns who leave the facility property shall be accompanied and the responsible party shall sign the resident out the facility on a resident sign-out sheet . Should an alarm on one of the exits to the outside of the facility be sounded , staff shall immediately respond to and determine the cause of the alarm. After the facility staff investigates an exit alarm , and no reason can be found for the sounding of that alarm, they shall announce a specific missing resident alert Code Green over the facility s public address system . Upon the announcement of the facility's missing resident alert code, the Director of Nursing or designee shall coordinate the accounting of all residents at risk for elopement. If , after all at-risk residents are accounted for , the cause of the alarm is still indeterminate, the Director of Nursing or designee shall continue a reasonable investigation to determine the cause of the alarm. Facility policy titled Daily Rounds Policy states including Procedure: 1. The observation form must be filled out by the CNA every two hours to determine resident status, such as sleep, awake, pass, or hospital. 2. All residents must be accounted for at the beginning of each shift. 3. Any resident that is not accounted for during rounds, the charge nurse will be notified immediately . 4. Upon notification that resident is not accounted for, charge nurse and CNA will determine resident's whereabouts. 5. If resident whereabouts cannot be determined, a code green will be initiated. See elopement policy. Review of facility 2-hour check sheet shows that on 2/25/22 R1 was observed up and about at 1PM. At 3 PM R1 was not observed on the floor. Facility did not know R1 was missing until around 4PM. V1 (Administrator) On 3/3/22 at11:40AM stated staff are supposed to supervise the residents . If during the 2- hour head count they are not on floor the staff are supposed to alert other staff immediately, to see where the resident is at. If the resident can't be located a code green has to be called. V2 (DON) On 3/3/22 at 11:33AM stated staff should have notified me when R1 was not on the floor at the 3PM head count. If I am not available, then my designee should have been notified. I was not notified. Based on observation, record review and interview the surveyor confirmed the following removal plan interventions were implemented: 1. R1 was returned to the facility. R1 was reassessed, and care plan updated on 03/01/2022. R1 was monitored by nursing staff every 30 minutes for the first 24 hours, then hourly for 48 hours and monitored at least every two hours after that. The electronic monitoring device (bracelet) will be check for placement each shift by nursing. 2. The social service staff On 3/01/2022 had reassessed all residents for risk for elopement and 10 residents were identified. Also, all new admission will be assessed for risk of elopement. A book is kept at each nurses' station and at the front desk that contains the photos of all residents who are at risk of elopement. This book was updated on 3/03/2022. A head count will be done every two hours for residents. Special attention will be paid to the 10 residents who are currently identified as at risk for elopement. 3. On 2/28/2022 the facility examined all electronic monitoring devices/or equipment and checked the door alarms for functionality. This will be checked weekly, and a log kept by Maintenance. An additional electronic monitoring equipment was placed on the first floor. Staff will be continually reminded to respond to any door alarm. The nursing staff will check for the place and function of a resident's electronic monitoring bracelet each shift and document it in the MAR (medication administration record). 4. Facility's staff members in services were initiated on 02/28/2022 with appropriate facility staff. The in services were modified on 3/08/2022 after the facility was asked how the staff would know what to do if an alarm goes off. Administrative and/or outside consultant conducted the in services which included the following: the facility policy and procedures for elopement, staff member's duties and obligations with respect to elopement, review of who the residents are who are at risk for elopement and review of what to do if an alarm sounds. For those employees not attending any initial in-service those employees would not be allowed to work until they have completed an in service.

Based on observations, interviews, and records reviewed, the facility failed to follow their own policy and care plan interventions to insure the safety of 1 resident (R57) of 3 reviewed for supervision while smoking. This failure resulted in R57 suffering burn wounds to his second and third fingers on 08/19/20. Findings include: R57's medical [DIAGNOSES REDACTED]. R57's Cognitive assessment dated [DATE] scored resident as 15, cognitively intact. R55's cognitive assessment dated [DATE] is 15, cognitively intact. On 10/6/20 at 7:46 AM surveyor observed R57 with wounds to his right 2nd, and 3rd fingers, surrounding area of the wounds. Areas swollen, and red, no drainage present. Second finger has a black blister. The third finger has a wound that is missing several layers of skin has a concave shape, and starting to form a scab. R57 states that wounds came from him smoking. On 10/8/20 at 11:25AM during an interview V2, Director of Nursing, said she was told on 08/19/20 that R57 has blisters on his fingers. V2 said V15, Doctor, was notified and ordered to cleanse his fingers and apply [MEDICATION NAME] topically, until healed. V2 said R57 told her he burned himself when he was smoking. On 10/8/20 at 12:20PM, during an interview with R55, outside on the smoking deck, R55 said he has seen R57 burn his fingers a lot when he is smoking. R55 said R57 will cuss or call out and when he asks R57 what happened R57 has said he burned himself. On 10/8/20 at 12:30 PM surveyor observed V16, Certified Nursing Assistant (CNA), take's R57 to smoke. Surveyor observed R57 holding the cigarette in his right hand between his 2nd and 3rd fingers, where his wounds are. Cigarette burning close to resident's fingers. On 10/8/20 at 12:40PM during an interview R16, CNA, said R57 had a cigarette holder in the past to prevent him from burning himself. R16 states she does not know what happened to R57's cigarette holder. On 10/8/2020 at 12:45PM R57 told surveyor he only has supervision while smoking on the weekends. On 10/8/2020 at 1:24PM, during a phone interview, V7 (Security Guard) said he did not receive training on how to supervise or monitor smokers. On 10/8/2020 at 1:49PM during an interview V10, Social Service Director, said R57 should use a cigarette holder. V10 said the facility needs to order him one. V10 said she learned on 10/7/20 that R57 no longer has a cigarette holder. V10 said R57 is a supervised smoker to prevent him from burning himself. V10 said a smoking assessment is completed for residents on admission and quarterly. V10 said none of the staff assigned to supervise smokers have been trained on how to monitor or supervise smokers. V10 said she has no evidence to present that staff has been trained on smokers and assistive devices and supervision for safe smoking. V10 said she is charge of the smoking program. On 10/8/2020 at 2:00 pm V10 showed surveyors a box containing a cigarette holder and said it was found by the receptionist desk (next to exit door of designated smoking area). On 10/9/20 at 9:45AM R57 and V2, Director of Nursing, in Physical Rehab room with survey team. R57 said he burned his fingers in August and that he has burned his fingers since then. On 10/9/20 at 10:53 AM V15, Doctor, said he ordered [MEDICATION NAME] for R57, a treatment he orders for burns. V15 said he has suggested R57 use a pipe to prevent R57 from burning himself. V15 said he believes interventions like the cigarette holder could be beneficial for R57. On 10/9/20 at 11:50 during an interview V1, Administrator, said she checked with V14, Vice President, and a smoking assessment should have been completed following the report of R57'[MEDICAL CONDITION] 8/19/20. Incident Report dated 8/19/20 for R57 completed by V2 notes that Resident burnt himself. V2 documented Social Services will with follow up with the resident. Review of the facility smoking schedule provided on 10/6/20 list times and departments responsible for supervising smokers, this includes Social Services and Security. R57 is listed as a supervised smoker. R57's care plan includes a Focus for Impaired Judgement related to Alzheimer's. Interventions include maintain safe environment. R57's care plan indicates he will be supervised during smoking activities. Resident will use cigarette holder effective date 05/20/20. No intervention listed to address 8/19/20 incident report. R57's Smoking Safety Risk assessment dated [DATE] states if the person is cognitively impaired and 2 or 3 coded the person should be placed on supervision or not permitted to smoke. The code is 2 moderate problem. Potential for causing injury to self or others from smoking in unauthorized areas or careless of smoking material coded 1 minimal problem. Potential for safely following the facility safe smoking policy coded 3 severe problem. Total score is 5, place on managed smoking program. Recommendation and outcome states may not be capable of handling carrying any smoking materials. Resident is on supervised smoking at this time. On 08/18/20 Smoking Safety Risk Assessment was completed. New assessment category history of hazardous behavior (examples sustaining burns) code 1 minimal problem. Resident is currently in supervised smoking till resident displays full responsibility of being able to smoke independently as well as ensure safety measures for him and others. Resident to smoke in authorized area under staff supervision. No smoking safety risk assessment done after 8/18/20. Facility policies related to smoking were reviewed on 10/8/20 and 10/9/20. A list of Supervised Smokers was provided on 10/6/20. 6 Supervised smokers identified on the list. R57 is listed as Supervised Smoker. The Smoking Policy dated 3/2/16 states Supervised Smokers are smokers who require supervision due to unsafe smoke practices, medical [DIAGNOSES REDACTED]. The facility's undated Smoking Safety Policy states smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan of care. The facility smoking safety policy dated 4/13/10 further states: Policy Objective: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. The following behaviors and/or conditions will jeopardize and cause revocation of the person's independent privileges: Self-harmful behaviors, such as burning clothing, hands, fingers, face or lips. This category includes residents who are generally careless while smoking and may present a significant risk of fire setting.

Based on observation, interview and record review, the facility failed to ensure that wound care treatment was performed as ordered and failed to ensure that a low air loss mattress was in place as ordered which affected one resident (R62) of two residents reviewed for pressure sores in a sample of 18. This failure caused R62's stage 4 left ischium and stage 4 right ischium pressure sores to decline and increase in size. Findings include: R62's Admission Record documents an admitted to the facility as 5/23/17. R62 has a history of [MEDICAL CONDITION]. On 4/10/18, V4 (Wound Care Nurse) indicated that R62 was admitted to the facility with left ischium and right ischium pressure sores. A document dated 5/23/17 and titled, Nursing-Weekly Skin Assessment denotes that R62 was admitted to the facility with three Stage 4 pressure sores which included right and left ischial areas. R62's Census Activity Sheet indicates that from 12/6/17 through 4/11/18, R62 has remained in the facility without any admissions to a local hospital. R62's Physician order [REDACTED]. On 4/10/18 at 10:45am, V9 (LPN-Licensed Practical Nurse) confirmed that R62 was transferred out on these two dates for issues with his suprapubic catheter. V9 indicated that R62 was not admitted to the hospital and returned to the facility the same day. On 4/10/18, V4 confirmed that if R62's bilateral ischium pressure sores worsened that it was not due to a hospital stay and that the worsening would have occurred in the facility. On 4/9/18 at 11:10am, R62 indicated that R62 does not have an air mattress. R62 stated, Air mattress had a hole in it. (V17-Maintenance), the maintenance man, removed it and it's been about a month. He didn't get a chance to order it. They (facility) knows about it. R62 indicated that he'll get in bed at 7:00pm and stay in bed until 7:00-8:00am the next morning. R62 also indicated that if R62's really tired, R62 will get back into bed after lunch from 1:00pm to 3:00pm. On 4/9/18 and 4/10/18, it was noted that R62 did not have a low air loss mattress. It was noted that R62's bed frame had an air mattress machine hanging on the foot board. The machine was not connected to the mattress. R62's bed had a standard mattress. On 4/10/18, V18 (Maintenance Director) indicated that he was not aware that R62 needed a new air mattress. V18 indicated that V17 (former Maintenance Director) no longer works in the facility. On 4/10/18, V2 (DON-Director of Nursing) indicated that V17 has not worked in the facility since (MONTH) 16, (YEAR). V2 confirmed that if R62 did not have a low air loss mattress and has not had a low air mattress since (MONTH) (YEAR). From (MONTH) 16, (YEAR) to (MONTH) 10, (YEAR), R62's left ischium pressure sore declined and increased in size four times and right ischial pressure sore declined and increased in size three times. R62's left ischial declined four times as evidenced by wound measurements that were documented on R62's Weekly Skin Assessments: 1/24/18: left ischial wound measured 4.5 centimeters (cm) length (l) x 4 cm width (w) x 0.4 cm depth (d). 1/31/18: The length of the wound increased to 5 cm. (5 cm (l) x 4 cm (w) x 1 cm (d)) 2/5/18: The length of the wound increased to 5.4 cm. (5.4 cm (l) x 1 cm (w) x 0.5 (d)) 2/14/18: The width increased to 4 cm and the depth increased to 0.9 cm. (4 cm (l) x 4 cm (w) x 0.9 cm (d)) 2/21/18: The depth increased to 1 cm. (4 cm (l) x 4 cm (w) x 1 cm (d)) R62's right ischial declined three times as evidenced by the wound measurements that were documented on R62's Weekly Skin Assessments: 2/5/18: right ischial wound measured 6.1 cm (l) x 9.5 cm (w) x 0.5 cm (d). 2/14/18: The length of the wound increased to 6.9 cm and the depth of the wound increased to 0.6cm. (6.9 cm (l) x 9.5 cm (w) x 0.6 cm (d)) 2/21/18: right ischial wound measured 6.1 cm (l) x 9.5 cm (w) x 0.5 cm (d). 2/28/18: The length of the wound increased to 6.9 cm. (6.9 cm (l) x 9.5 cm (w) x 0.6 cm (d)) 3/7/18: right ischial wound measured 6.9 cm (l) x 9.5 cm (w) x 0.6 cm (d). 3/14/18: The width of the wound increased to 10 cm. (6.5 cm (l) x 10 cm (w) x 0.6 cm (d)) R62's Physician order [REDACTED]. V7's (Wound Care Doctor) Wound Care Specialist Evaluation Notes dated 1/31/18 document: Recommendation-Continue to off-load wound. On 4/10/18, V2 (DON), V4 (Wound Care Nurse), V9 (LPN), V18 (Maintenance Director) and V20 (CNA-Certified Nurse Assistant) indicated that they do not know who is responsible for ensuring that R62 had a low air loss mattress. On 3/28/18, R62's POS documented an order that read: (MONTH) use air loss mattress for Stage 4 pressure ulcer. On 4/10/18, V8 (Minimum Data Set (MDS) Coordinator) indicated that she entered the order for the mattress and indicated that it was not a new order. V8 stated, I was auditing the orders and there were no orders for the (air mattress). On 4/11/18 at 2:30pm, V7 (Wound Care Doctor) stated, Air mattress was ordered from time that I saw R62 initially. I was not aware that resident was not on an air mattress. Air mattresses are beneficial for Stage 4 wounds because air mattresses are usually off-loading. They redistribute pressure. It's better for moisture and heat control and keeps wounds from getting worse. Worsening of sores can occur if on a regular mattress. R62's Care Plan documents: Focus: SKIN INTEGRITY: Presence of Skin Breakdown. Goals: Pressure ulcer will show healing process as evidenced by decrease in size and stage of pressure sore. Interventions: Provide pressure-relieving device(s) as appropriate. Air loss mattress. On 4/10/18 at 10:09am, R62's wound treatment was rendered by V4 (Wound Care Nurse). V4 applied Calcium Alginate to R62's right and left Stage 4 ischial wounds. During the wound care, V4 stated, Both of (R62's) wounds have Calcium Alginate and Collagen. R62's POS documents an order dated 12/7/17 which reads: Treatment order: Apply Silver Alginate to left ischium Daily and cover with dry protective dressing. Apply Silver Alginate to right ischium Daily and cover with dry protective dressing. On 4/10/18, V4 confirmed that she applied the wrong treatment and medication to R62's right and left ischium pressure sores. V4 confirmed that she should have applied Silver Alginate instead of Calcium Alginate. On 4/11/18 at 3:20pm, V4 indicated that she did not notify V7 (Wound Care Doctor) regarding applying the wrong medication to R62's bilateral ischium wounds. V4 stated, I got busy and forgot. On 4/11/18, V2 (DON) indicated that if the wrong medication or treatment is done, the doctor should be notified. On 4/11/18 at 2:30pm, V7 stated, I was not aware of the nurse using wrong treatment on (R62). I just put orders in and expect the facility to follow them. Chronic wounds require Silver Alginate and Collagen. This treatment controls bacteria and biothome that accumulates on the wound. Silver Alginate prevents that. It dissipates silver ions into the wounds and prevents bacteria from forming. V7 confirmed that if treatment not done as ordered, the pressure wounds can worsen. V7 indicated that Silver Alginate and Calcium Alginate are not the same treatment. R62's Care Plan documents: Interventions: Apply local treatments as ordered by MD (Medical Doctor). A facility policy dated 1/18 and titled, Physicians Orders Policy documents: Policy: Proper channels of communication are used to ensure accurate delivery of medications and treatments to all residents. A facility policy dated (MONTH) (YEAR) and titled, Pressure Ulcer Prevention and Guidelines documents: Procedure: 4. Residents assessed for severe/high risk, the following preventative measures will be implemented upon admission: B. Preventative mattress. DRESSING CHANGE PR[NAME]EDURE: 4. Review the physician's orders [REDACTED].>