Every finding on record at Gregory Ridge Health Care Center

Based on interview and record review, the facility failed to provide adequate supervision to one sampled resident (Resident #3) who had a known history of chronic suicidal ideations and self-harm. The facility failed to implement the facility policy and physician recommendation to provide one on one (1:1) supervision to a suicidal resident and the physician recommendation to remove all items from the resident space that he/she could self-harm with. On [DATE], 1:1 monitoring was not provided by a designated staff assigned to the resident and at 12:50 P.M., the resident was found in his/her resident room with a call light cord around his/her neck which hung from the ceiling. Staff performed Cardiopulmonary Resuscitation (CPR), and the resident was transported by emergency services to the hospital. The resident was sedated, intubated, placed on a ventilator for two days and was admitted to the intensive care unit. The facility census was 96.The Administrator was notified on [DATE] at 04:25 P.M. of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility Intensive Monitoring Policy, dated [DATE], showed:-To ensure a system is in place for residents who require increased monitoring for crisis, behavioral, psychiatric issues. -Residents who require more intensive monitoring due to crisis, behavioral, psychiatric symptoms will be monitored by the facility staff. -Intensive monitoring is defined as periodic (hourly, every two hours or every shift) check by a facility staff member. -One to one monitoring was a designated employee assigned by a facility supervisor. -Residents who require intensive monitoring of one to one will have a dedicated staff member within eyesight. -Resident may require more intensive monitoring based on their crisis, behavioral, psychiatric issues.-The level of intensive monitoring shall be identified by the specific situation or resident assessment. -Residents who are showing poor impulse control including crisis, behavioral, psychiatric issues such as physical aggression and decompensation mentally or crisis may be placed on intensive monitoring or 1:1 at the discretion of the administrative staff or facility supervisor.-Residents who require intensive monitoring of 1:1 will have an assigned employee within eyesight until resident has stabilized or returned to prior level of function.-Staff were educated on the reasoning for the intensive monitoring, including trigger and interventions for that specific resident. -Once the resident had stabilized and/or returned to prior level of function, the facility's interdisciplinary team will meet to discuss determination of intensive monitoring. -The facility staff will document the intensive monitoring in the resident's electric medical record. Review of the facility Suicide Prevention Policy, dated [DATE], showed:-The resident will be assessed for suicide risk upon admission as indicated. -Risk factors include, but are not limited to:--History of prior suicide attempts or self-injurious behaviors.--Current or past psychiatric disorder(s) and/or recent change in psychiatric treatment.--Family history of suicide, suicide attempts, and/or psychiatric disorders requiring hospitalization. --Triggering events leading to despair such the loss of a relationship or loss of a loved one. --Access to objects used to commit suicide (firearms, pills, rope, razor blades, etc.)-The resident would not be left alone.-One on one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. 1. Review of Resident #3's Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care), dated [DATE], showed:-Diagnoses included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), and post-traumatic stress disorder (PTSD is a mental health condition that can develop after you experience, witness, or learn about a severe traumatic event like violence, a serious accident, or a disaster).-He/She continued to exhibit persistent treatment-resistant psychotic features characterized by delusional thinking, poor insight, and impulsive behaviors. -He/She was evaluated due to chronic suicidal ideation with a stated plan. -The resident continued to display poor impulse control and behavioral dysregulation.-Assessment of suicide threats. -Twenty four hour protective oversight needed due to severity of behaviors of mental illness symptoms. -Individual cannot be without supervision at any time.-Maintain current living arrangement due to past history of suicide ideations, medication noncompliance and inability to care for self. -History of medication and treatment noncompliance and persistent psychotic symptoms.-Individual's needs could be met in a nursing facility at that time. -Given the resident's extensive psychiatric history, persistent treatment-resistant symptoms, impaired cognition, and poor judgement, continued nursing facility placement was clinically indicated. -Presented with significant behavioral dysregulation, which required 24-hour supervision to ensure here safety and the safety of others. -Psychotherapy for crisis was appropriate given his/her recent suicidal ideation and history of emotional dysregulation. -Establish individualized supports such as behavior intervention planning and targeted staff training. Review of the resident's undated care plan showed:-Problem of impaired coping, dated [DATE].--Outcome: resident will demonstrate effective coping mechanisms [DATE].--Intervention: staff to monitor for signs and symptoms of depression [DATE].-Problem of chronic suicidal ideations with plan and history of self-harm, dated [DATE].--Outcome: resident will remain safe in skilled nursing facility [DATE].--Intervention: crisis intervention services, dated [DATE]. -Problem: history of self-harm, has attempted to choke him/herself in the past, dated [DATE].--Outcome: protective oversight provided, dated [DATE].--Interventions: review the established suicide safety plan at least as needed when anxious and encourage use of identified internal coping mechanisms when distressed, dated [DATE].-Problem: had depression related to bipolar disorder, dated [DATE].--Outcome: will remain free of signs and symptoms of distress, dated [DATE].--Interventions included monitor, document, and report any risk for harm to self, suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, impaired judgement or safety awareness, possession of weapons or objects that could be used as weapons, dated [DATE]. Review of the resident's Progress Note, dated [DATE], showed:-At approximately 4:50 P.M., the resident tied a shoelace around his/her neck and scissors were needed to cut it off. -The resident was assessed with slight redness that dissipated in less than 5 minutes around his/her neck with no further injury. -The resident indicated he/she had placed the shoestring around their neck because he/she wanted to go to the hospital. During an interview on [DATE] at 12:30 P.M., the Psychiatric Counselor said: -He/She did not see the resident on [DATE] as the resident's counselor. -He/She was onsite for another client when a facility staff member brought the resident to him/her and showed him/her the shoelace tied around the resident's neck. -He/She had gone to get the nurse, because the knot was so tight they had to get scissors to cut it off. Review of the resident's Psychiatric Nurse Practitioner (PNP) A note, dated [DATE], showed:-The resident had suicidal ideation with no plan or intent and a depressed mood related to a family member's recent passing.-The resident endorsed passive suicidal ideation without plan or intent, in the context of acute grief over his/her family member's recent death. He/She remained on 1:1 observation for safety with no homicidal ideation elicited.-The resident plan included continued 1:1 observation. Review of the resident's care plan, updated [DATE], showed:-Problem: tied shoestring around his/her neck, self-harm in attempt to go to the hospital, dated [DATE].--Outcome: resident will not harm self, dated [DATE].--Interventions: nurse assessed resident, no injury noted to neck, and telehealth ordered increased monitoring until resolution, dated [DATE]. Review of the resident's Progress Note, dated [DATE], showed he/she had seen the PNP with the following chief complaint(s): suicidal ideation with no plan or intent, depressed mood related to a family member's recent passing. Review of the resident's Progress Note, dated [DATE] at 2:21 P.M., showed: -Incident Follow up note, late entry completed by the interim Director of Nurses (DON). -The resident had been seen and assessed by the PNP. The need for increased supervision has been discontinued. The resident verbalized he/she was no longer feeling upset and had not made any other attempts to harm him/herself or had behaviors to initiate being sent to the hospital. Review of the resident's Interdisciplinary Team (IDT) Summary Note, dated [DATE], showed:-Late Entry completed by the interim DON. -On [DATE] at approximately 4:50 P.M., the resident tied a shoelace loosely around his/her neck. -The resident wanted to be sent out to the hospital. -The nurse assessed the resident with no injury noted to his/her neck. -The resident was placed on increased monitoring until resolution. Review of the resident's Behavior Note, dated [DATE] at 04:23 P.M., showed:-He/She had a code green (facility response to a behavioral event) approximately at noon. -The resident was sent to the emergency room. -Staff reported the resident had returned from being out on pass with his/her guardian and had behaviors. Review of the resident's care plan, updated [DATE], showed:-Problem: increased agitation and shaking after family visit, dated [DATE]. --Outcome: ensure protective oversight provided, dated [DATE].--Intervention: staff would intervene as necessary. Review of the resident's medical records, dated [DATE] through [DATE], showed he/she was hospitalized for a medical behavioral issue. Review of the resident's Activity Progress Note, dated [DATE] at 1:36 P.M., showed he/she scored 8.0 and was considered a moderate risk on the suicide severity rating scale. Review of the resident's Trauma Informed Care Screen, dated [DATE], showed:-The resident experienced a possible trauma in the last quarter.-There had been a sudden accidental death of someone close to the resident.-The traumatic experience was a notification by the resident's guardian that a family member had passed away. The resident was given a keepsake picture of the family member. During an interview on [DATE] at 11:49 A.M., the Temporary Manager said:-The Social Services Director was responsible for the suicidal ideations risk assessment including the trauma informed care screen. He/She was responsible for reviewing them. -The resident was identified as a moderate risk on the suicide severity scale. Review of the resident's PNP A note, dated [DATE] at 2:58 P.M., showed: -The resident had suicidal ideation with a plan and intent and homicidal ideation with attempts to choke facility staff.-The resident had currently endorsed thoughts of hurting him/herself and reported having both a plan and intent to do so. -The resident reported attempting to choke staff members, going from person to person, though he/she was unable to articulate a reason for this behavior, stating only I don't know when asked about motivation or his/her intent toward others. -Assessment: The resident endorsed active suicidal ideation with a stated plan and intent to harm him/herself. Room safety was an immediate concern given his/her expressed intent to find means to self-harm.-The facility plan should include:--Removal of any items from the resident room that could be used for self-harm.--The resident should be placed on 1:1 observation.--He/She should be reassessed the next morning to determine whether 1:1 can be discontinued. Review of the resident's care plan showed no update from PNP A's note dated [DATE]. Review of the resident's Behavior Note, dated [DATE] at 5:44 P.M., showed: -The resident was very agitated and aggressive after multiple redirects along with PRN (as needed) medication. -PNP was contacted for behaviors, 1:1 was initiated. -The resident continued to display aggressive behaviors. -PNP, DON, Administrator, and resident's guardian contacted. -Facility staff were instructed to send the resident to the hospital for evaluation and remain on 1:1 until Emergency Medical Services (EMS) arrived to ensure safety and keep from self-harm. Review of the resident's Behavior Note, dated [DATE] at 11:56 P.M., showed: -The resident returned from the hospital and was noted to be highly agitated toward other residents and staff. -The resident remained on 1:1 observation for continued monitoring of behavior, safety, and response to medication. Review of the resident's Behavior Note, dated [DATE] at 06:52 A.M., showed:-The resident became behaviorally uncontrollable. Due to the escalation in behavior, plans were to send the resident to the hospital for further evaluation. -Law enforcement arrived on-site; however, they did not permit transport at that time and instructed staff to contact the resident's guardian. -The guardian was contacted and law enforcement spoke with the resident regarding his/her behavior. After the discussion law enforcement departed.-The resident remained at the facility. -Staff would continue to monitor the resident closely and notify the provider and guardian of any further changes in condition or behavior. Review of the resident's 1:1 documentation, dated [DATE], showed he/she was on 1:1 from [DATE] at 7:00 A.M. to [DATE] at 6:00 A.M. Review of the resident's 1:1 documentation, dated [DATE], showed he/she was on 1:1 from [DATE] at 6:00 A.M. to [DATE] at 6:00 A.M. Review of the resident's Physician/Practitioner Progress Note, dated [DATE] 1:37 P.M., showed he/she had visual hallucinations (seeing devils), had aggressive behavior toward staff, continued on 1:1 observation, and had follow-up for medication management. Review of the resident's PNP A note, dated [DATE] at 1:37 P.M., showed: -The resident had visual hallucinations (seeing devils), had aggressive behavior toward staff, continued 1:1 observation, and had follow-up for medication management. -Assessment: The resident was actively experiencing visual hallucinations, described seeing devils of different shapes and sizes in the room, which he/she believed he/she created accidentally.-The resident was responding to internal stimuli during the encounter and reported associated nervousness and anxiety. -Hallucinations were visual only; the resident denied auditory hallucinations. -Facility plan was to include:--Continued current antipsychotic regimen.--Continued 1:1 observation given recent agitation and aggression.--Follow up on Monday. Review of the resident's medical record showed there was no 1:1 documentation for [DATE] after 6:00 A.M. Review of the resident's PNP B note, dated [DATE], showed a resident with schizoaffective disorder bipolar type and multiple comorbidities was seen for psychiatric follow-up with ongoing psychosis and behavioral dysregulation requiring continued 1:1 observation. Review of the resident's 1:1 documentation, dated [DATE], showed he/she was on 1:1 on [DATE] at 6:00 A.M. to [DATE] at 7:15 A.M.; and [DATE] at 7:00 P.M. to [DATE] at 6:00 A.M. Review showed no documentation 1:1 was completed [DATE] from 7:15 A.M until 7:00 P.M. Review of the resident's 1:1 documentation, dated [DATE], showed he/she was on 1:1 from [DATE] at 7:00 A.M. to 7:00 P.M.; and [DATE] at 7:30 P.M. to [DATE] at 6:00 A.M. Review showed no documentation 1:1 was completed on [DATE] from 7:00 P.M. to 7:30 P.M. Review of the resident's medical record showed there was no 1:1 documentation for [DATE] after 6:00 A.M. Review of the resident's 1:1 documentation, dated [DATE], showed he/she was on 1:1 from 6:00 A.M. to [DATE] 6:00 A.M. Review of the resident's medical record showed there was no 1:1 documentation for [DATE] after 6:00 A.M. Review of the resident's Social Services Progress Note, dated [DATE] at 1:30 P.M., showed the resident was sent to the hospital due to a suicide attempt. Review of the resident's Health Status Note, dated [DATE] at 1:53 P.M., showed:-Certified Medication Technician (CMT) B went into the resident's room and came out yelling help. -CMT B approached Licensed Practical Nurse (LPN) A and stated to come to the resident's room. -The resident hung from the celling with the call light cord wrapped around his/her neck. -LPN A and CMT B were able get the resident down to start CPR. -LPN A and staff continued CPR until EMS arrived and took over. -The resident's pulse was documented as weak. During an interview on [DATE] at 2:40 P.M., CMT B said: -He/She worked on Sunday [DATE]. -The resident had no 1:1 present, so everyone was supposed to be watching the resident. -The resident was supposed to have 1:1. -He/She last saw the resident laying on his/her bed maybe sometime 30 minutes or less before.-That morning the resident was normal, had eaten breakfast and was up walking per usual. The resident said that morning he/she was going to lie down. -Lunch arrived and the resident had not arrived in the dining room. -He/She went to the resident's room and saw the resident hanging from the back, facing away from the door. The resident's hands were up and his/her knees were on the bed. -He/She yelled for the nurse who then called a code on his/her walkie. -LPN A was the first one in the room. -LPN A yelled out to the resident and several other staff entered the room. -When a 1:1 was assigned, it was expected you stick to that one resident. -He/She had read and heard the resident had suicidal ideation before, but recently only knew about the resident trying to choke people. Review of LPN A's witness statement, dated [DATE], showed he/she informed the Registered Nurse (RN) supervisor there was a staffing concern on the unit and there was not a 1:1 assigned to the resident. During an interview on [DATE] at 9:30 P.M., LPN A said: -On [DATE], he/she noticed there was no 1:1 assigned to the resident and he/she told the RN Supervisor. -There was nobody delegated to the resident for 1:1, so all the staff on the unit were to take turns watching the resident until someone came, but no one came. -Before lunch he/she had seen the resident lying in bed, maybe 10 minutes before CMT B yelled for him/her to come to the resident's room. -The resident's call light was wrapped around his/her neck and the call light hung from the rod in the ceiling. -The resident was facing towards the door, arms were hanging down, eyes were open with no eye contact. -The resident was kinda on the bed, off the bed dangling. -The resident did not respond when he/she walked into the room. -CMT C, loosened the cord around the resident's neck and they lowered the resident to the floor to start CPR.-He/She verified the resident had no pulse, no spontaneous respirations and began CPR. -The resident made a gurgling sound once CPR was started. -When EMS arrived, the resident had a pulse. -The resident had not acted unusual that morning, except the resident was giving people hugs. During an interview on [DATE] at 12:13 P.M., CMT C said:-He/She responded to the code and saw the resident hanging from the ceiling with CNA A trying to hold the resident up. -He/She got on the bed and helped pull the resident up to loosen the call light that was around the resident's neck. -The nurse went to get the crash cart and assisted with CPR. -There was no 1:1 assigned to the resident that day. During an interview on [DATE] at 12:50 P.M., CNA A said: -The resident had a 1:1 the day before. -On [DATE] there were 3 residents who were supposed to have 1:1 assignments and he/she was assigned to another resident 1:1. -The other 1:1 staff person said the relief person was not there yet and they all needed to watch the resident while they waited for the staff person to get there. -He/She saw the resident at 10:00 A.M. when several residents had gone outside. -About 11:00 A.M., the resident was giving hugs to the staff and other residents. -He/She heard the code and walked into the resident room. He/She saw the resident hanging from the ceiling rail by his/her call light cord with his/her head to the right side, arms down and feet dangling. -He/She called the Administrator while others were making calls, getting the resident down and starting CPR. -He/She knew the resident was supposed to be on a 1:1 and was told the staff person just had not come in yet. -The expectation for 1:1 assignment meant you were supposed to be within arm's reach from the resident at all times. During an interview on [DATE] at 1:36 P.M., CNA B said: -Nobody was on 1:1 with the resident, the nurse was asked who was going to do 1:1 and the nurse told the RN Supervisor. -At the time the code was called he/she was in the dining room getting ready for lunch. The last time he/she saw the resident was earlier in the day and the resident was sleeping. -He/She responded and saw the resident hanging, limp with the cord around his/her neck. The resident was facing towards the window. The resident's feet and legs and arms were dangling freely. -The expectation for 1:1 supervision was to stay with the resident and go everywhere they go, arm's length of the resident was the rule. -The resident was supposed to be on 1:1 and everyone knew it. -The night shift 1:1 left without having a relief and should have known you cannot leave without relief. Review of the RN Supervisor witness statement, dated [DATE], showed: -He/She was on the medical unit when the code was called and responded to the resident's locked behavioral unit. -He/She saw the resident hanging from the ceiling by his/her call light cord.-While staff were getting the resident down he/she called 911. -When EMS arrived and had taken over CPR, the resident had a pulse. During an interview on [DATE] at 2:23 P.M. the RN Supervisor said: -He/She responded to the code on the unit and found the nurse and several aides working on getting the resident down. -He/She called EMS and went to get the crash cart. -When he/she arrived back with the crash cart, staff had started compressions. -Upon arrival that day there was no staffing sheet posted. -He/She denied being made aware of the 1:1 not showing up and nobody had told him/her. -One on one expectation was monitoring the resident within arm's length distance to keep them safe at all times. Review of the resident's Social Services Progress Note, dated [DATE] at 1:53 P.M., showed the guardian had been notified the resident was admitted to the hospital. The guardian was on the way to the hospital. Review of the resident's Health Status Note, dated [DATE] at 3:03 P.M., showed:-LATE ENTRY: The hospital was called for a status update. The resident remained in the intensive care unit (ICU) and was intubated (tube in airway). The resident Glascow Coma Scale (GCS-measurement tool to determine a patient consciousness) was severely lacking consciousness with a score having improved from 4 to 7. -The resident was unable to be extubated (removal of the tube from the air way) at this time per the hospital nurse due to agitation. -The hospital nurse reported the resident would have a magnetic resonance imaging (MRI) in a few days and currently had an feeding tube in place. During an interview on [DATE] at 8:22 A.M., Hospital Care Manager A said: -The resident had a telepsych evaluation on [DATE] and was discharged to inpatient psychiatric care on [DATE] late in the day. -The resident's MRI showed no acute changes. -He/She had been the resident's case manager in the past. The resident was very expressive before and did have extreme withdrawal. This hospital stay the resident did not present with hyper-activity as before.-The resident did not recall the ICU stay and had no recollection of the suicide attempt. -The resident did not understand the consequences of his/her actions when attempting suicide. -The facility should have monitored the resident and the items in his/her room. During an interview on [DATE] at 2:27 P.M., the interim DON said:-The providers put in their own orders. -He/She did not double check the order for 1:1 for the resident after the provider visit. -The schedule was done on paper, typed, printed and posted delegating the 1:1 assignment for each day. -The scheduling coordinator hadn't left a copy of the schedule to post. -The resident was not usually on 1:1 and since it was a new thing the staff did not realize it was needed. During an interview on [DATE] at 2:33 P.M., PNP A said: -He/She expected the resident to have 1:1 supervision and that facility staff would be within arm's reach at all times. -The resident had indicated self-harm, was at risk previously and that was why he/she ordered the 1:1. -Had the resident been assigned a 1:1 the outcome may have been different for the resident.-Risk assessments should be completed thoroughly. The suicide safety plan was a 1:1. -He/She had verbally instructed staff. -He/She had told staff about the environmental factors to maintain safety and requested all items be removed in July the resident could harm him/herself. -He/She had seen the resident several times in July and on [DATE] and [DATE]. During an interview on [DATE] at 1:18 P.M., the Scheduling Coordinator said: -He/She was responsible for scheduling. -He/She placed the 1:1 assignment for facility staff on the schedule with the resident's name. The assignments were posted and he/she kept a copy. -There was a rotation of staff for the 1:1 assignment. -Staff on Sundays sign up for their election for assignment. -He/She assigned a nurse and CMT for each unit. -There was plenty of staff to assign for the 1:1 the date of incident.-He/She had forgotten to post the 1:1 assignment. -CMT A was assigned 1:1 for the resident on [DATE]. CMT A knew he/she was supposed to work on Sunday, but did not come to work on [DATE]. -The staff should have contacted the DON or the Scheduling Coordinator. During an interview on [DATE] at 2:00 P.M., the Administrator said:-The staff failed to ensure a 1:1 was in place for the resident when it was ordered. -The charge nurse should have recognized there was no 1:1 in place and assigned someone to 1:1 and/or notify administrative staff. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview, and record review, the facility failed to provide a safe environment for residents, staff and the public by ensuring commercial cooking equipment was maintained in safe operating condition to reduce the chance of fire, in accordance with State of Missouri rules and federal regulations. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 96 residents with a total licensed capacity of 116 residents at the time of the investigation. The Administrator was notified on 7/8/26 of the past noncompliance which began on 7/2/26. The facility immediately completed education to ensure commercial cooking equipment was maintained and in safe operating condition for all dietary staff. The deficiency was corrected on 7/3/26. 1. Review of the Missouri Fire Report form MO580-2782, dated 7/3/26 and submitted by the Administrator, showed:-A cook was frying something on the stove in their kitchen, grease splashed out into the stove, and the grease catch pan underneath the burners caught fire on 7/2/26 around 11:40 A.M., and another dietary staff member grabbed the Class K extinguisher (K extinguishers offer improved fire control for cooking fires by minimizing the splash hazard, forming a soapy foam on the surface of the hot cooking oil, holding in the vapors and steam, and smothering the fire) to extinguish the fire.-Under Circumstances That May Have Prevented the Fire it read, Cleaning Stove. Review of the Fire Prevention and Use of Fire Extinguisher Policy, last reviewed 11/6/23 and provided by the Assistant Administrator, showed:-Under Section I. Fire Prevention, at Point 2. it read, Keep all areas clean and free of non-essential combustible material.--At Point 3. it read, Recognize the hazards of essential combustible and flammable materials, i.e., gases, chemicals, greases, etc. During interviews on 7/8/26 between 11:45 A.M. and 12:57 P.M. the Assistant Administrator/Dietary Manager said:-It was not the food on the stove that caught fire, but a buildup of grease on the tray underneath.-They now had an itemized cleaning schedule from that date on.-They had schedules done before, but the previous Dietary Manager took all documents and binders, so they started new ones. During interviews on 7/8/26 between 11:45 A.M. and 12:57 P.M. the Day [NAME] said it was the grease drip tray under the burners that started the fire on 7/2/26.

Based on observation, interview, and record review, the facility failed to prevent resident-to-resident physical abuse for four sampled residents (resident #3, #5, #10, and #11) out of seven sampled residents. On 6/10/26 Resident #6 hit Resident #5 which caused the resident to land on the floor by the elevator. Resident #6 repeatedly hit Resident #5 in the head and stomped on his/her arm. Resident #5 was sent to the hospital for evaluation and remained afraid of Resident #6. On 6/13/26 Resident #3 lunged at Resident #4 and Resident #4 hit Resident #3. Resident #4 picked up Resident #3 and slammed Resident #3 to the floor and continued to hit and kick Resident #3 in the abdomen, chest and hand. Resident #3 had bruising on his/her abdomen and left hand which caused Resident #3 to be upset and angry. On 6/19/26 Resident #11 slapped/backhanded Resident #10 on the right side of his/her face. Resident #10 then struck Resident #11 in the face three times and Resident #11 fell on the floor. Resident #10 then struck Resident #11 three more times in the face which resulted in Resident #11 having a swollen and bruised eye. The facility census was 101 residents. Review of the facility Abuse and Neglect Policy, dated 6/12/24, showed:-Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish.-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.-Physical abuse is purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner.-Physical abuse also included, but is not limited to, hitting, slapping, punching, biting, and kicking. 1. Review of Resident #6's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizophrenia.-Post-traumatic stress disorder (PTSD), (a mental health condition triggered by experiencing or witnessing a life-threatening or deeply traumatic event).-Obsessive-compulsive disorder (a mental health disorder characterized by unwanted, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) performed to reduce anxiety).-Mild intellectual disability (a disorder characterized by mild limitations in intellectual functioning and adaptive behavior that affect conceptual, social, and practical skills).-Anxiety disorder.- Major depressive disorder (a mood disorder characterized by persistent feelings of sadness, loss of interest, and impaired daily functioning). Review of the resident's Care Plan report, dated 2/12/26, showed:-He/She had manifestations of behaviors including ineffective coping skills. Interventions included positive feedback for good behaviors, addressing root causes of changes in behavior or mood.-He/She had a history of intellectual disability and inability to connect actions and consequences. Interventions included making sure his/her environment was safe, providing with diversional activities, limiting changes to routines, and using a calm and gentle approach.-He/She had potential for verbal aggression. Interventions included de-escalation by removing him/her to a quiet environment and medications.-He/She had a history of PTSD which could flare up without any known trigger, and cause reactivity including aggressiveness and self-destructive behavior. Intervention was counseling services when needed. Review of Resident #6's MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #5's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizoaffective disorder (a mental health disorder characterized by symptoms of schizophrenia, such as hallucinations or delusions, occurring along with mood disorder symptoms, including depression or mania).-Schizophrenia (a chronic mental health disorder characterized by disturbances in thought processes, perception, emotions, and behavior, often including hallucinations, delusions, or disorganized thinking).-Anxiety disorder (a mental health disorder characterized by excessive fear, worry, or anxiety that interferes with daily functioning).-Impulse disorder (a mental health disorder characterized by difficulty resisting urges or impulses that may be harmful to oneself or others.-Paranoid schizophrenia (a form of schizophrenia characterized primarily by delusions of persecution or grandeur and auditory hallucinations, while cognitive function and emotional responsiveness are relatively preserved). Review of Resident #5's Quarterly Minimum data set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 5/27/26, showed he/she was cognitively intact. Review of the facility's Admin/Registered Nurse Investigation (RNI), dated 6/10/26 at 7:10 P.M., showed:-The incident was physical aggression involving the head.-The residents involved were Resident #5 and Resident #6.-At or about 7:10 P.M., a Code [NAME] (a facility response to a behavioral health event) was called.-Licensed Practical Nurse (LPN) A responded and was talking to both residents.-Resident #6 was very upset.-As the nurse was exiting the unit, Resident #5 approached him/her.-Resident #6 began to walk up to Resident #5, argued and repeatedly hit him/her in the head.-Resident #5 did not retaliate.-Resident #5 was on the floor wedged by the elevator door.-Staff attempted to pull them apart and were unsuccessful for a while.-Staff continued to intervene and Resident #6 was successfully pulled off or Resident #5.-Both residents were separated into different areas of the unit.-This incident resulted in abuse.-The altercation was not preventable. Review of Resident #6's Progress Note, dated 6/10/26 at 7:10 P.M., showed:-The residents involved were Resident #5 and Resident #6.-At or about 7:10 P.M., a Code [NAME] was called.-LPN A responded and was talking to both residents.-Resident #6 was very upset.-As the nurse was exiting the unit, Resident #5 approached him/her.-Resident #6 began to walk up to Resident #5, argued and repeatedly hit him/her in the head.-Resident #5 did not retaliate.-Resident #5 was on the floor wedged by the elevator door.-Staff attempted to pull them apart and were unsuccessful for a while.-Staff continued to intervene and Resident #6 was successfully pulled off or Resident #5.-Both residents were separated into different areas of the unit.-Resident #6 refused to get vitals done or have his/her hand assessed-Resident #6 refused tele health with nurse practitioner.-Resident #6's guardian had him/her sent to the hospital in attempt to get a citation while at the hospital. Review of Resident #5's written Witness Statement, dated 6/10/26, showed:-I don't even say anything, and he/she said I'm harassing him/her. He/She then came to me and beat the shit out of me.-Resident #6 had become more aggressive. Review of the local law enforcement police summons, dated 6/10/26 at 8:32 P.M., showed: -Resident #6 did by intentional, overt act inflict bodily injury or cause an unlawful offensive contact upon Resident #5 by hitting him/her in the head repeatedly. Review of Resident #5's Progress Note, dated 6/10/26 at 9:00 P.M., showed:- Pain Issue: No Change. Location: Head. Pain score: 10. Aching. Radiating. -Indicators of pain: Vocal complaints of pain. -Pain Note: Generalized pain all over and on the top of his head. Review of Resident #5's Progress Note, dated 6/10/26 at 9:40 P.M., showed:-Skin Issues: New skin Issue. Location: Rear head. Additional location information: Rear head ---Issue type: Bruising. Progress: New: new wound. -Wound acquired in-house. -Exact date: 06/10/2026-Signs and symptoms of infection: None. -Painful: Yes. Wound pain (Frequency): Continuous. -Wound pain interventions: Distraction techniques. Wound pain interventions: Relaxation techniques. Relief from interventions: Review of Resident #5's Progress Note, dated 6/11/26 at 10:35 A.M. as a late entry, showed:-Per staff a Code [NAME] was called.-At or about 6:10pm staff were talking to both parties.-He/She was very upset and as the staff were leaving the unit, the resident approached the staff. -Per staff, resident's peer (Resident #6) also walked up to the nurse but started arguing with Resident #5 and knocked him/her down hitting him/her repeatedly.-Staff immediately intervened to separate the two. -Both parties were moved to different areas of the unit. The psychiatric nurse practitioner was notified.-Tele health was done; an order was given to send Resident #5 out to hospital to be checked. Review of Resident #5's Progress Note, dated 6/12/26 at 1:52 P.M., showed:-He/She returned from the hospital with no new orders. -He/She returned back to the facility around 3:35 A.M. Review of Resident #5's nurse practitioner's Progress Note, dated 6/12/26 at 2:40 P.M., showed a physical altercation with another resident resulted in hospital visit, headaches and migraines, feeling unsafe in current living environment. During an interview on 6/16/26 at 11:30 A.M., Resident #5 said:-He/She was speaking with a nurse and asking to speak with him/her privately.-Resident #6 approached and wanted an as needed (PRN) injection.-Resident #6 became upset and struck him/her approximately 20 to 25 times on the back and top of the head.-Resident #6 stomped on his/her right arm.-He/She could barely lift his/her right arm.-Staff attempted to remove Resident #6 but were unsuccessful until a Code [NAME] was called.-Resident #6 struck him/her with a closed fist.-The incident occurred near the elevator on the unit.-He/She had argued with Resident #6 previously but had never been involved in a physical altercation with him/her.- Staff separated the residents and the resident was sent to the hospital for evaluation. -He/She was scared when Resident #6 began hitting him/her.-His/Her right arm remained sore and stiff from the neck down.-Resident #6 also kicked and stomped him/her on the side. -He/She stated there was no visible bruising.-He/She still felt somewhat afraid. During an interview on 6/16/26 at 11:55 A.M., Resident #6 said:-There had been an altercation with Resident #5.-He/She struck Resident #5 and Resident #5 did not strike him/her.-He/She was speaking with a nurse when Resident #5 interrupted the conversation.-He/She then put his/her hands on Resident #5.-He/She became upset when Resident #5 interrupted him/her.-Resident #5 repeatedly stated, I won't do it no more, I promise.-He/She struck Resident #5 with a closed fist, kicked him/her, and stomped on him/her.-Staff attempted to stop the altercation. Review of Certified Nursing Assistant (CNA) A's written Witness Statement, dated 6/10/26, showed:-Resident #5 said something to Resident #6, and Resident #6 began head-butting, punching, and kicking Resident #5.-Staff separated the residents. During an interview on 6/18/26 at 1:15 P.M., CNA A said:-He/She was present when Resident #5 and Resident #6 became involved in a physical altercation.-Resident #6 head-butted Resident #5, causing Resident #5 to fall to the floor against the elevator.-Resident #6 then kicked Resident #5.-He/She was holding a drink and only had one available hand to assist with separating Resident #6 from Resident #5.-He/She was afraid of being struck and stated it took three staff members to separate Resident #5 and Resident #6.-Another staff person pulled Resident #6 away from Resident #5.-Resident #5 stated he/she was afraid of Resident #6 and believed Resident #6 knew he/she would not fight back. During an interview on 6/18/26 at 2:45 P.M., Licensed Practical Nurse (LPN) A said:-He/She responded to the Code Green, which was called at about 7:10 P.M.-He/She was talking to Resident #6, who was upset.- Resident #6 attempted to ask for PRN medication or to leave the unit to calm down.-As he/she exited the unit, Resident #5 approached him/her.-Resident #5 said Resident #6 only wanted medication to get high.-This caused Resident #6 to be more agitated.-Resident #6 walked up to Resident #5, arguing, and knocked him/her down, and struck him/her repeatedly in the head.-Resident #5 did not retaliate. He/She was on the floor wedged between the medication cart and the elevator door.-Staff intervened and Resident #6 was successfully pulled off Resident #5.-Both residents were taken to separate areas of the unit. During an interview on 6/17/26 at 11:00 A.M., the Psychiatric Nurse Practitioner said:-Resident #5 commented that Resident #6 did not need the PRN medication and only wanted to get high.-Resident #6 reacted by striking Resident #5.-Resident #6 recognized he/she should not have struck Resident #5.-Resident #5 was sent to the hospital following the incident.-Resident #5's actions did not give Resident #6 the right to put his/her hands on Resident #5.-Hitting another resident constituted abuse. During an interview on 6/17/26 at 2:00 P.M., the Licensed Clinical Social Worker (LCSW) with Therapy Company A said:-He/She met with Resident #5 and Resident #6 following the altercation.-Resident #6 admitted being the instigator.-Resident #6 reported becoming frustrated because Resident #5 interrupted him/her.-There had been a prior disagreement between the residents involving Resident #6's belongings.-Hitting another resident constituted abuse.-All residents knew fighting was wrong. During an interview on 6/18/26 at 10:30 A.M., the Interim Director of Nursing (DON) and Regional Nurse Consultant said:-Resident #6 requested a PRN medication.-Resident #5 was not present when Resident #6 initially requested the PRN medication.-Resident #5 interjected into the conversation and stated Resident #6 wanted to get high.-He/She stated Resident #6 appropriately requested a PRN medication when becoming upset.-He/She stated Resident #5 inserted him/herself into the interaction between Resident #6 and a nurse.-Hitting and kicking was abuse. 2. Review of Resident #3's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Unspecified dementia (a disorder characterized by a decline in memory, thinking, and reasoning abilities that interferes with daily functioning, without a more specific type of dementia identified).-Schizoaffective disorder.-Bipolar disorder.-Major depressive disorder.-Diffuse traumatic brain injury with loss of consciousness (a traumatic injury affecting multiple areas of the brain that resulted in a period of unconsciousness and may impair cognitive, physical, emotional, or behavioral functioning). Review of Resident #3's MDS, dated [DATE], showed he/she was cognitively impaired. Review of Resident #4's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizophrenia.-Anxiety disorder.-Major depressive disorder.-Autistic disorder (a neurodevelopmental disorder characterized by persistent differences in social communication and interaction, along with restricted or repetitive patterns of behavior, interests, or activities). Review of Resident #4's MDS, dated [DATE], showed he/she was cognitively intact. Review of the facility's RNI for this event, dated 6/13/26, showed:-The incident involved physical aggressions not involving the head.-The residents involved were Resident #3 and Resident #4.-Resident #4 was very upset that a peer gave another resident some food and did not give him/her any.-Resident #4 became irate and started throwing chairs and hitting the tables in the dining room.-Staff was trying to redirect Resident #4 and calm him/her down but Resident #3 got upset and went up to Resident #4 and told him/her to stop and sit down.-Resident #4 angrily said, Who is going to make me?-Resident #3 responded by lunging at Resident #4 but did not hit him.-Resident #4 started hitting Resident #3.-A Code [NAME] was called.-Staff tried to intervene and Resident #4 picked up Resident #3 and slammed him/her to the floor and continued to hit him/her in the abdomen, chest and hand.-Staff intervened and separated both parties.-Staff were unable to get Resident #4 to move to a different area, but he/she was still irate, hitting walls and screaming and yelling.-Resident #4 was upset and unable to be redirected even with staff offering other choices.-Resident #3 approached Resident #4 while he/she was already upset and lunged at Resident #4 causing him/her to feel threatened.-This incident resulted in abuse.-The altercation was not preventable. Review of Resident #3's MAR, dated June 2026, showed he/she received Tylenol 325 mg, 2 tablets by mouth PRN for pain on 6/13/26 at 2:53 P.M. Review of Resident #3's progress note, dated 6/13/26 at 3:36 P.M., showed:-He/She was very upset that another peer, Resident #4, was throwing chairs, hitting the tables and screaming and hollering.-He/She went up to peer Resident #4 and told him/her to stop and sit down.-Resident #4 angrily said, Who's going to make me?-He/She responded by lunging at Resident #4 but did not hit him/her.-Resident #4 started punching Resident #3.-A Code [NAME] was called.-Staff tried to intervene, then Resident #4 picked Resident #3 up and slammed him/her to the floor and continued to hit him/her in his/her abdomen, chest, and hand. -Staff intervened and separated both parties. -Staff were able to get him/her to move to a different area. -He/She was evaluated and had bruises on his/her abdomen and left hand.-He/She did not complain of pain and refused to go to the hospital. Review of Resident #4's Progress Note, dated 6/13/26 at 5:25 P.M., showed:-The resident was very upset that a peer gave another resident some food and did not give him/her any. -He/She became irate and started throwing chairs and hitting the tables in the dining room. -A staff member was talking to the resident, trying to redirect him/her and calm him/her down but Resident #3 got upset and went up to Resident #4 and told him/her to stop and sit down.-Resident #4 angrily said who's going to make me.-Resident #3 responded by lunging at Resident #4 but did not hit him/her.-Resident #4 started punching Resident #3.-A Code [NAME] was called.-Staff tried to intervene and Resident #4 then picked Resident #3 up and slammed him/her to the floor and continued to hit him/her in his/her abdomen, chest, and hand. -Staff intervened and separated both parties. -Staff were able to get Resident #4 to move to a different area, but he/she was still irate, hitting walls and screaming and yelling.- Resident #4 refused to take a PRN medication. -The nurse practitioner gave orders to send Resident #4 out to the hospital if he/she was not able to be redirected. -Resident #4 was sent out to the hospital for a psychiatric evaluation. Review of Resident #3's Progress Note, dated 6/13/26 at 7:44 P.M., showed:-New skin issue, abdomen. Issue type: bruising.-New skin issue, left hand. Issue type, bruising and abrasion. Observation on 6/18/26 at 11:45 A.M., showed Resident #3 had a large, approximately apple sized area of dark purple discoloration on his/her abdomen that appeared to be a bruise and a small, discolored area on his/her left hand. During an interview on 6/18/26 at 11:45 A.M., Resident #3 said:-Resident #4 became upset because he/she did not get the lunch he/she wanted.-Resident #4 was kicking the water cooler.-He/She was sitting near the television and stood up and told Resident #4 to knock it off.-The residents approached each other.-He/She did not intend to hit Resident #4.-Resident #4 struck him/her in the neck, knocked him/her to the floor, and began kicking him/her.-He/She had a large bruise on his/her abdomen and hand.-Police responded to the facility, and he/she pressed charges for assault.-Two staff members attempted to separate the residents.-After he/she got up, Resident #4 stated, Stay down or I'll hit you again.-The incident upset him/her and made him/her angry.-He/She had been taking Tylenol for pain. Observation of Resident #4 on 6/18/26 at 12:48 P.M. showed no visible injury or bruising. During an interview on 6/18/26 at 12:48 P.M., Resident #4 said:-He/She became angry because the kitchen did not provide a deli sandwich in a timely manner after he/she declined the regular meal.-He/She initially wanted food from a restaurant across the street and became upset when staff could not immediately obtain it.-He/She kicked an ice bucket to express his/her anger.-Resident #3 approached while both residents were upset.-He/She told Resident #3 not to approach, but Resident #3 continued toward him/her.-He/She stated Resident #3 struck him/her twice in the chest with a closed fist. -He/She placed his/her leg behind Resident #3's legs, causing Resident #3 to fall to the floor.-He/She pinned Resident #3's arms behind his/her back and then released him/her.-He/She did not kick or strike Resident #3 and did not know how Resident #3 sustained bruising.-He/She was transported to the hospital following the altercation.-Police responded to the facility, and no arrests were made. During an interview on 6/17/26 at 3:30 P.M., Certified Medication Technician (CMT) B said:-He/She was preparing to begin passing medications around lunchtime.-Resident #4 became upset after seeing another resident eating food from outside the facility and stated he/she also wanted food from outside the facility.-Resident #4 began yelling and kicking an ice bucket.-He/She attempted to calm Resident #4, but Resident #4 did not calm down.-Resident #4 threw the nurses' station telephone and punched a window without breaking it.-He/She asked the front desk staff member to call Code Green.-Resident #3 approached Resident #4 and told him/her to shut up.-Resident #4 responded, Come make me shut up.-Resident #3 stated, I'll come make you shut up.-Resident #4 struck Resident #3 several times with a closed fist and threw Resident #3 to the floor.-He/She stated Resident #3 struck a table and chairs when thrown to the floor, causing the bruising. Review of the undated Activities Director's written Witness Statement showed:-He/She was assisting residents on the medical unit when he/she heard Resident #3 and Resident #4 arguing.-He/She immediately called Code [NAME] and separated the residents.-Resident #3 attempted to lunge at Resident #4, and he/she immediately separated the two residents. During an interview on 6/17/26 at 1:30 P.M., the Activities Director said:-He/She heard witness the physical altercation but heard the verbal argument between Resident #3 and Resident #4.-He/She would have arrived at the scene sooner but was dealing with another resident.-Resident #4 was upset about food and having an alternative.-He/She constantly reminded Resident #4 of his/her coping skills. -Resident #4 got involved because Resident #4 was yelling and he/she got frustrated.-Resident #3 only liked certain people near him/her and liked to control the TV remote.-He/She immediately positioned him/herself between the residents to separate them.-Resident #3 appeared to lunge toward Resident #4. -Resident #4 threw him/her on the floor.-He/She made Resident #3 go to his/her room and Resident #4 go to the nurse's station. During an interview on 6/18/26 at 10:30 A.M., the Interim DON and Regional Nurse Consultant said:-Staff were attempting to redirect Resident #4 before the altercation.- A Code [NAME] had already been initiated before Resident #3 became involved.- Resident #3 became upset because Resident #4 was creating a disturbance while Resident #3 was trying to watch television.-He/She stated staff were focused on calming Resident #4 when Resident #3 became involved in the situation.-Hitting and kicking is abuse. During an interview on 6/18/26 at 3:00 P.M., the Assistant Administrator said:-Resident #4 wanted Resident #3's food.-Resident #4 hitting and kicking Resident #3 constituted as abuse. During an interview on 6/18/26 at 3:20 P.M., the Administrator said hitting and kicking was abuse. 3. Review of Resident #11's Preadmission Screening and Resident Review (PASARR), dated 3/2/09, showed the resident:-Had a substantiated dementia or related condition. -Diagnoses including schizophrenia, mild mental retardation and autism.-History of becoming involved with drugs, alcohol and prostitution. -Was placed in long-term care as the family discovered they could no longer safely care for the resident. -Had a history of having temper tantrums, exposing his/herself, eloping from unlocked facilities, and been aggressive with staff. -Had problematic behaviors including being suspicious of others.-Asked the same questions repeatedly and childlike. Review of Resident #11's MDS, dated [DATE], showed the resident was mildly cognitively impaired. Review of Resident #10's PASARR, dated 3/24/2019, showed the resident:-Services were recommended to be provided at the nursing facility.-Implementation of systemic plans to change inappropriate behavior.-Medication therapy and monitoring to change inappropriate behavior or alter manifestations of psychiatric illness. -Provisions of a structured environment.-Development of person support networks.-Diagnoses including schizophrenia.-Started hearing voices at around age [AGE] years old. -Bizarre behavior, disorganized thoughts, poor insight and judgement, delusions and psychosis. -Multiple psychiatric hospitalizations. -History of illicit substance use/abuse and possible sex trafficking victim.-Typically stays to him/herself.-Had difficulty interacting appropriately with others and a history of altercations, eviction or fear or strangers. -Determined to have a serious mental illness as defined by PASARR.-Needed psychiatric rehabilitative services of lesser intensity which can be provided by the nursing facility. -Recommended services include implementing plans to change behavior, drug therapy and monitoring, provisions of structured environment, and develop a personal support network. -Secured placement was recommended. Review of Resident #10's MDS, dated [DATE], showed the resident was cognitively intact. Review of the facility investigation, dated 6/18/26, showed:-The type of incident was physical aggression involving the head. -The incident was unwitnessed.-Notifications were made to the guardian, physician, administrator, and director of nursing. -Resident #11 was yelling at Resident #10 about a watch Resident #11 planned to get.-Resident #10 said he/she tried to walk away.-Resident #10 stated Resident #11 slapped/backhanded him/her on the right side of his/her face. -Resident #10 struck Resident #11 in the face three times and Resident #11 fell on the floor.-Resident #10 then struck Resident #11 three more times in the face.-Resident #10 then informed staff of what happened in their room.-Resident #10 said he/she was just defending him/herself from Resident #11. -Resident #11 was upset about not being able to find a smart watch that he/she wanted. Review of Resident #10's Progress Note, dated 6/18/26 at 7:00 P.M., showed:-The resident notified staff he/she was slapped by Resident #11. -He/She hit Resident #11 back. Review of Resident #11's Progress Note, dated 6/18/26 at 7:08 P.M., showed:-Per staff unwitnessed resident to resident incident.-The resident was escorted to social services office.-The resident stated he/she fell and staff were getting him/her a new watch.-The resident's left eye was bruised. Review of Resident #11's Progress Note, dated 6/18/26 at 7:18 P.M., showed:-The resident came out the room with a swollen eye.-When asked what happened, Resident #11 said another resident had hit/smacked him/her. -Residents #10 and #11 were separated, an assessment was done and neurological checks performed.-Observed Resident #11's left upper cheek was swollen. Observation and interview on 6/24/26 at 12:10 P.M., showed Resident #11's left eye socket was dark purple and swollen.-He/She got hurt and lost his/her watch.-He/She did not disclose by who but did point towards the unit.-He/She said his/her eye hurt. During an interview on 6/24/26 at 12:14 P.M., Resident #10 said:-Resident #11 came in the room and he/she was in the bathroom. -Resident #11 slammed the door shut and when Resident #10 came out he/she asked why Resident #11 shut the door.-Resident #10 was on his/her side of the room.-Resident #11 was upset about a watch and then slapped him/her in the face.-Resident #10 punched Resident #11 three times in the face, Resident #11 fell to the floor and he/she slapped Resident #11 three more times in the face.-He/She then went and told LPN A. During an interview on 6/24/26 at 2:20 P.M., LPN A said:-Resident #10 came and told him/her Resident #11 had hit him/her. -Resident #10 did not say right away that he/she hit Resident #11. -He/She told Resident #10 to go to the dining area. -He/She didn't see any bruises on Resident #10 and asked where he/she was hit. -Resident #10 reported Resident #11 had pushed him/her at that time. -He/She got an assessment on Resident #11 next, and his/her eye was swollen. During an interview on 6/24/26 at 10:57 A.M. the Assistant Administrator said:-Resident #10 and #11 got into an altercation. -Resident #11 struck Resident #10 with the intent to harm due to thinking Resident #10 stole Resident #11's watch. -Resident #10 hit Resident #11 in defense, although it was a total of six times. During an interview on 6/24/26 at 3:10 P.M., the Director of Nursing (DON) said: -Resident #10 reported he/she was in the bathroom when Resident #11 came in the room and shut the door.-When Resident #10 came out of the bathroom Resident #11 mentioned a watch and then hit Resident #10. -Resident #10 then hit Resident #11 and reported the incident immediately. -He/She defined abuse as willful intent to take action with injury. 3043153, 3040578, 3049110

Based on interview and record review, the facility failed to provide the Ombudsman with a copy of one sampled resident's (Resident #1) 30-day discharge notice at the time the notice was issued, limiting the resident's opportunity to exercise his/her appeal rights out of eleven sampled residents. The facility census was 101 residents.1. Review of Resident #1's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis and weakness affecting the right dominant side of the body following a stroke).-Anxiety disorder (a mental health disorder characterized by excessive fear, worry, or anxiety that interferes with daily functioning).-Post-traumatic stress disorder (a mental health disorder that may develop after exposure to a traumatic event and is characterized by persistent distress, intrusive memories, avoidance behaviors, and heightened arousal). Review of the resident's Progress Notes, dated 6/8/26 at 3:37 P.M. showed:-The resident verbalized he/she was not happy at the facility and wanted referrals sent to all local facilities in Kansas City.-Later that day, the resident stated he/she did not want to move and, if asked to move, would appeal the discharge. During an interview on 6/17/26 at 2:05 P.M., the facility Social Worker said:-As of 6/9/26, to the best of his/her knowledge, the resident had been accepted for admission at another sister facility.-The resident contacted the sister facility and made threatening statements.-The resident had been told the facility had 30 days to issue discharge referrals, and the resident initially stated he/she understood.-After receiving the 30-day discharge notice, that night the resident stated he/she was ready to leave and demanded to be discharged immediately.-The resident's sister later informed facility staff that the resident no longer wanted to leave.-He/She spoke with the Ombudsman about the discharge but did not provide a copy of the discharge notice to the Ombudsman because he/she did not believe it was required until the resident was officially discharged . During an interview on 6/17/26 at 2:30 P.M., Resident #1 said:-He/She stated that nobody in [NAME] City knew about the 30-day discharge notice, so he/she could not appeal the discharge.-He/She stated the sister facility did not agree to accept him/her. During an interview on 6/18/26 at 10:30 A.M., the Interim Director of Nursing (DON) and Regional Nurse Consultant said:-The facility Social Worker was responsible for notifying the Ombudsman regarding 30-day discharges.-He/She was not sure of the notification process.-The facility was redacting the previous 30-day discharge notice, amending the discharge date , and issuing the resident a new notice.-He/She was not sure why the facility was taking that action. During an interview on 6/17/26 at 1 P.M., the Ombudsman said:-The resident had contacted the office and wanted to appeal the discharge. -The facility had not provided a copy of the letter to the Ombudsman office. -The facility should have sent a copy of the discharge letter to enable the resident to advocate for him/herself in appeal rights. During an interview on 6/18/26 at 3:00 P.M., the Assistant Administrator said:- The Ombudsman should be notified before or at the time the 30-day discharge notice was issued.- If the Ombudsman was not notified until the time of discharge, the resident would not have the opportunity to appeal the discharge.- There was definitely training that needed to be completed. During an interview on 6/18/26 at 3:30 P.M., the Administrator said:-The Ombudsman should have been notified of the 30-day discharge on the same day the notice was issued.-The facility Social Worker was responsible for sending the notification to the Ombudsman.-The Ombudsman should have been sent the same copy of the discharge notice that was provided to the resident. 3049601, 3040425

Based on interview and record review, the facility failed to ensure proper notification to the resident's guardian for one sampled resident (Resident #2) when on 6/8/26 the resident was transferred to the hospital for behavior type issues out of eleven sampled residents. The facility census was 101 residents.Review of the facility's undated Resident Rights Policy showed:-The facility must immediately inform the resident, consult with the resident's physician, and, if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status.-The facility must immediately inform the resident, consult with the resident's physician, and, if known, notify the resident's legal representative or an interested family member when there is a decision to transfer or discharge the resident from the facility.-The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. 1. Review of Resident #2's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:- Schizoaffective disorder (a mental health disorder characterized by symptoms of schizophrenia, such as hallucinations or delusions, occurring along with mood disorder symptoms, including depression or mania).- Anxiety disorder (a mental health disorder characterized by excessive fear, worry, or anxiety that interferes with daily functioning).- Bipolar disorder (a mental health disorder characterized by alternating episodes of depression and mania or hypomania that affect mood, energy, and behavior). - Major depressive disorder (a mood disorder characterized by persistent feelings of sadness, loss of interest, and impaired daily functioning).- Asperger's syndrome (a neurodevelopmental disorder characterized by persistent difficulties with social interaction, communication, and restricted or repetitive patterns of behavior, without significant language or cognitive delay). - Unspecified intellectual disability (a disorder characterized by limitations in intellectual functioning and adaptive behavior when the severity cannot be fully specified because of insufficient information or the individual's condition). - Schizophrenia (a chronic mental health disorder characterized by disturbances in thought processes, perception, emotions, and behavior, often including hallucinations, delusions, or disorganized thinking).- Catatonic schizophrenia (a form of schizophrenia characterized by significant disturbances in movement and behavior, including immobility, rigidity, excessive or purposeless movement, or diminished responsiveness). Review of the County Public Administrator Emergency Call Information dated 3/31/26 showed:-The Public Administrator (PA)'s name who was assigned to the resident.-The PA's email address.-A list of examples of expected uses of the on-call phone vs. using the direct line and/or email.-The on-call phone number was to be used for consent to send a ward to the hospital.-This document was signed by the facility Social Worker. Review of the Resident's Progress Notes dated 6/8/26 at 9:33 P.M. showed:-The physician was notified of the incident, and an order was given to send to the emergency room for evaluation and treatment.-The patient's guardian was notified of transfer to the hospital.-This was a late entry. Review of the Resident's Progress Notes dated 6/8/26 at 9:39 P.M. showed:-He/she attempted to gain access to peer's room in an aggressive manner.-He/she attempted to push through this writer and was unsuccessful.-He/she was redirected to his/her room to calm down.-He/she then reported he/she wanted to cause harm to himself/herself.-The Nurse Practitioner was notified, and an order was given to send the patient to the hospital for evaluation and treatment for thoughts of self-harm. Review of the Resident's Progress Notes dated 6/9/26 at 2:20 A.M. showed:-The patient returned to the facility at 1:45 A.M. from this hospital via Z-trip.-The patient had been sent out for suicidal ideations between 9:30 P.M and 9:45 P.M. on 6/8/26 via ambulance. During an interview on 6/17/26 at 1:00 P.M., Certified Medication Technician (CMT) A said:-The facility left a message for the resident's guardian regarding the resident but did not speak directly with the guardian. The call occurred during the night shift.-To the best of his/her knowledge, if staff were unable to reach the guardian, follow-up calls were not required until the resident returned to the facility.-When calling the guardian, the system prompted staff to call only the emergency contact number.-He/She did not consider the resident's behavior to be an emergency.-Based on his/her nursing judgment, he/she did not use the emergency contact number unless there was a true emergency, such as a physical problem like a heart attack.-He/She may have been mistaken regarding the notification process, may require additional education, and was open to the possibility that his/her understanding was incorrect.-The resident was sent to the hospital because the resident made statements about self-harm.-The transfer was necessary because of the statements made, not because the resident had engaged in self-harm. -There had been no attempts at self-harm.-The resident was evaluated at the hospital and returned to the facility quickly without receiving treatment. -The guardians did not have on-call staff except for emergencies. -The emergency contact number was intended for actual health emergencies and not for providing updates.-The resident had made verbal statements only and had not acted on those statements. -The resident did not do anything with the fork and did not reach the other resident.-The incident was entirely verbal. During an interview on 6/27/26 at 1:15 P.M., the Psychiatric Nurse Practitioner said:-Leaving voicemail constituted as notification.-If staff could not send a resident to the hospital because they had to wait for the guardian's approval, it could result in a negative outcome for the resident.-If someone agreed to serve as a resident's guardian, he/she needed to be available. During an interview on 6/17/26 at 2:15 P.M. Guardian A said:-The resident was at the hospital for approximately three hours.-There was someone on call 24 hours a day, seven days a week for the guardian's office.-An email was sent to the facility with the guardian's information.-There was a notice identifying the deputy assigned to the resident.-The emergency on-call number was listed, along with the reasons it should be used, and facility staff could speak with the deputy on call.-A specific form was provided to the facility identifying which telephone number to call and the reasons for calling.-The information should also have been included on the facility face sheet.-The facility should have called when the resident was sent to the hospital. During an interview on 6/18/26 at 10:30 A.M., the Interim Director of Nursing (DON) and Regional Nurse Consultant said:-The guardian or responsible party would be contacted when a resident was sent to the hospital.-If it were an emergency, the resident would be sent to the hospital, and the guardian would be notified of the circumstances when he/she returned the call.-If it was the middle of the night and a voicemail was left, staff could follow up later.-Staff should attempt to follow up but do not always reach the guardian.-The resident face sheets were created through a team effort.-As updated information was obtained during the resident's stay, it should be added to the face sheet.-Not every PA had a back-up telephone number.-Some PA's had back-up telephone numbers that were the same as the primary number and rolled over after hours.-Every PA had different preferences and needs.-When updated information was received, it should have been added to the resident contact information.-Whoever received the updated information was responsible for updating the contact information on the face sheet. During an interview on 6/18/26 at 10:45 A.M., the Social Worker said:-Some guardians provided information regarding who should be contacted, but not every guardian did so.-Nursing staff would have to look at the resident face sheet for guardian contact information.-The information on the resident face sheet was the same information that was uploaded into Point Click Care (PCC), an electronic medical record system.-When a resident was admitted with a guardian, the guardian's telephone numbers were provided by the guardian.-Many guardians did not want residents to have access to those telephone numbers.-The resident had been assigned a new PA, possibly in March.-If nursing staff did not review the documents in PCC, they would not know the emergency telephone number.-The emergency telephone number document was uploaded into PCC under the documents tab.-He/She signed the document and acknowledged he/she should have added the information to the resident face sheet. During an interview on 6/19/26 at 3:00 P.M., the Assistant Administrator said:-The CNA should not have called the emergency telephone number.-The resident was sent to the hospital due to behavioral concerns.-If it had been a true emergency, the resident would not have returned to the facility within a couple of hours.-Examples of a true emergency included cardiac issues, respiratory distress, or unresponsiveness.-A behavioral situation could constitute an emergency.-The resident was sitting in a chair when emergency medical services (EMS) arrived.-The resident got onto the gurney independently.-The resident stated he/she was going to harm him/herself with a fork but never had possession of a fork.-The resident stated he/she wanted to harm him/herself.-The behavior was for attention.-He/She did not consider it a true medical emergency.-The resident's vital signs were within normal limits and the resident was stable.-The resident returned to the facility within two hours.-Some notification was better than no notification. During an interview on 6/19/26 at 3:30 P.M., the Administrator said:-The secondary guardian phone number should have been added to the face sheet. -The nurse should have known there was an emergency. -He/She understood the nurse's viewpoint that it was not emergent.-He/She would have expected the Social Worker to put the complete information on the face sheet.-The face sheet was a working document and should be as complete as possible.-The resident's circumstance was enough to contact the emergency number. 3039092

Based on observation, interview, and record review, the facility failed to protect two sampled residents Resident #1and Resident #9 out of 10 sampled residents. On 5/23/26 Resident #2 had pulled Resident #1's hair and hit Resident #1 in the face resulting in bruising. On 5/29/26 Resident #2 hit Resident #9 in the face resulting in a small mark to the lower lip. The facility census was 101 residents.Review of the facility's policy titled Abuse and Neglect Policy dated 6/12/2024 showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident to resident altercations.-It included verbal abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology.-Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner.-Physical abuse also included, but was not limited to, hitting, slapping, punching, biting, and kicking.-The facility would identify, correct, and intervene in situations in which abuse was more likely to occur.-Prevention would also include assessment care planning and monitoring of residents with needs or behaviors which may lead to conflict or neglect. 1. Review of Resident #1's admission Record showed he/she admitted to the facility with a diagnosis of schizoaffective disorder (a mental health condition that includes features of both schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and a mood disorder). Review of Resident #1's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 4/16/26 showed the resident was cognitively intact. Review of Resident #2's admission Record showed he/she was diagnosed with schizophrenia on 2/10/2024. Review of Resident #2's quarterly MDS dated [DATE] showed:-The resident had severely impaired cognition.-The resident did not have any hallucinations (perceptual experiences in the absence of real external sensory stimuli) within the seven-day look back period.-The resident did not have any delusions (misconceptions or beliefs that are firmly held, contrary to reality) within the seven-day look back period.-The resident did not have physical behavioral symptoms within the seven-day look back period.-The resident did not have verbal behavioral symptoms within the seven-day look back period.-The resident experienced other behavioral symptoms not directed towards others one to three days within the seven-day look back period. Review of an Admin/RN Investigation dated 5/23/26 showed:-The incident occurred on 5/23/26 at 6:00 P.M.-The incident type was physical aggression involving the head.-Resident #1 and Resident #2 were involved in the incident.-Certified Nursing Assistant (CNA) A was a witness to the altercation.-Resident #6 was a witness to the altercation.-Resident #1 was standing in the hallway and talking to CNA A.-Resident #2 came down the hall behind Resident #1.-Resident #2 then pulled Resident #1's hair and started to hit Resident #1 in the face and chest.-Staff separated Resident #1 and Resident #2.-Resident #2 was removed from the unit for the safety of the other residents on the unit.-Resident #1 stated that he/she did not have any interaction with Resident #2 leading up to the incident.-Resident #1 stated that he/she didn't do anything wrong and that he/she did not hit Resident #2 back.-CNA A reported that there were no warning signs that Resident #2 showed prior to the altercation.-No injuries were reported at that time of the incident.-It was noted that on 5/24/26 that Resident #1's left eye may have bruising as the hyperpigmentation appeared darker.-Resident #2 had no recollection of the altercation.-The root cause of the incident was behavioral related due to poor impulse control.-The incident was not the result of abuse. Review of Resident #1's Skin Check dated 5/23/26 showed:-The resident had a new skin issue to his/her face.-The resident had bruising to his/her face.-The bruising was painful and aching. Review of Resident #2's Incident Note dated 5/23/26 at 5:55 P.M. showed:-Around 6:00 P.M. Resident #2 was walking in the hallway and turned to Resident #1 and hit him/her in the face.-A code green (a behavioral emergency and/or incident needing physical support and presence when an individual poses a threat to himself/herself or others) was called.-Resident #2 was unable to say what happened.-Staff informed the writer that Resident #2 had walked down the hall and started pulling Resident #1's hair and hit Resident 1 in the face with a closed fist. During an interview and observation on 6/1/26 at 1:07 P.M. Resident #1 said:-Resident #2 attacked him/her out of nowhere.-He/She was talking with staff when Resident #2 came up to him/her and hit him/her in the face and chest.-Resident #2 did not say anything to him/her before he/she was hit.-He/She reported no injuries.-Observation of Resident #1 showed bruising to Resident #1's face.-The staff separated him/her from Resident #2, and nothing happened after that.-Resident #2 had been physical with other residents before this altercation.-He/She had been avoiding Resident #2 since the incident occurred.-He/She did not feel safe at the facility. During an interview on 6/1/26 at 1:30 P.M. Resident #2 said:-He/She did not remember the incident.-He/She was unable to answer any questions related to the altercation. During an interview on 6/1/26 at 3:21 P.M. CNA A said:-Resident #1 was standing in the hall.-Resident #2 walked up to Resident #1 and pulled Resident #1's hair.-Resident #2 then turned Resident #1 around and started to hit Resident #1.-Resident #1 did not hit Resident #2 back.-The staff then called a code green and separated the residents.-Resident #1 had redness to the face and chest after the altercation.-He/She felt that staff responded appropriately to the incident. During an interview on 6/2/26 at 1:48 P.M. Assistant Director of Nursing (ADON) A said:-The incident between Resident #1 and Resident #2 would be considered as abuse.-Resident #2 didn't know any better in either situation because of his/her delusions and hallucinations. During an interview on 6/2/26 at 3:27 P.M. the Director of Nursing (DON) said:-He/She understood that Resident #2 struck Resident #1.-The incident between Resident #1 and Resident #2 would be considered as abuse.-Resident #2 was unpredictable, but hitting another resident still counted as physical abuse.-He/She felt that the reported root cause of the incident between Resident #1 and Resident #2 was not related to poor impulse control because Resident #2 was unable to control any of his/her impulses. 2. Review of Resident #9's admission Record showed he/she admitted to the facility with a diagnosis of borderline personality disorder (a mental health condition characterized by severe difficulties in regulating emotions). Review of Resident #9's comprehensive MDS dated [DATE] showed:-The resident was cognitively intact.-The resident had verbal behavioral symptoms directed toward others one to three times within the seven-day look back period.-The resident had other behavioral symptoms not directed toward others one to three times within the seven-day look back period. Review of an Admin/RN Investigation dated 5/29/26 showed:-The incident occurred on 5/29/26 at 6:30 P.M. -The incident type was physical aggression involving the head.-Resident #2 and Resident #9 were involved in the incident.-Certified Medication Technician (CMT) A was a witness to the incident.-Resident #9 was in the hallway stating that he/she wanted medication and began getting loud.-Resident #2 passed Resident #9 and hit the resident in the face.-The root cause of the altercation was behavioral related due to poor impulse control. Review of Resident #9's care plan dated 5/30/26 showed the resident was involved in a physical altercation with a peer, the peer was reacting to Resident #9's loud voice. Review of Resident #2's Incident Note dated 5/29/26 showed Resident #2 was walking in the hallway when Resident #2 turned to Resident #9 and hit Resident #9 in the face. Review of Resident #9's Incident Note dated 5/29/26 showed:-Resident #9 was in the hallway and had been asking for medication.-Resident #9 began getting loud when Resident #2 was walking passed Resident #2.-Resident #2 then hit Resident #9 in the face. During an interview on 6/2/26 at 12:30 P.M. the Assistant Administrator said:-He/She had been notified of the altercation between Resident #2 and Resident #9.-He/She informed the Regional Nurse Consultant (RNC) of the incident between Resident #2 and Resident #9.-He/She had been told that Resident #2 swatted at Resident #9 in more of a startled response to the commotion that Resident #9 was causing.-There were no injuries to Resident #2 or Resident #9 related to the incident. During an interview on 6/2/26 t 12:42 P.M. Licensed Practical Nurse (LPN) A said:-Resident #2 was walking by Resident #9 when Resident #2 started hitting Resident #9.-It was more of a swat than an actual hit.-He/She thought Resident #2 might have been surprised by Resident #9 based off of Resident #9's location which may have caused the started response.-He/She felt the altercation did not count as abuse because Resident #2 did not intentionally hit Resident #9. During an interview and observation on 6/2/26 at 1:40 P.M. Resident #9 said:-Resident #2 came up to him/her, pulled his/her hair, and started to hit him/her.-He/She defended himself/herself and hit Resident #2 back.-He/She scratched Resident #2 in the face.-His/Her left side of the face still hurt related to the incident.-He/She had been hit in the lip, and it left a mark on his/her lower lip.-Nothing happened after the incident.-He/She felt like the facility didn't really do anything for him/her after the altercation occurred.-He/She felt that he/she had been abused by Resident #2. -Observation of Resident #9's face showed no bruising, swelling, or redness to any part of Resident #9's face.-Observation of Resident #9's mouth showed a quarter to half inch white mark to the inside of the lower lip, though the mark appeared older than 4 days-old. During an interview on 6/2/26 at 1:48 P.M. ADON A said:-The incident between Resident #2 and Resident #9 would not be considered as abuse.-He/She had been told that Resident #2 unintentionally swatted at Resident #9.-Loud noise and commotion were one of Resident #2's triggers, which could have Resident #2's response. During an interview on 6/2/26 at 3:23 P.M. CMT A said:-Resident #2 came behind Resident #9 and started hitting Resident #9 in the face using his/her fists.-In response, Resident #9 hit Resident #2 back and scratched Resident #2's face.-Staff immediately separated the residents.-Nothing happened after the incident.-He/She was unsure if there was a specific trigger that caused Resident #2 to hit Resident #9.-He/She felt that the staff intervened appropriately.-He/She would consider Resident #2's and Resident #9's altercation as abuse.-Resident #2 intentionally hit Resident #9 and in response Resident #9 hit and scratched Resident #2. During an interview on 6/2/26 at 3:27 P.M. the DON said:-He/She felt that the investigation related to Resident #2's and Resident #9's altercation was incomplete after discussing the investigation during the interview.-Resident #2's and Resident #9's altercation would be considered abuse.-He/She was unsure of how/why the staff who completed the investigations determined that abuse had not occurred. During an interview on 6/5/26 at 11:45 A.M. the Regional Nurse Consultant (RNC) said:-He/She was not in the building to complete the investigation related to Resident #2's and Resident #9's altercation.-The investigation was incomplete.-He/She thought the Assistant Administrator and/or ADON A had interviewed all of the parties involved in the incident between Resident #2 and Resident #9.-The root cause of Resident #2's and Resident #9's altercation was not related to poor impulse control.-The root cause of Resident #2's and Resident #9's altercation was overstimulation.-He/She felt that the incident between Resident #2 and Resident #9 would not be considered as abuse because the altercation was not an intentional act. 3022671

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure Resident #1's physical, mental, and psychosocial well-being in accordance with the resident's identified needs related to mental health care needs and substance use disorders. The facility failed to implement interventions to reduce known hazards and risks to the resident. Facility staff were aware of the resident's family's concern the resident needed a legal guardian to assist them in making health care decisions in September 2025. The facility was aware of behaviors that were escalating and becoming dangerous with the resident leaving the facility all day, taking illicit drugs and drinking alcohol. In February 2026, the resident received a new Preadmission Screening and Resident Review (PASRR) II ( Level II - an in-depth assessment of resident's serious mental illness or related condition which evaluates the need for facility services, specialized services and confirms if nursing facility care is appropriate). The PASRR identified the resident had ongoing use of illicit drugs and alcohol with poor insight and compromised safety judgment. Due to the resident's severe psychiatric condition, ongoing substance use, significant behavioral dysregulation, and complex medical needs, the resident was identified to need 24-hour care in a highly structured setting. Illicit drug use was identified to undermine psychiatric stability and posed serious safety concerns. The resident demonstrated inability to remain safely within the facility, nonadherence to medication and treatment when unsupervised, and vulnerability in the community. The facility failed to implement interventions in the PASRR including assistance to the family to facilitate guardianship proceedings and coordinate communication with legal and community resources, in order for the resident to receive services in setting that could better address high-risk behaviors, ongoing risk for substance use, and enhance safety. Local police were called to manage resident's behavior on multiple occasions, with the resident having been jailed on at least two occasions. The resident had a history of leaving the facility and returning back with signs of having consumed large amounts of alcohol and illicit drugs. On 4/24/26, the resident showed signs of an overdose after being in the community and was sent to the hospital, testing positive for alcohol, fentanyl (a highly potent synthetic opioid used medically for severe pain an anesthesia), PCP (a potent illegal street drug with hallucinogenic and dissociative effects), and marijuana- resulting in the physician ordering the resident on a 72 hour facility hold for safety and detox. The census was 103 residents. The Administrator was notified on 5/15/26 at 2:00 P.M. of the Immediate Jeopardy (IJ) which began on 2/26/26. The IJ was removed on 5/15/26, as confirmed by surveyor onsite verification.Review of the facility's Care Assessment Summary and Individualized Care Plan policy, revised 11/6/23, showed:-The Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) would be completed by Interdisciplinary Team members (Nursing, Activities, Social Services, Dietary) to address the needs of the individual resident.-After completing the MDS the Care Area Assessment (CAA) would be used to further assess triggered areas of concern. The care area triggered alerts to the assessor that interventions must be put in place to address care concerns in the plan of care for the individual resident.-The care plan should address:--Improvement where possible.--Maintenance and prevention of avoidable declines in all care area triggers. Review of the facility policy for Discharge, Immediate Discharge, Transfer and Therapeutic Leave, revised on 6/12/25, showed:-The purpose of the policy was to establish a policy and procedure regarding the transfer/discharge of residents to ensure no inappropriate discharges were made and that no discharges were made in an unsafe manner.-Reasons for discharge/transfer was when a resident's welfare and needs could not be met by the facility, and/or the resident's safety in the facility was in danger, the health of the resident could be in danger.-Reasons for Immediate Discharge included actual harm to self or others, non-compliance with medications which lead to severe behaviors, repeated disregard or destruction of facility property and/or sexual acting out with potential harm to self or others. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).-Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems).-Psychoactive substance abuse with psychoactive substance-induced disorder - a disconnection from reality characterized by hallucinations (sensory experiences which aren't related to reality) and delusions (false beliefs) attributed to substance intoxication.-Depression - a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living.-Acquired absence of right leg below knee and left leg below knee. Review of the resident's undated care plan showed problem identified as: -He/She had a psychosocial well-being problem with anxiety and ineffective coping revised on 4/5/24:--Staff were to provide opportunities for the resident and family to participate in care.--When conflict arose, staff were to remove the resident to a calm, safe environment and allow to vent feelings.-He/She was at risk for signs and symptoms of his/her schizophrenia, revised 6/4/24:--When speaking about the resident's hallucinations, the staff were to focus on how those hallucinations made the resident feel rather than the hallucinations themselves.-He/She was to reside in the least restrictive environment revised 4/5/24--The staff were to define for the resident his/her roles and expectations for being a resident in the facility.-He/She was to have resided in the facility of his/her choice revised 9/18/24:--The staff were to have sent our referrals for new placement at the resident's request.-The resident was to have had a decrease in behaviors during the next review period revised 12/24/24.--The resident was to have been offered PRN (as needed) medication to assist with outbursts and kept in a calm environment.-He/She had increased outbursts, initiated 12/24/24, showed: --The resident yelled and cussed at two little girls on his/her shoulders and frightened other residents.--Staff were to offer medications as needed to assist with outbursts and allow the resident to have outbursts in a private area. Review of an email sent by the facility Social Services Designee (SSD), dated 9/3/25, showed to the Director of Nursing (DON) as well as other former administrative staff the SSD got a phone call from the resident's primary family member requesting a letter with the resident's diagnoses as he/she attempted to obtain guardianship for the resident. Review of an email sent by the facility SSD, dated 9/17/25, to the facility DON requested a referral be sent to a sister facility for the resident as soon as possible, as his/her behaviors were escalating and becoming dangerous with the resident leaving the facility all day, taking illicit drugs and drinking alcohol. Review of an email received by the DON, dated 9/23/25, from a Health and Wellness Facility showed:-After receiving the resident's behavior notes the Health and Wellness Facility replied that the resident's notes showed he/she had been found outside of the facility, had aggressive behaviors towards others, took illicit drugs from the street when he/she was outside the facility.-Due to these behaviors, they would not accept the resident into their community. Review of an email received by the DON, dated 10/28/25, sent from Assistant Director of Nursing (ADON) B showed the physician wanted to know if the DON wanted him/her to write a letter recommending the facility to get legal guardianship in light of the resident's poor impulse control and drug use. Record review of the resident's Electronic Medical Record, from October 2025 until May 2026, showed no documentation of any follow-up completed having the physician write a letter recommending the facility obtain guardianship. Review of the resident's undated care plan showed problem identified as: -He/She had depression related to schizophrenia revised on 1/20/26: --The resident had the following signs and symptoms related to schizophrenia:aggression, anxiety, inability to make decisions, delusions (fixed beliefs that can't be reasoned with), eyes that dart back and forth, fearfulness, hallucinations (hearing, seeing, feeling, and/or smelling things that aren't there), difficulty focusing, no interest in activities, irritability, making hand gestures as if having a conversation, mumbling, poor hygiene, isolation, and talking to self.--The resident states there are multiple little girls living on his/her shoulders who gang up on him/her and are mean.--Interventions included:---Administering medications for anxiety or hallucination according to physician orders.---Avoid arguing.---Notify charge nurse if observing resident experiencing signs/symptoms of schizophrenia.---Be careful when using reassuring touch.---Focus the resident on how the hallucination makes them feel rather than the content of the hallucination. Review of an email received by the DON and SSD, dated 2/10/26, sent by the facility Administrator said:-He/She had spoken to Regional Director of Operations (RDO) A regarding the most effective way for the facility to deal with Resident #1 in order to mitigate the resident's aggressive behaviors.-The resident was currently self-responsible and was suspected to have been a trigger for other residents in the facility.-On 2/6/26, the Administrator informed RDO A that he/she urgently needed to discharge the resident in order to prevent potential harm to the other residents.-On 2/9/26 he/she informed RDO A that he/she needed to either do an immediate discharge on the resident or need RDO A's assistance on placement to initiate a 30-day notice. -RDO A suggested sending a request to the corporate legal team, however the Administrator thought it best to reach out to the Ombudsman to learn of any resources that the team may not have tried before initiating an immediate discharge.-There was also a suggestion that the physician write an order to remove access for therapeutic leaves since it was not safe for the resident regardless of his/her status. -On 2/10 he/she informed RDO A the resident had been banned from the corner store and had received multiple police citations in the past 24 hours. -He/She then stated that he/she had left a message for the Ombudsman.-He/She also asked the SSD to send out a mass referral on behalf of the resident, stating that in the case of safety, the resident did not have to give consent reinforcing that day one started when the facility accepted the resident. -He/She was hoping to hear from the Ombudsman by day's end of business 2/10/26.-He/She also asked the DON to reach out to the provider to ask that they write an order for the resident to not be able to sign themselves out due to safety, which he/she hoped would cover their bases for oversight. Record review of the resident's Electronic Medical Record, from February 2026 until May 2026, showed there was no documentation of any follow-up with the Ombudsman resources for the resident or follow-up with the resident's physician to remove the therapeutic leave. Review of the resident Level II PASRR, dated 2/26/26 showed: -Besides the diagnoses mentioned on the admission Record the resident was also diagnosed with:--Bipolar disorder - Mood disorder that can cause intense mood swings.--Disruptive behavior disorder.--Conduct disorder, adolescent onset - a serious mental health condition, usually seen in children and adolescents, characterized by a consistent pattern of aggression, theft, vandalism, and rule violations that violate the rights of others.--Borderline Personality Disorder - a serious mental illness characterized by pervasive instability of moods, self-image, interpersonal relationships, and marked impulsivity.-The resident had a chronic pattern of severe psychiatric decompensation characterized by persistent auditory and visual hallucinations involving an imaginary little girl, fixed delusional content, and frequent responding to internal stimuli. He/She had recurrent verbal aggression, intimidation of peers, and escalation toward physical altercations, including lunging from his/her wheelchair, striking walls, damaging facility property and engaging in threatening behaviors that required staff intervention. He/She demonstrated repeated smoking and contraband violations and elopement to the adjacent gas station despite prior warnings and law enforcement involvement. He/She continued to go outside in his/her wheelchair most days and sit at the gas station next door.-The resident had been observed spending time outside at the corner store using recreational drugs; however, the specific substance type was not reported. -Progress notes reflected a pattern of behavioral dysregulation occurring in the context of active psychosis, poor impulse control, and suspected substance use. -The resident required 24-hour protective oversight due to the severity of behaviors or mental illness symptoms and medication management.-Mental health care needs exceeded what could be managed in previous/current living situation due to aggression, substance use, or medication non-compliance leading to exacerbation of symptoms.-Documentation indicated no active discharge planning and no referrals initiated. This appeared to contradict current nursing facility reports describing active efforts toward rehabilitation placement and guardianship pursuit.-The resident had ongoing use of illicit drugs and alcohol with poor insight and compromised safety judgment. -Due to the resident's severe and treatment-refractory psychiatric condition, ongoing substance use, significant behavioral dysregulation, and complex medical needs, the resident continued to require 24-hour care in a highly structured setting. His/Her chronic psychosis is characterized by persistent auditory and visual hallucinations, paranoid ideation, gross disorganization, and frequent response to internal stimuli which significantly impair his/her reality testing and behavioral regulation. He/She had been involved in multiple episodes of verbal and physical aggression, often in the context of responding to internal stimuli or perceived threats. In the nursing home setting the resident's symptoms remained only moderately controlled. His/Her illicit drug use continued to undermine psychiatric stability and posed serious safety concerns. The resident had a history of bilateral below knee amputations due to frostbite, resulting in mobility limitations and the need for continued assistance with activities of daily living (ADLs, feeding, dressing, grooming) and medical oversight. His/Her demonstrated inability to remain safely within the facility, nonadherence to medication and treatment when unsupervised, and vulnerability in the community highlight the necessity of a structured and secure environment. Placement in a nursing facility with a locked behavioral unit should be considered for the resident to address his/her ongoing elopement, enhance safety, and provide the containment necessary to support adherence, minimize risk of harm, and reduce access to illicit substances.-Given the resident's persistent substance use and repeated elopement for the purpose of obtaining drugs and alcohol, integrated dual-diagnosis therapy was strongly recommended to target both his/her psychiatric illness and substance use disorder.-The resident needed among other supports: medication set up and administration by staff monitoring for medication compliance, supports to prevent elopement, and assessment of supervision required to prevent harm to self or others. -Plan for crisis intervention that promoted emotional support, education, safety planning and case management to handle immediate crisis. A crisis plan should be developed to create clear steps that are to be taken to support the resident during a behavioral health crisis including who to contact for assistance, how to work together with the client during a crisis, and how to determine when the crisis is over. The plan should identify a physician and emergency medical services that should be contacted. The facility may also utilize Department of Mental (DMH) Health Behavioral Crisis hotline. Assault precautions and elopement precautions should be part of the crisis intervention plan. -At this time priority should be given to supporting the resident's family member in pursuing guardianship as the resident's poor insight, current psychosis, substance related behaviors, and documented refusal of previously arranged rehabilitation significantly limit his/her ability to participate meaningfully in discharge planning or adhere to treatment recommendations independently. The facility should provide assistance to the family to facilitate guardianship proceedings and coordinate communication with legal and community resources. If guardianship was achieved and sustained clinical stabilization occurred the primary recommendation would be residential or intensive substance use treatment and rehabilitation services given the resident's high-risk behaviors, ongoing risk for substance use, and prior refusal of rehabilitation placement. Review of the resident's Electronic Medical Record from February 2026 through May 2026 showed there was no safety plan created or implemented for the resident while he/she was outside of the building. Review of the resident's undated care plan showed problem identified as: -The resident continued to have increased behaviors including refusal of cares, along with verbal and physical aggression towards staff and peers revised 2/26/26. --The staff were to attempt to anticipate the resident's needs, attempt to discuss the resident's behaviors including why they were inappropriate and attempt to determine the cause for those behaviors, intervening as necessary while protecting the resident's rights. Further review of the resident's care plan showed recommendations from the 2/26/26 PASRR such as, providing support to the resident's family to obtain guardianship, providing 24/7 protective oversight on a locked unit, or providing outside counseling and drug/alcohol rehabilitation. Review of the resident's progress notes, from February 2026 - May 2026, showed no documentation of follow up regarding assisting the resident's family member to pursue guardianship of the resident as directed by the PASRR or to find alternate placement for the resident. Review of the resident's undated Individual Care Service Report (ICSP) showed: -The resident's crisis intervention plan showed triggers were hallucinations and stupid actions. --Staff were to monitor behaviors and attempt to determine underlying cause, monitor, document, and report any adverse psychotropic medication reactions, risk of harm to self or others, and or risky actions by the resident and any signs and symptoms of depression.-- They were to monitor, record and report depression and increased anger that could cause him/her to lash out at others.--They show that he/she was self-responsible and able to leave on pass without supervision of staff. -Mental health interventions/de-escalation steps were to:--Avoid arguing, respect personal space, and use simple clear language.--Notify charge nurse if observing the resident experiencing signs and symptoms of schizophrenia (hallucinations, delusions, difficulty focusing, inability to make decisions, poor hygiene, isolation, irritability, talking to self, mumbling, making hand gestures as if having a conversation, eyes darting, anxiety, and aggression) or if resident is suspected of violating the smoking policy.--Focus the resident on how the hallucination makes them feel rather than the content of the hallucination. During an interview on 5/12/26 at 2:15 P.M., the Administrator and DON said:-They were not aware that a new PASRR had been completed in February 2026. -They did not know who had requested a new PASRR, nor were they aware of recommendations for obtaining a guardian for the resident nor that the resident had been deemed no longer appropriate for residence in the facility due to his/her behaviors. -They were not aware of the recommendations that the resident be placed on a locked unit so he/she could not leave unaccompanied by staff.-Once a new PASRR was recommended, the facility SSD should have been made aware and should have notified the Administrator, DON, MDS Coordinator and Care Plan Coordinator (CPC). -Those individuals should then incorporate the new recommendations into the resident's care plan after doing a Change of Condition MDS. -Without the knowledge that a new PASRR had even been completed, none of those procedures were followed.-They did share their concerns for the resident's safety earlier in the year with former RDO A asking for assistance in getting the resident out of the facility and/or emergency guardianship completed. -RDO A had reached out to the Ombudsman back in February 2026, but RDO A had not followed up. -They had also reached out in attempt to get corporate legal assistance in assisting the resident's primary family member in obtaining guardianship but were told there was no longer anyone on the corporate legal team who assisted with guardianship. -Their concern was that while the resident was still his/her own person, as a facility, they could not physically keep the resident inside the building, nor could they force him/her to take his/her medication every day as he/she had a right to refuse and they feared getting in trouble for limiting the resident's freedoms. During an interview on 5/5/26 at 11:10 A.M., the SSD said:-He/She didn't know who was responsible for following up on PASRR recommendations but thought the Care Plan Coordinator did that.-He/She didn't know the PASRR had recommended guardianship.-The resident's family member was going to pursue guardianship and then said he/she wouldn't. -On 4/24/26 the resident's family member asked if the facility could pursue the guardianship.-He/She had not initiated the guardianship process and didn't know if the Administrator had done so.-He/She didn't know if the IDT ever discussed a safety plan for when the resident was outside. During an interview on 5/5/26 at 11:54 A.M., the Care Plan Coordinator said:-The expectation was he/she was to review the PASRR recommendations and add them to the care plan. -He/She didn't realize the family member had asked the facility to pursue the guardianship and didn't know if the facility tried to pursue an emergency guardianship.-Recently the resident said he/she wanted his/her family member to pursue guardianship, and he/she assumed the family member was doing that.-The resident wasn't safe inside or outside the building because he/she was using drugs at the corner store and he/she needed a guardian.-He/She didn't know if the facility ever discussed the resident's need for a guardian. -He/She was not aware of the PASRR update from 2/26 or the new interventions that were recommended so he/she did not incorporate those interventions into the residents care plan. Review of the resident's March Medication Administration Record (MAR) showed the resident refused the following ordered psychotropic medications: -Benztropine Mesylate 0.5 milligrams (mg) (a medication used to manage drug-induced movement disorders extrapyramidal symptoms caused by antipsychotic medications) at 8:A.M., daily for paranoid schizophrenia was refused on 3/13/26, 3/23/26, and 3/24/26. -Cymbalta capsule delayed release particles 30 mg, (commonly prescribed to treat depression), two capsules by mouth in the morning were refused on 3/2/26, 3/3/26, 3/4/26, 3/7/26, 3/13/26, 3/23/26 and 3/24/26. -Trazadone HCI tablet 100 mg, one tablet by mouth at bedtime (a prescription antidepressant of the [NAME] class (Serotonin Antagonist and Reuptake Inhibitor) is primarily used to treat major depressive disorder) was refused on 3/4/26, 3/5/26, 3/10/26, 3/15/26, 3/18/26, 3/19/26 3/23/26, 3/24/26, 3/27/26 3/28/26 and 3/29/26. -Haloperidol tablet 10 mg, one tablet by mouth two times a day (a first-generation typical antipsychotic medication used primarily to treat schizophrenia, acute psychotic episodes, and Tourette's syndrome) for paranoid schizophrenia was refused on 3/2/26, 3/3/26, 3/4/26, 3/7/26, 3/13/26, 3/23/26, and 3/24/26. -Depakote tablet delayed release 500 mg (an FDA-approved prescription medication primarily used to treat epilepsy (seizures), stabilize mood in bipolar disorder (specifically manic episodes) by mouth three times per day was refused on 3/2/26, 3/3/26, 3/4/26, 3/7/26, 3/13/26, 3/23/26, and 3/24/26. Review of the resident's March 2026 progress notes showed no documentation regarding the resident's missing his/her medications or notifying the physician of the resident's missing medications. Review of the resident's most recent Mental Status Exam (MSE), dated 3/4/26, showed:-The resident continued to go outside in his/her wheelchair most days and sit at the gas station next door. The resident was on six psychotropic medications (drugs that affect brain function, altering mood, thoughts or behaviors). -The psychoactive substance abuse was worsening. Encourage the resident to refrain from outside drugs.-Insight and judgment were at baseline and were impaired as evidenced by decisions of recent past. -Multiple refusals for labs.-Care plan goals:--To continue haloperidol (Haldol - antipsychotic medication used to treat mental illness, such as schizophrenia, behavior problems, agitation, and symptoms of Tourette's syndrome (a neurodevelopmental disorder). --Demonstrate improved reality through medication compliance and therapeutic interactions. -The MSE did not show what staff were to do when the resident refused medication. Review of the resident's undated care plan showed problem identified as: -He/She had physical altercation incident initiated 3/5/26:--The resident was involved in a physical altercation with another resident.--Staff escorted the resident out of the building and educated the resident on side effects of drugs.--Staff were looking into new placement.-The resident had altered social interactions related to psychosis revised 3/10/26.-He/She had behaviors related to mental illness revised on 3/10/26:--His/her behaviors might disturb others and involve conversing with self and imaginary people.--Staff were to administer medications, address root cause of behavioral changes or mood as needed, and if disturbing others encourage the resident to go to a more private area to decrease episodes of disturbing others.-He/She had impaired social interaction psychotic disorder initiated 3/10/26:--The resident could be verbally loud and aggressive, yelling and cursing at staff and other residents.--Interventions showed:---Encourage recreational activities.---Monitor for negative thoughts and feelings.---Redirect to a private area if resident is verbally aggressive. Review of the resident's quarterly MDS, dated [DATE], showed the resident:-Was cognitively intact.-Felt down and depressed seven to 11 days out of the past 14.-Had verbal behaviors directed toward others.-Had other behaviors (e.g. - self harm, property destruction, disruptive behaviors).-Was diagnosed with schizophrenia/schizoaffective disorder and depression.-Within the past seven days routinely took an antipsychotic medication and an antidepressant. Review of the resident's Alert Note, dated 3/26/26 at 1:12 A.M., showed:-The resident returned to the facility at approximately 1:00 A.M. smelling strongly of alcohol with very bloodshot eyes. -His/her speech was slow and deliberate with an inability to focus. Review of the resident's care plan showed staff did not update the care plan with interventions after the resident came back on 3/26/26 with a strong smell of alcohol and signs of being intoxicated. Review of the resident's April 2026 MAR showed the resident refused the following ordered psychotropic medications:-Benztropine Mesylate 0.5 mg at 8:A.M., daily for paranoid schizophrenia was refused on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, 4/20/26, and 4/24/26. -Cymbalta capsule delayed release particles 30 mg, two capsules by mouth in the morning for Major Depressive Disorder (MDD) was refused on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, and 4/24/26.-Trazadone HCI tablet 100 mg, one tablet by mouth at bedtime for insomnia secondary to depression was refused on 4/1/26, 4/2/26, 4/5/26, 4/6/26, 4/7/26, 4/10/26, 4/11/26, 4/15/26, 4/16/26, 4/17/26, 4/20/26, 4/21/26, and 4/24/26.-Haloperidol tablet 10 mg, one tablet by mouth two times a day for paranoid schizophrenia was refused at 8:00 A.M. and 4:00 P.M. on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, 4/20/26, and 4/24/26.-Depakote tablet delayed release 500 mg by mouth three times a day for paranoid schizophrenia and schizoaffective disorder was refused at 8:00 A.M., 2:00 P.M., and 8:00 P.M. on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, 4/20/26 and 4/24/26. Review of the resident's April 2026 progress notes showed no documentation regarding the resident's missing his/her medications or notifying the physician of the resident's missing medications. Review of the resident's Behavioral Note, dated 4/8/26 at 5:15 A.M., showed:-The resident had verbal and threatening physical behaviors toward staff and had to be redirected three times.-He/She believed the staff had stolen drinks from his/her bathroom, which caused him/her to accuse the staff and led to the behaviors. -The Administrator, DON and ADON were notified of behaviors.-911 was called and the police officers arrived. No report to note. Advised the resident to not fight with the staff and to wait in the other room and the resident agreed. Review of the resident's undated care plan showed problem identified as: -The resident had a history of negative behaviors such as screaming, yelling and hallucinating revised 4/9/26.--The staff were to have provided counseling, outside support networks and a structured environment.-He/She was at risk for adverse reaction related to a history of having illicit drug on his/her person revised 4/9/26:--The physician would be notified if the resident was in possession of illicit drugs to review and evaluate medication for any changes to be made. --Review pharmacy consult recommendations and follow up as needed. Review of the resident's Behavior Note, dated 4/12/26 at 7:45 P.M., showed:-The resident was noted coming into the facility upset while in the lobby area.-The resident began to slam the facility phone during his/her outburst.-The nurse came in to try to de-escalate the situation when the resident grabbed the nurse by the hair and struck him/her in the eye. The resident also noted hitting and cracking the front door entrance to the facility.-The resident was still upset which prompted assistance from Emergency Medical Technicians (EMT) and the local police department.-The resident was taken to Hospital A for altered mental status. Review of the Resident's Physical Aggression Involving the Head investigation, dated 4/13/26, showed:-The Investigative Narrative showed:--On 4/12/26 Around 7:30 P.M. the resident was seen coming into the lobby verbally aggressive. --The ADON told the resident he/she would have to get off the phone when the resident slammed the desk phone. This upset the resident and he/she became extremely aggressive toward the ADON, eventually reaching the ADON to strike his/her eye and pull his/her hair. --Police were called, charges were pressed, and the resident was sent to the hospital. The hospital indicated the resident was aggressive there as well. --At 9:00 A.M. on 4/13/26 the Administrator asked the resident what happened, and he/she stated the ADON was talking crazy telling him/her to get off the phone and stuff like that. The ADON was all in his/her business. When asked if the resident hit the ADON the resident said not for real.--The Administrator discussed recent behaviors and the

Based on observation, interview, and record review, the facility failed to provide necessary behavioral health care and services to attain the highest practicable physical, mental, and psychosocial well-being in accordance with the resident's identified needs related to mental health care needs and substance use disorders. The facility failed to review, collaborate with the resident's interdisciplinary team (IDT), and create a plan of care after the resident receive an updated Preadmission Screening and Resident Review (PASRR) II (Level II - an in-depth assessment of resident's serious mental illness or related condition which evaluates the need for facility services, specialized services and confirms if nursing facility care is appropriate) to aid in preventing or relieving the residents behaviors, and help maintain the resident's safety. The facility failed to review and revise behavioral health care plans that had not been effective. The resident had multiple verbal and physical outbursts. Local police were called to manage resident's behavior on multiple occasions, with the resident having been jailed on at least two occasions. The resident had a history of leaving the facility and returning back with signs of having consumed large amounts of alcohol and illicit drugs, including an overdose which required the physician to order the resident on a 72 hour facility hold for safety and detox. The census was 103 residents.Review of the facility's Care Assessment Summary and Individualized Care Plan policy, revised 11/6/23, showed:-The Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) would be completed by Interdisciplinary Team members (Nursing, Activities, Social Services, Dietary) to address the needs of the individual resident.-After completing the MDS the Care Area Assessment (CAA) would be used to further assess triggered areas of concern. The care area triggered alerts to the assessor that interventions must be put in place to address care concerns in the plan of care for the individual resident.-The care plan should address:--Improvement where possible.--Maintenance and prevention of avoidable declines in all care area triggers. Review of the facility policy for Discharge, Immediate Discharge, Transfer and Therapeutic Leave, revised on 6/12/25, showed:-The purpose of the policy was to establish a policy and procedure regarding the transfer/discharge of residents to ensure no inappropriate discharges were made and that no discharges were made in an unsafe manner.-Reasons for discharge/transfer was when a resident's welfare and needs could not be met by the facility, and/or the resident's safety in the facility was in danger, the health of the resident could be in danger.-Reasons for Immediate Discharge included actual harm to self or others, non-compliance with medications which lead to severe behaviors, repeated disregard or destruction of facility property and/or sexual acting out with potential harm to self or others. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).-Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems).-Psychoactive substance abuse with psychoactive substance-induced disorder - a disconnection from reality characterized by hallucinations (sensory experiences which aren't related to reality) and delusions (false beliefs) attributed to substance intoxication.-Depression - a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living.-Acquired absence of right leg below knee and left leg below knee. Review of the resident's undated care plan showed problem identified as: -He/She had a psychosocial well-being problem with anxiety and ineffective coping revised on 4/5/24:--Staff were to provide opportunities for the resident and family to participate in care.--When conflict arose, staff were to remove the resident to a calm, safe environment and allow to vent feelings.-He/She was at risk for signs and symptoms of his/her schizophrenia, revised 6/4/24:--When speaking about the resident's hallucinations, the staff were to focus on how those hallucinations made the resident feel rather than the hallucinations themselves.-He/She was to reside in the least restrictive environment revised 4/5/24--The staff were to define for the resident his/her roles and expectations for being a resident in the facility.-He/She was to have resided in the facility of his/her choice revised 9/18/24:--The staff were to have sent our referrals for new placement at the resident's request.-The resident was to have had a decrease in behaviors during the next review period revised 12/24/24.--The resident was to have been offered PRN (as needed) medication to assist with outbursts and kept in a calm environment.-He/She had increased outbursts, initiated 12/24/24, showed: --The resident yelled and cussed at two little girls on his/her shoulders and frightened other residents.--Staff were to offer medications as needed to assist with outbursts and allow the resident to have outbursts in a private area. Review of an email sent by the facility Social Services Designee (SSD), dated 9/3/25, showed to the Director of Nursing (DON) as well as other former administrative staff that the SSD got a phone call from the resident's primary family member requested a letter with the resident's diagnoses as he/she attempted to obtain guardianship for the resident. Review of an email sent by the facility SSD, dated 9/17/25, to the facility DON requested a referral be sent to a sister facility for the resident as soon as possible, as his/her behaviors were escalating and becoming dangerous with the resident leaving the facility all day, taking illicit drugs and drinking alcohol. Review of an email received by the DON, dated 9/23/25, from a Health and Wellness Facility showed:-After receiving the resident's behavior notes the Health and Wellness Facility replied the resident's notes showed he/she had been found outside of the facility, had aggressive behaviors towards others, took illicit drugs from the street when he/she was outside the facility.-Due to these behaviors, they would not accept the resident into their community. Review of an email received by the DON, dated 10/28/25, sent from Assistant Director of Nursing (ADON) B showed the physician wanted to know if the DON wanted him/her to write a letter recommending the facility to get legal guardianship in light of the resident's poor impulse control and drug use. Record review of the resident's Electronic Medical Record, from October 2025 until May 2026, showed no documentation of any follow-up completed having the physician write a letter recommending the facility obtain guardianship. Review of the resident's undated care plan showed problem identified as: -He/She had depression related to schizophrenia revised on 1/20/26: --The resident had the following signs and symptoms related to schizophrenia:aggression, anxiety, inability to make decisions, delusions (fixed beliefs that can't be reasoned with), eyes that dart back and forth, fearfulness, hallucinations (hearing, seeing, feeling, and/or smelling things that aren't there), difficulty focusing, no interest in activities, irritability, making hand gestures as if having a conversation, mumbling, poor hygiene, isolation, and talking to self.--The resident states there are multiple little girls living on his/her shoulders who gain up on him/her and are mean.--Interventions included:---Administering medications for anxiety or hallucination according to physician orders.---Avoid arguing.---Notify charge nurse if observing resident experiencing signs/symptoms of schizophrenia.---Be careful when using reassuring touch.---Focus the resident on how the hallucination makes them feel rather than the content of the hallucination. Review of an email received by the DON and SSD, dated 2/10/26, sent by the facility Administrator said:-He/She had spoken to Regional Director of Operations (RDO) A regarding the most effective way for the facility to deal with Resident #1 in order to mitigate the resident's aggressive behaviors.-The resident was currently self-responsible and was suspected to have been a trigger for other residents in the facility.-On 2/6/26, the Administrator informed RDO A that he/she urgently needed to discharge the resident in order to prevent potential harm to the other residents.-On 2/9/26 he/she informed RDO A that he/she needed to either do an immediate discharge on the resident or need RDO A's assistance on placement to initiate a 30-day notice. -RDO A suggested sending a request to the corporate legal team, however the Administrator thought it best to reach out to the Ombudsman to learn of any resources that the team may not have tried before initiating an immediate discharge.-There was also a suggestion that the physician write an order to remove access for therapeutic leaves since it was not safe for the resident regardless of his/her status. -On 2/10 he/she informed RDO A that the resident had been banned from the corner store and had received multiple police citations in the past 24 hours. -He/She then stated that he/she had left a message for the Ombudsman.-He/She also asked the SSD to send out a mass referral on behalf of the resident, stating that in the case of safety, the resident did not have to give consent reinforcing that day one started when the facility accepted the resident. -He/She was hoping to hear from the Ombudsman by day's end of business 2/10/26.-He/She also asked the DON to reach out to the provider to ask that they write an order for the resident to not be able to sign themselves out due to safety, which he/she hoped would cover their bases for oversight. Record review of the resident's Electronic Medical Record, from February 2026 until May 2026, showed there was no documentation of any follow-up with the Ombudsman resources for the resident or follow up with the resident's physician to remove the therapeutic leave. Review of the resident Level II PASRR, dated 2/26/26 showed: -Besides the diagnoses mentioned on the admission Record the resident was also diagnosed with:--Bipolar disorder - Mood disorder that can cause intense mood swings.--Disruptive behavior disorder.--Conduct disorder, adolescent onset - a serious mental health condition, usually seen in children and adolescents, characterized by a consistent pattern of aggression, theft, vandalism, and rule violations that violate the rights of others.--Borderline Personality Disorder - a serious mental illness characterized by pervasive instability of moods, self-image, interpersonal relationships, and marked impulsivity.-The resident had a chronic pattern of severe psychiatric decompensation characterized by persistent auditory and visual hallucinations involving an imaginary little girl, fixed delusional content, and frequent responding to internal stimuli. He/She had recurrent verbal aggression, intimidation of peers, and escalation toward physical altercations, including lunging from his/her wheelchair, striking walls, damaging facility property and engaging in threatening behaviors that required staff intervention. He/She demonstrated repeated smoking and contraband violations and elopement to the adjacent gas station despite prior warnings and law enforcement involvement. He/She continued to go outside in his/her wheelchair most days and sit at the gas station next door.-The resident had been observed spending time outside at the corner store using recreational drugs; however, the specific substance type was not reported. -Progress notes reflected a pattern of behavioral dysregulation occurring in the context of active psychosis, poor impulse control, and suspected substance use. -The resident required 24-hour protective oversight due to the severity of behaviors or mental illness symptoms and medication management.-Mental health care needs exceeded what could be managed in previous/current living situation due to aggression, substance use, or medication non-compliance leading to exacerbation of symptoms.-Documentation indicated no active discharge planning and no referrals initiated. This appeared to contradict current nursing facility reports describing active efforts toward rehabilitation placement and guardianship pursuit.-The resident had ongoing use of illicit drugs and alcohol with poor insight and compromised safety judgment. -Due to the resident's severe and treatment-refractory psychiatric condition, ongoing substance use, significant behavioral dysregulation, and complex medical needs, the resident continued to require 24-hour care in a highly structured setting. His/Her chronic psychosis is characterized by persistent auditory and visual hallucinations, paranoid ideation, gross disorganization, and frequent response to internal stimuli which significantly impair his/her reality testing and behavioral regulation. He/She had been involved in multiple episodes of verbal and physical aggression, often in the context of responding to internal stimuli or perceived threats. In the nursing home setting the resident's symptoms remained only moderately controlled. His/Her illicit drug use continued to undermine psychiatric stability and posed serious safety concerns. The resident had a history of bilateral below knee amputations due to frostbite, resulting in mobility limitations and the need for continued assistance with activities of daily living (ADLs, feeding, dressing, grooming) and medical oversight. His/Her demonstrated inability to remain safely within the facility, nonadherence to medication and treatment when unsupervised, and vulnerability in the community highlight the necessity of a structured and secure environment. Placement in a nursing facility with a locked behavioral unit should be considered for the resident to address his/her ongoing elopement, enhance safety, and provide the containment necessary to support adherence, minimize risk of harm, and reduce access to illicit substances.-Given the resident's persistent substance use and repeated elopement for the purpose of obtaining drugs and alcohol, integrated dual-diagnosis therapy was strongly recommended to target both his/her psychiatric illness and substance use disorder.-The resident needed among other supports: medication set up and administration by staff monitoring for medication compliance, supports to prevent elopement, and assessment of supervision required to prevent harm to self or others. -Plan for crisis intervention that promoted emotional support, education, safety planning and case management to handle immediate crisis. A crisis plan should be developed to create clear steps that are to be taken to support the resident during a behavioral health crisis including who to contact for assistance, how to work together with the client during a crisis, and how to determine when the crisis is over. The plan should identify a physician and emergency medical services that should be contacted. The facility may also utilize Department of Mental (DMH) Health Behavioral Crisis hotline. Assault precautions and elopement precautions should be part of the crisis intervention plan. -At this time priority should be given to supporting the resident's family member in pursuing guardianship as the resident's poor insight, current psychosis, substance related behaviors, and documented refusal of previously arranged rehabilitation significantly limit his/her ability to participate meaningfully in discharge planning or adhere to treatment recommendations independently. The facility should provide assistance to the family to facilitate guardianship proceedings and coordinate communication with legal and community resources. If guardianship was achieved and sustained clinical stabilization occurred the primary recommendation would be residential or intensive substance use treatment and rehabilitation services given the resident's high-risk behaviors, ongoing risk for substance use, and prior refusal of rehabilitation placement. Review of the resident's Electronic Medical Record from February 2026 through May 2026 showed there was no safety plan created or implemented for the resident while he/she was outside of the building. Review of the resident's undated care plan showed problem identified as: -The resident continued to have increased behaviors including refusal of cares, along with verbal and physical aggression towards staff and peers revised 2/26/26. --The staff were to attempt to anticipate the resident's needs, attempt to discuss the resident's behaviors including why they were inappropriate and attempt to determine the cause for those behaviors, intervening as necessary while protecting the resident's rights. Further review of the resident's care plan showed recommendations from the 2/26/26 PASRR such as, providing support to the resident's family to obtain guardianship, providing 24/7 protective oversight on a locked unit, or providing outside counseling and drug/alcohol rehabilitation. Review of the resident's progress notes, from February 2026 - May 2026, showed no documentation of follow up regarding assisting the resident's family member to pursue guardianship of the resident as directed by the PASRR or to find alternate placement for the resident. Review of the resident's undated Individual Care Service Report (ICSP) showed: -The resident's crisis intervention plan showed triggers were hallucinations and stupid actions. --Staff were to monitor behaviors and attempt to determine underlying cause, monitor, document, and report any adverse psychotropic medication reactions, risk of harm to self or others, and or risky actions by the resident and any signs and symptoms of depression.-- They were to monitor, record and report depression and increased anger that could cause him/her to lash out at others.--They show that he/she was self-responsible and able to leave on pass without supervision of staff. -Mental health interventions/de-escalation steps were to:--Avoid arguing, respect personal space, and use simple clear language.--Notify charge nurse if observing the resident experiencing signs and symptoms of schizophrenia (hallucinations, delusions, difficulty focusing, inability to make decisions, poor hygiene, isolation, irritability, talking to self, mumbling, making hand gestures as if having a conversation, eyes darting, anxiety, and aggression) or if resident is suspected of violating the smoking policy.--Focus the resident on how the hallucination makes them feel rather than the content of the hallucination. During an interview on 5/12/26 at 2:15 P.M., the Administrator and DON said:-They were not aware that a new PASRR had been completed in February 2026. -They did not know who had requested a new PASRR nor were they aware of recommendations for obtaining a guardian for the resident nor that the resident had been deemed no longer appropriate for residence in the facility due to his/her behaviors. -They were not aware of the recommendations that the resident be placed on a locked unit so he/she could not leave unaccompanied by staff.-Once a new PASRR was recommended, the facility SSD should have been made aware and should have notified the Administrator, DON, MDS Coordinator and Care Plan Coordinator (CPC). -Those individuals should then incorporate the new recommendations into the resident's care plan after doing a Change of Condition MDS. -Without the knowledge that a new PASRR had even been completed, none of those procedures were followed.-They did share their concerns for the resident's safety earlier in the year with former RDO A asking for assistance in getting the resident out of the facility and/or emergency guardianship completed. -RDO A had reached out to the Ombudsman back in February 2026, but RDO A had not followed up. -They had also reached out in attempt to get corporate legal assistance in assisting the resident's primary family member in obtaining guardianship but were told there was no longer anyone on the corporate legal team who assisted with guardianship. -Their concern was that while the resident was still his/her own person, as a facility, they could not physically keep the resident inside the building, nor could they force him/her to take his/her medication every day as he/she had a right to refuse and they feared getting in trouble for limiting the resident's freedoms. During an interview on 5/5/26 at 11:10 A.M., the SSD said:-He/She didn't know who was responsible for following up on PASRR recommendations but thought the Care Plan Coordinator did that.-He/She didn't know the PASRR had recommended guardianship.-The resident's family member was going to pursue guardianship and then said he/she wouldn't. -On 4/24/26 the resident's family member asked if the facility could pursue the guardianship.-He/She had not initiated the guardianship process and didn't know if the Administrator had done so.-He/She didn't know if the IDT ever discussed a safety plan for when the resident was outside. During an interview on 5/5/26 at 11:54 A.M., the Care Plan Coordinator said:-The expectation was he/she was to review the PASRR recommendations and add them to the care plan. -He/She didn't realize the family member had asked the facility to pursue the guardianship and didn't know if the facility tried to pursue an emergency guardianship.-Recently the resident said he/she wanted his/her family member to pursue guardianship, and he/she assumed the family member was doing that.-The resident wasn't safe inside or outside the building because he/she was using drugs at the corner store and he/she needed a guardian.-He/She didn't know if the facility ever discussed the resident's need for a guardian. -He/She was not aware of the PASRR update from 2/26 or the new interventions that were recommended so he/she did not incorporate those interventions into the residents care plan. Review of the resident's March Medication Administration Record (MAR) showed the resident refused the following ordered psychotropic medications: -Benztropine Mesylate 0.5 milligrams (mg) (a medication used to manage drug-induced movement disorders extrapyramidal symptoms caused by antipsychotic medications) at 8:A.M., daily for paranoid schizophrenia was refused on 3/13/26, 3/23/26, and 3/24/26. -Cymbalta capsule delayed release particles 30 mg, (commonly prescribed to treat depression), two capsules by mouth in the morning were refused on 3/2/26, 3/3/26, 3/4/26, 3/7/26, 3/13/26, 3/23/26 and 3/24/26. -Trazadone HCI tablet 100 mg, one tablet by mouth at bedtime (a prescription antidepressant of the [NAME] class (Serotonin Antagonist and Reuptake Inhibitor) is primarily used to treat major depressive disorder) was refused on 3/4/26, 3/5/26, 3/10/26, 3/15/26, 3/18/26, 3/19/26 3/23/26, 3/24/26, 3/27/26 3/28/26 and 3/29/26. -Haloperidol tablet 10 mg, one tablet by mouth two times a day (a first-generation typical antipsychotic medication used primarily to treat schizophrenia, acute psychotic episodes, and Tourette's syndrome) for paranoid schizophrenia was refused on 3/2/26, 3/3/26, 3/4/26, 3/7/26, 3/13/26, 3/23/26, and 3/24/26. -Depakote tablet delayed release 500 mg (an FDA-approved prescription medication primarily used to treat epilepsy (seizures), stabilize mood in bipolar disorder (specifically manic episodes) by mouth three times per day was refused on 3/2/26, 3/3/26, 3/4/26, 3/7/26, 3/13/26, 3/23/26, and 3/24/26. Review of the resident's March 2026 progress notes showed no documentation regarding the resident's missing his/her medications or notifying the physician of the resident's missing medications. Review of the resident's most recent Mental Status Exam (MSE), dated 3/4/26, showed:-The resident continued to go outside in his/her wheelchair most days and sit at the gas station next door. The resident was on six psychotropic medications (drugs that affect brain function, altering mood, thoughts or behaviors). -The psychoactive substance abuse was worsening. Encourage the resident to refrain from outside drugs.-Insight and judgment were at baseline and were impaired as evidenced by decisions of recent past. -Multiple refusals for labs.-Care plan goals:--To continue haloperidol (Haldol - antipsychotic medication used to treat mental illness, such as schizophrenia, behavior problems, agitation, and symptoms of Tourette's syndrome (a neurodevelopmental disorder). --Demonstrate improved reality through medication compliance and therapeutic interactions. -The MSE did not show what staff were to do when the resident refused medication. Review of the resident's undated care plan showed problem identified as: -He/She had physical altercation incident initiated 3/5/26:--The resident was involved in a physical altercation with another resident.--Staff escorted the resident out of the building and educated the resident on side effects of drugs.--Staff were looking into new placement.-The resident had altered social interactions related to psychosis revised 3/10/26.-He/She had behaviors related to mental illness revised on 3/10/26:--His/her behaviors might disturb others and involve conversing with self and imaginary people.--Staff were to administer medications, address root cause of behavioral changes or mood as needed, and if disturbing others encourage the resident to go to a more private area to decrease episodes of disturbing others.-He/She had impaired social interaction psychotic disorder initiated 3/10/26:--The resident could be verbally loud and aggressive, yelling and cursing at staff and other residents.--Interventions showed:---Encourage recreational activities.---Monitor for negative thoughts and feelings.---Redirect to a private area if resident is verbally aggressive. Review of the resident's quarterly MDS, dated [DATE], showed the resident:-Was cognitively intact.-Felt down and depressed seven to 11 days out of the past 14.-Had verbal behaviors directed toward others.-Had other behaviors (e.g. - self harm, property destruction, disruptive behaviors).-Was diagnosed with schizophrenia/schizoaffective disorder and depression.-Within the past seven days routinely took an antipsychotic medication and an antidepressant. Review of the resident's Alert Note, dated 3/26/26 at 1:12 A.M., showed:-The resident returned to the facility at approximately 1:00 A.M. smelling strongly of alcohol with very bloodshot eyes. -His/her speech was slow and deliberate with an inability to focus. Review of the resident's care plan showed staff did not update the care plan with interventions after the resident came back on 3/26/26 with a strong smell of alcohol and signs of being intoxicated. Review of the resident's April 2026 MAR showed the resident refused the following ordered psychotropic medications:-Benztropine Mesylate 0.5 mg at 8:A.M., daily for paranoid schizophrenia was refused on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, 4/20/26, and 4/24/26. -Cymbalta capsule delayed release particles 30 mg, two capsules by mouth in the morning for Major Depressive Disorder (MDD) was refused on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, and 4/24/26.-Trazadone HCI tablet 100 mg, one tablet by mouth at bedtime for insomnia secondary to depression was refused on 4/1/26, 4/2/26, 4/5/26, 4/6/26, 4/7/26, 4/10/26, 4/11/26, 4/15/26, 4/16/26, 4/17/26, 4/20/26, 4/21/26, and 4/24/26.-Haloperidol tablet 10 mg, one tablet by mouth two times a day for paranoid schizophrenia was refused at 8:00 A.M. and 4:00 P.M. on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, 4/20/26, and 4/24/26.-Depakote tablet delayed release 500 mg by mouth three times a day for paranoid schizophrenia and schizoaffective disorder was refused at 8:00 A.M., 2:00 P.M., and 8:00 P.M. on 4/1/26, 4/2/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/17/26, 4/20/26 and 4/24/26. Review of the resident's April 2026 progress notes showed no documentation regarding the resident's missing his/her medications or notifying the physician of the resident's missing medications. Review of the resident's Behavioral Note, dated 4/8/26 at 5:15 A.M., showed:-The resident had verbal and threatening physical behaviors toward staff and had to be redirected three times.-He/She believed the staff had stolen drinks from his/her bathroom, which caused him/her to accuse the staff and led to the behaviors. -The Administrator, DON and ADON were notified of behaviors.-911 was called and the police officers arrived. No report to note. Advised the resident to not fight with the staff and to wait in the other room and the resident agreed. Review of the resident's undated care plan showed problem identified as: -The resident had a history of negative behaviors such as screaming, yelling and hallucinating revised 4/9/26.--The staff were to have provided counseling, outside support networks and a structured environment.-He/She was at risk for adverse reaction related to a history of having illicit drug on his/her person revised 4/9/26:--The physician would be notified if the resident was in possession of illicit drugs to review and evaluate medication for any changes to be made. --Review pharmacy consult recommendations and follow up as needed. Review of the resident's Behavior Note, dated 4/12/26 at 7:45 P.M., showed:-The resident was noted coming into the facility upset while in the lobby area.-The resident began to slam the facility phone during his/her outburst.-The nurse came in to try to de-escalate the situation when the resident grabbed the nurse by the hair and struck him/her in the eye. The resident also noted hitting and cracking the front door entrance to the facility.-The resident was still upset which prompted assistance from Emergency Medical Technicians (EMT) and the local police department.-The resident was taken to Hospital A for altered mental status. Review of the Resident's Physical Aggression Involving the Head investigation, dated 4/13/26, showed:-The Investigative Narrative showed:--On 4/12/26 Around 7:30 P.M. the resident was seen coming into the lobby verbally aggressive. --The ADON told the resident he/she would have to get off the phone when the resident slammed the desk phone. This upset the resident and he/she became extremely aggressive toward the ADON, eventually reaching the ADON to strike his/her eye and pull his/her hair. --Police were called, charges were pressed, and the resident was sent to the hospital. The hospital indicated the resident was aggressive there as well. --At 9:00 A.M. on 4/13/26 the Administrator asked the resident what happened, and he/she stated the ADON was talking crazy telling him/her to get off the phone and stuff like that. The ADON was all in his/her business. When asked if the resident hit the ADON the resident said not for real.--The Administrator discussed recent behaviors and the resident interrupted saying, you are supposed to be the head person and now you are talking to me crazy. Bitch The interview could not be continued due to escalating speech. The resident went to his/her room. --On 4/17/26 the resident apologized to the ADON and did not believe he/she hit the ADON. The resident refused to cooperate.-The conclusion showed:-The resident had been educated numerous times. -The facility was coordinating with facility Activities to find a group to host Alcohol Anonymous (AA) meetings inside the facility and/or other alternates to be a resource to all residents. -The resident was still unwilling to go to AA meetings. Review of ADON's Witness Statement showed:-On 4/12/26 around 7:45 P.M. he/she was in his/her office getting ready to go home when he/she heard the resident shouting and yelling. -The resident came into the facility angry at someone on the outside. The resident went straight to the phone and made a call.-He/She noticed the resident's eyes were blood red and he/she was slurring his/her words. The resident was hollering in the phone then the resident slammed the phone down twice really hard. -Staff asked the resident to calm down and told him/her lets go smoke. The resident refused and started charging the staff and flipped over the chair.-He/She informed the staff we needed to get the resident outside, but the resident started swinging and hitting at everyone. -The resident then caught ahold of his/her top and pulled him/her in and hit

Based on observation, interview, and record review, the facility failed to keep one sampled resident (Resident #4) safe from abuse out of 11 sampled residents when on 5/11/26 at approximately 9:55 P.M., Resident #4 was hit by another resident with his/her fist while sleeping which caused a large bruise on Resident #4's right bicep area and a cut under his/her left eye. The facility census was 103 residents.Review of the facility Abuse and Neglect Policy, dated 11/28/16 and revised on 06/12/24, showed Physical Abuse is purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal of inhumane manner. Handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. It can include, but not limited to hitting, slapping, punching, biting, kicking, and corporal punishment.1. Review of Resident #2's Preadmission Screening and Resident Review (PASRR, DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; this includes dually certified beds both Medicare and Medicaid), dated 7/29/15, showed he/she had the following diagnoses:-Schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, and behaviors, often causing a disconnection from reality).-He/She endorsed audible hallucinations (sensory perceptions of hearing sounds such as voices, music, or noises, without any corresponding external stimulus) and was frequently seen talking to himself/herself. Review of Resident #2's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 4/8/26, showed he/she was cognitively intact. Review of Resident #2's Individualized Care and Services Plan (ICSP), taken from the resident's care plan and used by the facility staff dated 4/21/26, showed:-His/Her triggers were hostile people, fidgeting, people stealing from him/her, being touched and invasions of his/her boundaries.-His/Her coping skills were to be left alone.-The staff were to intervene before the resident escalated if he/she became agitated, guide him/her away from the source of distress and engage him/her calmly in conversation. -The staff were to notify the Charge Nurse if the resident voiced any delusions or hallucinations. Review of Resident #2's progress note, dated 5/12/26 at 12:00 A.M., showed:-Resident #2 was seen outside his/her room showing a fighting stance.-Upon entering the residents', who were roommates, room, Resident #4 was still in bed with blood on his/her face.-Resident #4 stated Resident #2 hit him/her while he/she was sleeping.-The incident occurred in the residents room and was not witnessed by staff.-Resident #2 told staff he/she was told by God to attack his/her roommate, so he/she did.-Resident #2 stated Resident #4 was cussing at him/her prior to the incident.-Resident #2 later stated Resident #4 said, fuck my mother and fuck my hood and talked shit for two hours.-Resident #2 stated he/she asked the Lord if he/she could fight Resident #4.-Resident #2 stated that Resident #4 went to his/her hood on 29th street and told the people his/her hood was better and the people wanted to get him/her before Resident #2 did, so Resident #2 fought him/her.-Resident #2 also explained that he/she was blind at the time so couldn't see the people on 29th street so didn't know who they were.-Resident #4 stated that he/she was asleep and there had been no discussion between the two residents prior to the incident and Resident #2 didn't say anything after the incident, he/she just walked away and stood outside the door.-Resident #2 had no injuries and was moved to a different room and Resident #4 agreed to counseling. -Resident #2 was placed on one-to-one staff observation in a private room.-Resident #2 had a recent Gradual Drug Reduction of his/her Risperidone which was put back at the original dosage. Review of Resident #2's Facility Skin Assessment, dated 5/11/26 at 12:00 A.M., showed no injuries were noted. 2. Review of Resident #4's PASRR, dated 10/10/24, showed the resident had the following diagnoses:-Schizophrenia.-Bi-polar Disorder (a chronic, severe mental health condition characterized by at least one, often hospitalized , manic episode lasting at least 7 days or requiring immediate care, usually alternating with intense depressive episodes). Review of Resident #4's admission MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #4's ICSP, dated 4/14/26, showed:-The staff were to monitor the resident for signs of depression, labile mood or agitation, whether the resident felt threatened by others, resistance to care and withdrawal from others.-The staff were to converse with the resident, assist with staying on task, be aware of their body stance and facial expressions.-The staff was to closely watch the resident for signs of anxiety and act before the resident lost control.-The staff was to set limits that the resident needed to follow. Review of Resident #4's progress note dated 5/12/26 at 12:00 A.M., showed:-Resident #2 was seen outside his/her room showing a fighting stance.-Upon entering the residents', who were roommates, room, Resident #4 was still in bed with blood on his/her face.-Resident #4 stated Resident #2 hit him/her while he/she was sleeping.-The incident occurred in the resident' room and was not witnessed by staff.-Resident #2 told staff he/she was told by God to attack his/her roommate, so he/she did.-Resident #2 stated Resident #4 was cussing at him/her prior to the incident.-Resident #2 later stated Resident #4 said, fuck my mother and fuck my hood and talked shit for two hours.-Resident #2 stated he/she asked the Lord if he/she could fight Resident #4.-Resident #2 stated that Resident #4 went to his/her hood on 29th street and told the people his/her hood was better and the people wanted to get him/her before Resident #2 did, so Resident #2 fought him/her.-Resident #2 also explained that he/she was blind at the time so couldn't see the people on 29th street so didn't know who they were.-Resident #4 stated that he/she was asleep and there had been no discussion between the two residents prior to the incident and Resident #2 didn't say anything after the incident, he/she just walked away and stood outside the door.-Resident #2 had no injuries and was moved to a different room and Resident #4 agreed to counseling. -Resident #2 was placed on one-to-one staff observation in a private room.-Resident #2 had a recent Gradual Drug Reduction of his/her Risperidone which was put back at the original dosage. Review of Resident #4's Facility Skin Assessment, dated 5/12/26 at 12:00 A.M., showed:-He/She had a small 2 centimeter (cm) scratch under his/her left eye.-He/She had a small 1 cm scratch on the bridge of his/her nose. 3. Review of the facility Registered Nurse Investigation (RNI), dated 5/11/26 at 12:00 A.M., showed:-The incident involved physical aggression involving the head.-The incident was not witnessed but Resident #2 was noted outside his/her room in a fighting stance and was taken off the unit to de-escalate.-Resident #2 told staff he/she was told by God to attack his/her roommate, so he/she did.-Resident #2 stated Resident #4 was cussing at him/her prior to the incident.-Resident #2 later stated Resident #4 said, fuck my mother and fuck my hood and talked shit for two hours.-Resident #2 stated he/she asked the Lord if he/she could fight Resident #4.-Resident #2 stated that Resident #4 went to his/her hood on 29th street and told the people his/her hood was better and the people wanted to get him/her before Resident #2 did, so Resident #2 fought him/her.-Resident #2 also explained that he/she was blind at the time so couldn't see the people on 29th street so didn't know who they were.-Resident #4 stated that he/she was asleep and there had been no discussion between the two residents prior to the incident and Resident #2 didn't say anything after the incident, he/she just walked away and stood outside the door.-Resident #2 was placed on one-to-one staff observation in a private room.-Resident #2 had a recent Gradual Drug Reduction of his/her Risperidone which was put back at the original dosage.-Resident #2 showed no recent hallucinations, however, review of the prior 30 days did show some pattern of hallucinations.-Resident #2 also had two prior reported incidents of aggression in April 2026 where he/she was the aggressor. -The action taken post-incident was to educate the staff to review the communication dashboard and/or the ICSP for each resident in their care prior to their shift.-Resident #4 had a small scratch under his/her left eye and a small scratch on his/her nose.-Resident #4 said he/she got the injuries from Resident #2 hitting him/her while he/she was sleeping. Review of Resident #2's written statement, dated 5/11/26 and 5/12/26, showed:-He/She stated Resident #4 was cussing at him/her prior to the incident.-Resident #4 said, fuck my mother and fuck my hood and talked shit for two hours.-He/She asked the Lord if he/she could fight Resident #4.-Resident #4 went to his/her hood on 29th street and told the people his/her hood was better and the people wanted to get him/her before Resident #2 did, so Resident #2 fought him/her.-He/She was blind at the time so couldn't see the people on 29th street so didn't know who they were.-Resident #2 was asleep and there had been no discussion with Resident #4 prior to the incident and Resident #2 didn't say anything after the incident, Resident #2 just walked away and stood outside the door.-He/She was not trying to hurt Resident #4, he/she was just obeying God. During an interview on 5/18/26 at 2:30 P.M., Resident #2 said:-Resident #4 was his/her old roommate.-The Lord told him/her to fight Resident #4.-He/She hit Resident #4 a few times and left the room.-Resident #4 never hit back.-He/She had to do what the Lord told him/her to do.-He/She wasn't trying to hurt anyone, just trying to obey the Lord. Review of Resident #4's written statement, dated 5/11/26, showed he/she was just sleeping and his/her roommate started hitting him/her. Observation and interview on 5/18/26 at 2:42 P.M., showed:-Resident #4 had a two millimeter (mm) in circumference scab below his/her left eye and had a three-inch oval shaped bruise which had colors of blue, purple, green and yellow showing varying stages of healing, on his/her right bicep area. The resident said: -He/She just woke up with Resident #2 on top of him/her hitting him/her in the face and arm.-Resident #2 hits a lot of people.-He/She said the bruise and scab came from the incident with Resident #2. During an interview on 5/20/2026 at 2:53 P.M., Registered Nurse (RN) A said:-The residents were both assessed and Resident #4 was found to have two small scratches under Resident #4's his/her left eye and on the resident's chin. -Simple first aid was provided. During an interview on 5/20/26 at 1:45 P.M., the Director of Nursing (DON) said:-Resident #2 had a Gradual Drug Review (GDR) of his/her Risperidone (an antipsychotic medication used to treat schizophrenia) and soon after that he/she began having increased hallucinations. -They had contacted the psychiatric Nurse Practitioner (NP) and he/she had increased the resident's Risperidone back to where it was prior to the increase in hallucinations.-This incident was related to the GDR and not abuse. During an interview on 5/20/26 at 2:00 P.M., the Administrator said:-He/She did not believe this was abuse as it was different than the prior incidents with other residents.-In the prior incidents Resident #2 had a noted escalation in behavior before lashing at a resident.-In this case, there was no noted escalation, and it seemed to be totally caused by the GDR causing the resident to have hallucinations that he/she was acting on.-They realize they have to do the GDR's but frequently they end up causing an increase in behaviors with the residents soon after.-Since they had restored his/her medication dosage, he/she has leveled out in his/her behaviors. 3010863

Based on record review and interview, the facility failed to provide sufficient and appropriate social services to meet one resident's needs (Resident #1). The facility failed to provide or obtain services from outside entities to determine if the resident needed a legal representative or guardian to assist in making health care decisions. Family, physicians, administrative staff, and a PASRR assessment identified the need for the facility to facilitate guardianship proceedings and coordinate communication with legal and community resources, however, steps were not taken to begin the process. The facility census was 103 residents. 1. Review of Resident #1's undated care plan showed problem identified as: -He/She had depression related to schizophrenia revised on 1/20/26: --The resident had the following signs and symptoms related to schizophrenia:aggression, anxiety, inability to make decisions, delusions (fixed beliefs that can't be reasoned with), eyes that dart back and forth, fearfulness, hallucinations (hearing, seeing, feeling, and/or smelling things that aren't there), difficulty focusing, no interest in activities, irritability, making hand gestures as if having a conversation, mumbling, poor hygiene, isolation, and talking to self.--The resident states there are multiple little girls living on his/her shoulders who gain up on him/her and are mean.--Interventions included:---Administering medications for anxiety or hallucination according to physician orders.---Avoid arguing.---Notify charge nurse if observing resident experiencing signs/symptoms of schizophrenia.---Be careful when using reassuring touch.---Focus the resident on how the hallucination makes them feel rather than the content of the hallucination. Review of an email sent by the facility Social Services Designee (SSD), dated 9/3/25, showed to the Director of Nursing (DON) as well as other former administrative staff that the SSD got a phone call from the resident's primary family member requesting a letter with the resident's diagnoses as he/she attempted to obtain guardianship for the resident. Review of an email sent by the facility SSD, dated 9/17/25, to the facility DON requested a referral be sent to a sister facility for the resident as soon as possible, as his/her behaviors were escalating and becoming dangerous with the resident leaving the facility all day, taking illicit drugs, and drinking alcohol. Review of an email received by the DON, dated 10/28/25, sent from Assistant Director of Nursing (ADON) B showed the physician wanted to know if the DON wanted him/her to write a letter recommending the facility to get legal guardianship in light of the resident's poor impulse control and drug use. Review of the resident's Electronic Medical Record, from October 2025 until May 2026, showed no documentation of any follow-up completed having the physician write a letter recommending the facility obtain guardianship. Review of an email received by the DON and SSD, dated 2/10/26, sent by the facility Administrator said:-He/She had spoken to Regional Director of Operations (RDO) A regarding the most effective way for the facility to deal with Resident #1 in order to mitigate the resident's aggressive behaviors.-The resident was currently self-responsible and was suspected to have been a trigger for other residents in the facility.-On 2/6/26, the Administrator informed RDO A that he/she urgently needed to discharge the resident in order to prevent potential harm to the other residents.-On 2/9/26, he/she informed RDO A that he/she needed to either do an immediate discharge on the resident or need RDO A's assistance on placement to initiate a 30-day notice. -RDO A suggested sending a request to the corporate legal team, however the Administrator thought it best to reach out to the Ombudsman to learn of any resources that the team may not have tried before initiating an immediate discharge.-On 2/10/26, he/she informed RDO A the resident had been banned from the corner store and had received multiple police citations in the past 24 hours. Review of the resident Level II PASRR, dated 2/26/26 showed: -Besides the diagnoses mentioned on the admission Record the resident was also diagnosed with:--Bipolar disorder - Mood disorder that can cause intense mood swings.--Disruptive behavior disorder.--Conduct disorder, adolescent onset - a serious mental health condition, usually seen in children and adolescents, characterized by a consistent pattern of aggression, theft, vandalism, and rule violations that violate the rights of others.--Borderline Personality Disorder - a serious mental illness characterized by pervasive instability of moods, self-image, interpersonal relationships, and marked impulsivity.-The resident had a chronic pattern of severe psychiatric decompensation characterized by persistent auditory and visual hallucinations involving an imaginary little girl, fixed delusional content, and frequent responding to internal stimuli. He/She had recurrent verbal aggression, intimidation of peers, and escalation toward physical altercations, including lunging from his/her wheelchair, striking walls, damaging facility property and engaging in threatening behaviors that required staff intervention. He/She demonstrated repeated smoking and contraband violations and elopement to the adjacent gas station despite prior warnings and law enforcement involvement. He/She continued to go outside in his/her wheelchair most days and sit at the gas station next door.-The resident had been observed spending time outside at the corner store using recreational drugs; however, the specific substance type was not reported. -Progress notes reflected a pattern of behavioral dysregulation occurring in the context of active psychosis, poor impulse control, and suspected substance use. -The resident required 24-hour protective oversight due to the severity of behaviors or mental illness symptoms and medication management.-Mental health care needs exceeded what could be managed in previous/current living situation due to aggression, substance use, or medication non-compliance leading to exacerbation of symptoms.-Documentation indicated no active discharge planning and no referrals initiated. This appeared to contradict current nursing facility reports describing active efforts toward rehabilitation placement and guardianship pursuit.-The resident had ongoing use of illicit drugs and alcohol with poor insight and compromised safety judgment. -Due to the resident's severe and treatment-refractory psychiatric condition, ongoing substance use, significant behavioral dysregulation, and complex medical needs, the resident continued to require 24-hour care in a highly structured setting. His/Her chronic psychosis is characterized by persistent auditory and visual hallucinations, paranoid ideation, gross disorganization, and frequent response to internal stimuli which significantly impair his/her reality testing and behavioral regulation. He/She had been involved in multiple episodes of verbal and physical aggression, often in the context of responding to internal stimuli or perceived threats. In the nursing home setting, the resident's symptoms remained only moderately controlled. His/Her illicit drug use continued to undermine psychiatric stability and posed serious safety concerns. The resident had a history of bilateral below knee amputations due to frostbite, resulting in mobility limitations and the need for continued assistance with activities of daily living (ADLs, feeding, dressing, grooming) and medical oversight. His/Her demonstrated inability to remain safely within the facility, nonadherence to medication and treatment when unsupervised, and vulnerability in the community highlight the necessity of a structured and secure environment. Placement in a nursing facility with a locked behavioral unit should be considered for the resident to address his/her ongoing elopement, enhance safety, and provide the containment necessary to support adherence, minimize risk of harm, and reduce access to illicit substances.-Given the resident's persistent substance use and repeated elopement for the purpose of obtaining drugs and alcohol, integrated dual-diagnosis therapy was strongly recommended to target both his/her psychiatric illness and substance use disorder.-The resident needed among other supports: medication set up and administration by staff monitoring for medication compliance, supports to prevent elopement, and assessment of supervision required to prevent harm to self or others. -Plan for crisis intervention that promoted emotional support, education, safety planning and case management to handle immediate crisis. A crisis plan should be developed to create clear steps that are to be taken to support the resident during a behavioral health crisis including who to contact for assistance, how to work together with the client during a crisis, and how to determine when the crisis is over. The plan should identify a physician and emergency medical services that should be contacted. The facility may also utilize Department of Mental (DMH) Health Behavioral Crisis hotline. Assault precautions and elopement precautions should be part of the crisis intervention plan. -At this time priority should be given to supporting the resident's family member in pursuing guardianship as the resident's poor insight, current psychosis, substance related behaviors, and documented refusal of previously arranged rehabilitation significantly limit his/her ability to participate meaningfully in discharge planning or adhere to treatment recommendations independently. The facility should provide assistance to the family to facilitate guardianship proceedings and coordinate communication with legal and community resources. If guardianship was achieved and sustained clinical stabilization occurred the primary recommendation would be residential or intensive substance use treatment and rehabilitation services given the resident's high-risk behaviors, ongoing risk for substance use, and prior refusal of rehabilitation placement. Review of the resident's undated care plan showed problem identified as: -The resident continued to have increased behaviors including refusal of cares, along with verbal and physical aggression towards staff and peers, revised 2/26/26. Review of the resident's care plan showed recommendations from the 2/26/26 PASRR assessment not included in the resident's care plan including supporting the resident's family to obtain guardianship, need for 24/7 protective oversight on secured unit, and outside counseling and drug/alcohol rehabilitation. Review of the resident's progress notes, from February 2026 - May 2026, showed no documentation of follow up regarding assisting the resident's family member to pursue guardianship of the resident as directed by the PASRR or to find alternate placement for the resident. During an interview on 5/12/26 at 2:15 P.M., the Administrator and DON said:-They were not aware a new PASRR had been completed in February 2026. -They did not know who had requested a new PASRR, nor were they aware of recommendations for obtaining a guardian for the resident nor that the resident had been deemed no longer appropriate for residence in the facility due to his/her behaviors. -They did share their concerns for the resident's safety earlier in the year with former RDO A asking for assistance in getting the resident out of the facility and/or emergency guardianship completed. -They had also reached out in attempt to get corporate legal assistance in assisting the resident's primary family member in obtaining guardianship, but were told there was no longer anyone on the corporate legal team who assisted with guardianship. -Their concern was that while the resident was still his/her own person, as a facility, they could not physically keep the resident inside the building, nor could they force him/her to take his/her medication every day as he/she had a right to refuse and they feared getting in trouble for limiting the resident's freedoms. During an interview on 5/5/26 at 11:10 A.M., the SSD said:-He/She didn't know who was responsible for following up on PASRR recommendations, but thought the Care Plan Coordinator did that.-He/She didn't know the PASRR had recommended guardianship.-The resident's family member was going to pursue guardianship and then said he/she wouldn't.-On 4/24/26 the resident's family member asked if the facility could pursue the guardianship.-He/She had not initiated the guardianship process and didn't know if the Administrator had done so. During an interview on 5/5/26 at 11:54 A.M., the Care Plan Coordinator said:-The expectation was he/she was to review the PASRR recommendations and add them to the care plan. -He/She didn't realize the family member had asked the facility to pursue the guardianship and didn't know if the facility tried to pursue an emergency guardianship.-Recently the resident said he/she wanted his/her family member to pursue guardianship, and he/she assumed the family member was doing that.-The resident wasn't safe inside or outside the building because he/she was using drugs at the corner store and he/she needed a guardian.-He/She didn't know if the facility ever discussed the resident's need for a guardian. During an interview on 5/14 /26 at 11:00 A.M., Resident #1's primary family member said:-He/She felt that he/she had gotten no real assistance from the facility SSD. -He/She felt the facility didn't watch the resident close enough or keep the resident in the facility as they should.-The facility staff told him/her they couldn't keep the resident in the facility against the resident's will as long as the resident was self-responsible.

Based on observation, interview, and record review, the facility failed to protect three sampled residents (Resident #1, #5 and #8) from physical abuse out of 15 sampled residents. On 4/18/26 Resident #6 choked Resident #5 around his/her neck which left scratch marks to Resident #5's neck. On 4/22/26 Resident #7 hit Resident #8 in the face that caused bruising to Resident #8's left eye. On 4/24/26 Resident #2 hit Resident #1 in the face that caused bruising to Resident #1's left eyebrow/forehead area and nose. The facility census was 104 residents.Review of the facility's policy titled Abuse and Neglect Policy, dated 6/12/2024, showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident to resident altercations.-It included verbal abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology.-Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner.-Physical abuse also included, but was not limited to, hitting, slapping, punching, biting, and kicking.-The facility would identify, correct, and intervene in situations in which abuse was more likely to occur.-Prevention would also include assessment care planning and monitoring of residents with needs or behaviors which may lead to conflict or neglect. 1.Review of Resident #5's admission Record showed he/she admitted to the facility with a diagnosis of paranoid schizophrenia (a chronic mental health condition characterized by a combination of schizophrenia symptoms such as hallucinations or delusions) and mood disorder symptoms (mania or depression). Review of Resident #5's quarterly Minimum Data Set (MDS- a federally mandated assessment completed by facility staff), dated 3/5/26, showed:-The resident was cognitively intact.- The resident had no behavioral symptoms within the seven day look back period. Review of an Incident Note, dated 4/18/26 at 9:05 A.M., from Resident #5's showed:-The resident was observed in his/her wheelchair and Resident #6 was standing over Resident #5 hitting Resident #5 several times in the chest and face.-Resident #5 reported that he/she was turning the channel on the TV and then he/she was hit by Resident #6.-Resident #5 had redness on the left side of his/her face and chest area with a scratch under his/her neck.-Resident #5 was sent to a local hospital upon request. Review of Resident #6's admission Record showed he/she was admitted to the facility with a diagnosis of schizoaffective disorder. Review of an Incident Note, dated 4/18/26 at 9:05 A.M., from Resident #6s EMR showed:-The resident was observed to be standing over Resident #5 and hit Resident 35 several times.-Resident #6 reported that Resident #5 took the TV remote from him/her.-Resident #6 was educated on not hitting people.-Resident #6 began to cuss out the staff member and attempted to charge Resident 5 who was sitting at the nurse's station. Review of an Admin/RN (Administrator/ Registered Nurse) Investigation, dated 4/18/26 at 9:10 A.M., showed:-The incident occurred on 4/18/26 at 9:10 A.M.-The type of incident was physical aggression involving the head.-Resident #5 and Resident #6 were involved in an incident.-Resident #9 was a witness to the incident.-The Assistant Director of Nurses (ADON) was on the phone with the Director of Nursing (DON) when he/she heard commotion at the far-left table in front of the TV in the main dining room.-The ADON saw Resident #6 standing over Resident #5 and appeared to be hitting Resident #5 but was not sure due to the angle he/she was looking from.-Resident #9 said the following:--Resident #5 and Resident #6 were fighting/arguing over the TV remote.--Resident #6 wanted to put on a movie while Resident #5 was asking for the TV remote back.--Resident #6 declined to give the TV remote back, stood up, and hit Resident #5.--He/She was certain that Resident #5 had been hit, but he/she could not tell if it had been with an open or closed hand.-Resident #5 and Resident #6 were interviewed by the police before being transported to the hospital.-The facility concluded the following:--Resident #6 made physical contact with Resident #5 during a dispute over the TV remote in the main dining room.--A staff member observed Resident #6 standing over and appeared to strike Resident #5.--Based on staff observations and assessment findings, the physical interaction between Resident #5 and Resident #6 did occur, so the allegation was substantiated.-The incident was a result of abuse. Review of Resident #5's care plan, dated 4/18/26, showed the resident was involved in a physical altercation with a peer on 4/18/26 with a noted minor injury. Review of Resident #6's care plan, dated 4/18/26, showed:-Do not argue or get defensive with the resident.-Watch the resident closely for signs of agitation and work with the resident to reduce impulsive feelings of anger.-The resident had been involved in a physical altercation with a peer on 4/18/26 which resulted in a minor injury to the peer. Review of a Skin Check dated 4/18/26 at 9:05 A.M. from Resident #5's EMR showed the resident had redness on the left side of his/her face and a scratch on his/her neck. Review of a Skin Check dated 4/18/26 at 9:05 A.M. from Resident #6's EMR showed no skin issues were found. Review of Police Report, dated 4/18/26 at 3:37 P.M., showed:-The incident was a non-aggravated assault.-They were dispatched to the facility at 9:15 A.M.-The call notes stated that one resident had assaulted another resident.-Resident #6 was the suspect and was charged with the assault.-Resident #5 was the victim.-The police officer made contact with Resident #5 first.-Resident #5 said:--He/She had been sitting in the cafeteria in his/her electric wheelchair watching TV.--Resident #6 handed him/her the TV remote to control the TV.--He/She told Resident #6 that he/she was going to put on a movie.--Resident #6 then became angry and came to the right side of his/her wheelchair.--Resident #6 put two hands around his/her neck and began to choke him/her.--He/She tried to grab Resident #6's hands to get Resident #6 to stop.--Staff then responded to the incident and separated Resident #6 from him/her.--He/She did not lose consciousness from being choked.-The officer then made contact with Resident #6.-Resident #6 said:--He/She had the TV remote when Resident #5 ripped the remote out of his/her hands.--He/She tried to get the TV remote back from Resident #5 when Resident #5 started to pull at his/her hair.--He/She then hit with an open hand Resident #5 in the chest.--Staff came and separated them.--He/She denied choking Resident #5.-The officer then made contact with the ADON.-The ADON said:--Resident #5 and Resident #6 were in the cafeteria watching tv with their backs to him/her.--He/She looked up and saw arms moving in a hitting motion.--He/She went over to see what was going on.--He/She saw Resident #6 standing over the side of Resident #5's wheelchair with two hands around Resident #5's neck.--Staff broke up and separated the residents before calling the police.--He/She thought Resident #6's behavior had been escalating towards employees and other residents over the past few days.-The officer observed scratches to Resident #5's neck.-The officer did not observe any marks to Resident #6's body. Review of Resident #5's witness statement, dated 4/18/26, showed:-He/She was watching TV.-Resident #6 then gave him/her the TV remote to find a movie to watch.-Resident #6 then stood over him/her.-Resident #6 then went to hit him/her. During an interview on 4/27/26 at 4:00 P.M., Resident #5 said:-Resident #6 stood over him/her.-Resident #6 then started to hit him/her.-Resident #5 then ended the interview. During an interview on 4/27/26 at 3:38 P.M., Resident #6 said:-He/She had been using the TV remote.-Resident #5 wanted to use the TV remote, so he/she handed the remote to Resident #5.-Resident #5 yanked it out of his/her hands and changed the channel.-He/She questioned Resident #5 and asked for the TV remote back.-He/She reached out his/her hand to get the TV remote back.-Resident #5 must have thought that he/she was trying to do something because Resident #5 then started pulling his/her hair.-Resident #5 also hit him/her in the neck.-Resident #5 pulled out a handful of his/her hair.-He/She denied choking Resident #5, but he/she did strike Resident #5 in the chest to get Resident #5 to let go of his/her hair. Review of Resident #9's quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #9's written statement, dated 4/18/26, showed:-Resident #5 and Resident #6 were fighting over a TV remote.-Resident #5 was trying to change the TV to a movie.-Resident #6 asked for the TV remote back and Resident #5 told Resident #6 no.-Resident #6 then stood up and hit Resident #5 in the face.-He/She could not tell if Resident #6 hit Resident #5 with an open or closed hand. During an interview on 4/28/26 at 11:56 A.M., Resident #9 did not want to say anything. During an interview on 4/28/26 at 12:03 P.M., the ADON said:-He/She had been at the nurse's station when the altercation occurred.-He/She was unsure of what led to the incident.-He/She saw Resident #5's hands waving and Resident #6 leaned over Resident #5.-He/She couldn't really tell at first if Resident #5 and Resident #6 were having a physical altercation.-Resident #6 hit Resident #5 in the chest area and face.-He/She did observe Resident #6's hands around Resident #5's neck, but not in a choking manner.-Resident #6 did try to hit Resident #5 again while at the nurse's station.-He/She observed redness to Resident #5's face and chest. During an interview on 4/28/26 at 1:14 P.M., Nurse Practitioner (NP) B said:-He/She had been notified after the altercation.-He/She had not observed or heard of any behavior that Resident #6 exhibited before this altercation occurred.-He/She had not been really told what happened.-He/She thought that the staff didn't really know what happened either.-If Resident #6 had hit Resident # 5 then the altercation would be considered abuse. During an interview on 4/28/26 at 2:37 P.M., the Director of Nurses (DON) and Regional Nurse Consultant (RNC) said:-The TV remote was the root cause of the altercation.-There was no outcome related to the altercation.-The DON thought the altercation was a behavioral incident.-They did not think that the altercation could have been prevented and that staff responded appropriately. 2. Review of Resident #8's admission Record showed he/she admitted to the facility with a diagnosis of schizoaffective disorder (a mental health condition that includes features of both schizophrenia and mood disorder), bipolar (a mood disorder that can cause intense mood swings) type. Review of Resident #7's admission Record showed he/she was admitted to the facility with a diagnosis of schizoaffective disorder, bipolar type. Review of Resident #7's quarterly MDS, dated [DATE], showed:-The resident was cognitively intact.-The resident did not have any hallucinations or delusions within the seven day look back period.-The resident had no behavioral symptoms within the seven day look back period. Review of Resident #8's quarterly MDS, dated [DATE], showed:-The resident was cognitively intact.-The resident had no behavioral symptoms within the seven-day look back period. Review of an Admin/RN Investigation, dated 4/23/26 at 3:20 P.M., showed:-The incident occurred on 4/22/26 at 7:30 P.M.-The type of incident was physical aggression invColving head.-Resident #7 was the aggressor in the incident.-Resident #8 was the victim in the incident.-A code green was called at 7:30 P.M. regarding a physical altercation in the hallway.-Upon arrival, staff separated Resident #7 and Resident #8.-Resident #7 was found sitting in a chair in the dining area and stated that another resident had poured something on him/her. -A skin check was performed on Resident #7 and no injuries were found.-Resident #8 was found standing in the doorway of another resident's room.-Resident #8 reported that another resident became angry about not getting some noodles that Resident #8 had had in his/her hands.-Resident #7 then proceeded to call Resident #8 names and hit him/her near his/her left eye several times before falling to the ground.-The nurse had observed a bruise over Resident 8's left upper eye. -Resident #8 was given some pain medication and an ice pack was applied. -The residents had not been sent to the hospital.-The facility concluded that a peer-to-peer physical altercation had occurred.-The residents had been immediately separated, assessed, and treated. Review of a Skin Check dated 4/22/26 at 7:30 P.M., showed Resident #8 had a hematoma (a collection of blood beneath the skin) to his/her left temporal area close to his/her left eye. Review of an Incident Note, dated 4/22/26 at 7:49 P.M., from Resident #7's EMR showed:-Upon arrival, Resident #7 was found in the dining area sitting in a chair with no physical injuries noted.-When asked what happened, Resident #7 stated another resident had poured something on him/her. Review of an Incident Note, dated 4/22/26 at 8:35 P.M., from Resident #8's EMR showed:-Upon arrival, Resident #8 was standing in the doorway of another resident's room.-The nurse observed a knot over the resident's left upper eye.-When asked what happened, Resident #8 stated that another resident became angry related to some noodles that Resident #8 had in his/her hands.-Resident #8 then said that the other resident had called him/her several names and attacked him/her by hitting him/her by his/her eye several times. -Both residents then fell to the floor. Review of Resident #8's care plan, dated 4/23/26, showed the resident had been involved in a physical altercation with a peer on 4/22/26 and had an injury to the left eye. Review of Resident #7's written statement, dated 4/23/26, showed:-Resident #8 threw tomato sauce on him/her at lunch time.-He/She felt Resident #8 took it too far after he/she flipped him/her off.-He/She had given Resident #8 a dirty look and that was why Resident #8 flipped him/her off.-He/She hit Resident #8 and then Resident #8 pinned him/her to the ground. During an interview on 4/27/26 at 2:35 P.M., Resident #7 said:-He/She had flipped off Resident #8.-Resident #8 then flipped him/her off back.-Resident #8 had Vienna sausages with him/her.-Resident #8 then threw the contents of the container at him/her.-This prompted him/her to hit Resident #8 really hard in the eye.-He/She intended to hurt Resident #8 and would have killed Resident #8 if staff had not held him/her back.-He/She felt that the altercation was self-defense.-Staff told him/her afterwards to not get into fights and to avoid Resident #8.-He/She had bad hallucinations recently. Review Resident #8's written statement, dated 4/23/26, showed:-Resident #7 wanted some coffee.-Resident #7 was unable to get coffee.-Resident #7 then started flipping him/her off.-Resident #7 was cussing at him/her.-He/She went back to the hallway and Resident #7 started threatening him/her.-He/She told Resident #7 off.-Resident #7 then proceeded to hit him/her four times above his/her eye.-He/She and Resident #7 went down to the ground and some of his/her Vienna sausages ended up on Resident #7 and him/her.-Resident #7 said that he/she had thrown the Vienna sausages at him/her.-He/She ended up putting Resident #7 in a chokehold.-He/She did not hit Resident #7 back. Observation and interview on 4/27/26 at 3:09 P.M., showed Resident #8 had had purple and red bruising to his/her left eye; and had yellow bruising around his/her left eye, eyebrow, and forehead. He/She said: -Resident #7 wanted coffee.-He/She had been given coffee and Resident #7 was not given any.-Resident #7 then got upset and took it out on him/her.-He/She felt like he/she had just been a convenient target for Resident #7's aggression.-Vienna sausage juice had gotten on Resident #7 during the altercation, but he/she had not thrown anything on Resident #7 prior to the altercation.-His/Her eye had started to heal up by the time SA interviewed him/her and was no longer in pain.-He/She did not feel safe at the facility because of the altercation.-He/She had not reported his/her safety concerns to any of the staff members prior to the interview. Review of Certified Nursing Assistant (CNA) D's witness statement, dated 4/22/26, showed:-He/She had been conducting the 7:30 P.M. smoke break.-He/She overheard residents arguing.-He/She then opened the door and saw Resident #7 and Resident #8 on the floor fighting.-He/She then separated the residents and called a Code green (response to a behavioral incident). During an interview on 4/28/26 at 8:58 A.M., CNA D said:-He/She was in the smoke room when he/she heard loud yelling.-He/She exited the smoke room and saw Resident #7 and Resident #8 fighting.-He/She saw Resident #7 hitting Resident #8. Review of CNA F's witness statement, dated 4/22/26, showed:-He/She was sitting in the common area.-Resident #7 and Resident #8 were in a physical altercation in the hallway around 7:20 P.M.-He/She yelled for CNA D. During an interview on 4/28/26 at 9:04 A.M., CNA F said:-He/She had been looking through a resident's chart when the altercation occurred.-He/She looked up and saw Resident #7 and Resident #8 fighting in the hallway.-Resident #7 was hitting Resident #8. During an interview on 4/28/26 at 12:32 P.M. ADON said the altercation between Resident #7 and Resident #8 would be considered abuse. During an interview on 4/28/26 at 1:14 P.M., NP B said:-He/She thought the altercation occurred because of coffee.-Resident #7 had hallucinations and delusions as part of his/her baseline.-He/She felt the altercation would be considered as abuse.-He/She did not think that the incident could have been prevented due to Resident #7's impulsiveness. During an interview on 4/28/26 at 2:37 P.M., the DON and RNC said:-The root cause of the altercation was related to an unmet need. Resident #7 wanted coffee and Resident #8 had the coffee that Resident #7 wanted.-The DON did not think that Resident #7 had actual intent to harm Resident #8. 3. Review of Resident #1's admission Record showed he/she admitted to the facility with the diagnosis of disorder of brain, unspecified. Review of Resident #1's annual MDS, dated [DATE], showed:-The resident was cognitively intact.-The resident had no behavioral symptoms within the seven day look back period. Review of a Social Services Progress Note, dated 4/24/26 at 5:00 P.M., from Resident #1's EMR showed:-The resident was the aggressor in the resident-to-resident altercation.-Resident #1 and Resident #2 were sitting in the dining area and having a conversation.-Resident #1 felt that Resident #2 was talking down to him/her.-Resident #2 had been telling Resident #1 that he/she wasn't a good parent because Resident #1 would rather smoke cigarettes and eat all day long rather than do good by his/her children.-Resident #1 did not like that so he/she threw a cup of juice at Resident #2's face.-Resident #2 responded by hitting Resident #1 in the face. Review of Resident #2's admission Record showed he/she admitted to the facility with a diagnosis of other schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of Resident #2's quarterly MDS, dated [DATE], showed:-The resident was cognitively intact.-The resident had no behavioral symptoms within the seven day look back period. Review of a Social Services Progress Note, dated 4/24/26 at 5:00 P.M., from Resident #2's EMR showed:-The resident was the victim in the resident-to-resident altercation.-Resident #2 said he/she and Resident #1 were having a conversation about getting out of the facility.-Resident #2 told Resident #1 that as a parent he/she should be doing everything so he/she could get to his/her kids.-Resident #2 also told Resident #1 that Resident #1 was less of a parent because all Resident #1 ever thought about was eating and smoking.-Resident #1 then threw a cup of Kool-Aid in Resident #2's face.-Resident #2 lost his/her composure after Resident #1 threw the Kool-Aid. Review of an Admin/RN Investigation, dated 4/24/26, showed:-The incident occurred on 4/24/26 at 4:50 P.M.-The type of incident was physical aggression involving the head.-Resident #1 and Resident #2 were involved in the incident.-Resident #2 struck Resident #1 in the face.-Upon arrival, Resident #2 was observed in his/her room sitting on the side of the bed breathing heavily and appearing anxious.-Resident #2 stated, We were talking, and he/she got upset about me telling him/her the fact of life. Resident #1 picked up his/her cup. I told Resident #1 three times not to throw the drink on me. He/She did it anyway, so I hit him/her.-Resident #2 had superficial scratches to his/her upper chest area.-The facility concluded that Resident #1 and Resident #2 had been in a physical altercation initiated by a drink being thrown.-The incident was determined not to be a result of abuse. Review of a Police Report, dated 4/25/26 at 1:41 A.M., showed:-The incident was a non-aggravated assault.-The officers had been dispatched to the facility at 11:43 P.M.-Resident #1 and Resident #2 were considered victims.-When the police officers arrived at the facility, the head nurse had reported that there had been a physical altercation between Resident #1 and Resident #2.-The officer made contact with Resident #2 first.-Resident #2 said:--He/She had been sitting with Resident #1 in the lunchroom.--He/She had gotten into a verbal altercation over family matters with Resident #1.--Resident #1 picked up a drink to throw at him/her.--Resident #2 stated If you throw your juice on me, I am going to beat your ass.--Resident #1 proceeded to throw juice on him/her.--He/She then got up and punched Resident #1 in the face multiple times with a closed fist.--At that point, staff had separated the residents.-The officer then made contact with Resident #1.-Resident #1 said:--Resident #2 was sitting with Resident #1 in the lunchroom.--He/She had gotten into a verbal altercation with Resident #2 over family matters.--He/She picked up a drink to throw at Resident #2.--Resident #2 stated If you throw your juice on me, I am going to beat your ass.--He/She then proceeded to throw juice on Resident #2.--Resident #2 then got up and punched Resident #1 in the face multiple times with a closed fist.--At that point, staff had separated the residents.-Resident #1 appeared to have minor injuries to his/her nose and forehead. Review of Resident #1's care plan, dated 4/25/26, showed the resident had been involved in a physical altercation with a peer related social conflict with noted emotional distress and bruising to nose. Review of Resident #2's care plan, dated 4/25/26, showed the resident had been involved in a physical altercation with a peer related to social conflict with noted anxiety, labored breathing, and superficial scratches to chest. Review of Resident #1's written statement, dated 4/27/26, showed:-Resident #2 hit him/her because he/she had thrown a cupcake when talking about his/her daughter.-Resident #2 called him/her dumb.-He/She had pain to his/her nose and above his/her eyes. Observation and interview on 4/27/26 at 12:58 P.M., showed Resident #1 had yellow and purple bruising to his/her nose and left eyebrow/forehead area. He/she said: -Resident #2 had been talking bad about him/her.-He/She threw a cup of juice at Resident #2.-Resident #2 responded by hitting him/her.-If he/she had known that Resident #2 was going to hit him/her then he/she would not have thrown the juice at Resident #2.-He/She talked with staff afterwards about using coping skills and kind words.-He/She would not throw juice at anyone else. Review of Resident #2's witness statement, dated 4/24/26, showed:-Resident #1 had asked what's for dinner.-Resident #2 told Resident #1 what was for dinner.-Resident #1 then asked again, so in response Resident #2 said he/she needed to try to remember.-Resident #1 then said that he/she wasn't talking to Resident #2. During an interview on 4/27/26 at 1:16 P.M., Resident #2 said:-He/She had been sitting at a table with Resident #1.-They were sitting across from each other.-Resident #1 rolled his/her eyes and got hateful.-He/She told Resident #1 he/she didn't need to be a smartass.-Resident #1 then called him/her a dumbass.-He/She was talking to Resident #1 about the different things that he/she could do to be able to get back with his/her daughter.-Resident #1 looked like he/she was going to throw water at him/her.-He/She told Resident #1 not to do that and had reminded him/her three different times.-He/She told Resident #1 that he/she would whoop his/her ass if he/she threw the water.-Resident #1 then threw the juice at him/her.-He/She then responded by hitting Resident #1 in the face.-He/She then blacked out and when he/she came to, he/she was still punching Resident #1 in the face and staff were pulling him/her off of Resident #1.-He/She cared about Resident #1, and his/her impulse got the better of him/her.-He/She was ashamed and remorseful of his/her actions. Review of CNA G's witness statement, dated 4/24/26, showed:-He/She witnessed punching Resident #2 punching Resident #1 in the face.-A conversation led to the altercation.-Resident #2 had been talking about Resident #1's child.-Resident #2 wanted Resident #1 not to throw juice at him/her or else he/she would whoop Resident #1's ass. During an interview on 4/28/26 at 9:18 A.M., CNA G said:-Resident #1 and Resident #2 were sitting at a table.-Resident #2 was talking to Resident #1 about how Resident #1 was going to take care of his/her daughter if Resident #1 could not take care of himself/herself.-At some point before the altercation he/she did remember Resident #2 saying if you throw it, I will whoop your ass.-This triggered Resident #1 and Resident #1 then threw water at Resident #2.-Everything happened so quickly and there was no time to respond to the threat.-Resident #1 told him/her that Resident #1's daughter caused Resident #1 to throw water at Resident #2. Review of CNA B's witness statement, dated 4/24/26, showed:-Resident #1 and Resident #2 were arguing about something.-He/She overheard Resident #2 say if you throw that water at me, I am going to whoop your ass.-He/She then told Resident #1 not to throw water on Resident #2.-Resident #1 initially did not throw the water at Resident #2 after the reminder.-All of the sudden Resident #1 threw water at Resident # #2. During an interview on 4/28/26 at 9:51 A.M., CNA B said:-Resident #1 and Resident #2 were having a conversation.-The conversation turned into an argument.-He/She checked-in with Resident #2 to see if everything was okay.-Everything went quiet after that.-He/She then heard Resident #1 tell Resident #2 that he/she would throw water at Resident #2.-Staff told Resident #1 not to do that and everything went quiet again and he/she went back to charting.-All of a sudden, he/she saw juice flying and Resident #2 hit Resident 1.-He/She did not think that the resident's would get into a physical altercation because Resident #1 and Resident #2 were close.-The altercation would be considered abuse. Review of CMT B's witness statement, dated 4/24/26, showed:-Around 4:37 P.M. he/she had been at his/her medication cart.-He/She heard a voice from one of the staff members.-The staff member was shouting and telling the residents to stop it.-He/She then ran to the altercation and saw Resident #2 hitting Resident #1 in the face.-He/She then separated the residents. During an interview on 4/28/26 at 10:13 A.M., CMT B said:-He/She wasn't in the best position to see what had happened.-He/She had been looking for his/her keys when he/she heard a staff member say, stop it.-He/She then ran to the incident and saw Resident #2 hitting Resident #1 in the face.-He/She was unsure of what triggered the altercation.-He/She saw redness to Resident #1's ears and face and some bruising after the altercation ended. -He/She reminded Resident #1 to use self-defense when a resident becomes physical.-He/She felt the incident could have been prevented.-The altercation would be considered abuse. Review of Resident #12's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of Resident #12's witness statement, dated 4/24/26, showed:-Resident #1 threw Kool-Aid on Resident #2.-Resident #2 responded by punching Resident #1 about two to three times. During an interview on 4/28/26 at 11:25 A.M., Resident #12 said:-Resident #1 and Resident #2 were talking about kids.-Resident #1 then threw juice at Resident #2.-Resident #2 then started punching Resident #1.-The altercation happened in the dining room. Review of Resident #13's annual MDS, dated [DATE], showed the resident had mildly impaired cognition. Review of Resident #13's witness statement, dated 4/24/26, showed:-Resident #2 was putting Resident #1 down and saying mean things.-Resident #1 then threw the juice at Resident #2.-Resident #2 then started hitting Resident #1.-A Code [NAME] was then called. During an interview on 4/28/26 at 11:51 A.M., Resident #13 said:-Resident #2 put Resident #1 down and then started wailing on Resident #1.-Resident #1 had thrown Kool-Aid at Resident #2 during the altercation. During an interview on 4/28/26 at 12:23 P.M., the ADON said:-The altercation could have been prevented.-Staff heard the situation going on and they all knew that Resident #2 escalated things quickly.-When staff overheard Resident #2 warn Resident #1 multiple times that would have been the opportunity for intervention.-Staff only intervened verbally when they should have intervened by walking over to the residents to figure out how to best respond.-Staff could have taken Resident #2 off the unit or could have taken the juice away from Resident #1.-The altercation would be considered as abuse. During an interview on 4/28/26 at 1:14 P.M., NP B said:-He/She had been notified of the altercation and did telehealth appointments that night with Resident #1 and Resident #2.-Resident #1 reported to him/her the following:--Resident #2 had been talking to Resident #1 about not being a good parent.--Resident #1 then picked up a drink and told Resident #2 that he/she would throw it at Resident #2.--Resident #2 told Resident #1 that he/she would beat Resident #1's ass if Resident #1 threw the drink at Resident #2.--Resident #1 then set the drink down.--Staff had also told Resident #1 not to throw the drink at Resident #2.--Resident #1 ended up throwing the cup at Resident #2 anyway.--Resident #2 then struck Resident #1 in the face.-Resident #2 told him/her the following:--He/She had been talking to Resident #1.--Resident #2 had told Resident #1 that Resident #1 needed to worry about more things like getting out of the facility to be with his/her daughter instead of focusing on food, drinks, and cigarettes.--Resident #1 interpreted that as Resident #2 calling Resident #1 a bad parent.--He/She responded in self-defense to Resident #1's actions.-The altercation would be considered abuse. During an interview on 4/28/26 at 2:37 P.M., the DON and RNC said:-If staff thought the altercation could have been prevented, then it probably could have been prevented.-The altercation would be considered as abuse. 2994292, 2991969, 2987506, and 2987549

Based on observation, interview, and record review, the facility failed to utilize the facility practices and procedures to call a Code [NAME] (behavioral health response) at the start of a verbal escalation per facility policy for one sampled resident (Resident #2) resulting on 4/24/26 Resident #2 hit Resident #1 in the face causing bruising to Resident #1's left eyebrow/forehead area and nose out of 15 sampled residents. The facility census was 104 residents.Review of the facility's policy titled Behavior Health Services Policy dated 10/31/24 showed:-It was the policy of the facility to ensure all residents received necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning.-The facility utilized the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care.-All facility staff, including staff and volunteers, should receive education to ensure appropriate competencies and skill sets for meeting behavioral health needs of residents.-Education should be based on the role of the staff member and resident needs identified through the facility assessment.-The facility staff would implement person-centered approaches designed to meet the individual goals and needs of each resident, which included non-pharmacological interventions (refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being).-Examples of individualized, non-pharmacological interventions to help meet behavioral needs of all ages could include, but were not limited to:--Assisting residents with access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem-solving therapy.--Providing support with skills related to verbal de-escalation, coping skills, and stress management. 1. Review of Resident #2's admission Record showed he/she admitted to the facility with the following diagnoses:-Other schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).-Anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life).-Major depressive disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, unspecified. Review of Resident #2's quarterly Minimum Data Set (MDS- a federally mandated assessment completed by facility staff), dated 3/5/26 3/5/26 showed:-The resident was cognitively intact.-The resident had no behavioral symptoms within the seven day look back period. Review of Resident #2's undated care plan showed:-The resident had been involved in a physical altercation with a peer related to social conflict with noted anxiety, labored breathing, and superficial scratches to chest.- The resident is at risk for the following signs and symptoms r/t the diagnosisanxiety disorder: Cursing, hollering, moving around in or frequently getting upand down from the chair, nervousness, pacing on the unit, and restlessness. -The following interventions were in place:--Closely watch me for signs of anxiety and act before I lose control.--Do not get into a power struggle with the resident.--Don't get to close and remember personal space.--Offer activities to keep me from getting bored and provide an opportunity torelease energy in a healthy way.--Offer non-invasive coping mechanisms first to try to reduce my anxiety level. Assistwith finding the cause of the anxiety.The resident was at risk for the following signs/symptoms related to their diagnosis ofSchizophrenia: Aggression, anxiety, inability to make decisions, delusions, fearful, hallucinations, hard time focusing or showing no interest in activities/projects, and irritability.-The following interventions were in place:--Avoid arguing or getting defensive with the resident.--Be respectful, honest, and nonjudgmental with the resident at all times.--Please notify charge nurse if staff observed the resident experiencing any of the signs and symptoms of schizophrenia.--Please respect the resident's personal space.--Residents that hallucinate are often fearful of people coming near them, be carefulwhen using reassuring touch.--Use simple, clear language with me.- The resident had negative behaviors including: yelling, screaming, slamming doors, threatening to hurt people, head banging, and throwing objects. -The following interventions were in place:--Coping skills including reading and writing, music and tv, cleaning and staying busy.--The resident needed supports including counseling, structured environment, outside support network, and coping skills training.--Preferred interventions including talking to staff when upset and feeling heardby staff, cleaning, keeping busy with staff around the facility.--The resident's support system included his/her mom and sister.--The resident had triggers including rude people, dirt and filth, yelling and cursing, people not listening to him/her. Review of Resident #1's admission Record showed he/she was admitted to the facility with the diagnosis of disorder of brain, unspecified. Review of Resident #1's annual MDS dated [DATE] showed:-The resident was cognitively intact.-The resident had no behavioral symptoms within the seven day look back period. Review of Resident #1's care plan dated 4/25/26 showed the resident had been involved in a physical altercation with a peer related social conflict with noted emotional distress and bruising to nose. Review of an Admin/Registered Nurse (RN) Investigation dated 4/24/26 showed:-The incident occurred on 4/24/26 at 4:50 P.M.-The type of incident was physical aggression involving the head.-Resident #1 and Resident #2 were involved in the incident.-Resident #2 struck Resident #1 in the face.-Upon arrival, Resident #2 was observed in his/her room sitting on the side of the bed breathing heavily and appearing anxious.-Resident #2 stated, We were talking, and he/she got upset about me telling him/her the fact of life. Resident #1 picked up his/her cup. I told Resident #1 three times not to throw the drink on me. She did it anyway, so I hit him/her.-Resident #2 had superficial scratches to his/her upper chest area.-The facility concluded that Resident #1 and Resident #2 had been in a physical altercation initiated by a drink being thrown. Review of Resident #1's witness statement dated 4/27/26 showed:-Resident #2 hit him/her because he/she had thrown a cupcake for talking about his/her daughter.-Resident #2 called him/her dumb.-He/She had pain to his/her nose and above his/her eyes. Observation and interview on 4/27/26 at 12:58 P.M. showed Resident #1 had yellow and purple bruising to his/her nose and left eyebrow/forehead area. He/she said: -Resident #2 had been talking bad about him/her.-He/She threw a cup of juice at Resident #2.-Resident #2 responded by hitting him/her.-If he/she had known that Resident #2 was going to hit him/her then he/she would not have thrown the juice at Resident #2.-He/She had talked with staff afterwards about using coping skills and kind words.-He/She would not throw juice at anyone else. Review of Resident #2's witness statement dated 4/24/26 showed:-Resident #1 had asked what's for dinner.-Resident #2 told Resident #1 what was for dinner.-Resident #1 then asked again, so in response Resident #2 said she needed to try to remember.-Resident #1 then said that he/she wasn't talking to Resident #2. During an interview on 4/27/26 at 1:16 P.M. Resident #2 said:-He/She had been sitting at a table with Resident #1.-They were sitting across from each other.-Resident #1 rolled his/her eyes and got hateful.-He/She told Resident #1 that Resident #1 didn't need to be a smartass.-Resident #1 then called him/her a dumbass.-He/She was talking to Resident #1 about the different things that Resident #1 could do to be able to get back with his/her daughter.-Resident #1 looked like he/she was going to throw water at him/her.-He/She told Resident #1 not to do that and had reminded her three different times.-He/She told Resident #1 that he/she would whoop his/her ass if he/she threw the water.-Resident #1 then threw the juice at him/her.-He/She then responded by hitting Resident #1 in the face.-He/She then blacked out and when he/she came to, he/she was still punching Resident #1 in the face and staff were pulling him/her off of Resident #1.-He/She cared about Resident #1, and his/her impulse got the better of him/her.-He/She was ashamed and remorseful of his/her actions. Review of Certified Nurse's Aide (CNA) G's undated witness statement dated 4/24/26 statement:-He/She witnessed punching Resident #2 punching Resident #1 in the face.-A conversation led to the altercation.-Resident #2 had been talking about Resident #1's child.-Resident #2 wanted Resident #1 not to throw juice at him/her or else he/she would whoop Resident #1's ass.-A Code [NAME] was then called.-He/She intervened and took Resident #2 back to his/her room.-He/She remained with Resident #2 until Code [NAME] was determined to be all clear. During an interview on 4/28/26 at 9:18 A.M. CNA G said:-The conversation that Resident #1 and Resident #2 was the trigger to Resident #2's behavior.-Resident #2's main triggers were dirtiness and mouthy people.-He/She felt that Resident #2 was probably bored which also trigged his/her behavior.-He/She felt that if staff had intervened when the argument first started and helped Resident #2 with his/her learned coping skills that the incident could have been prevented. Review of CNA B' s witness statement dated 4/24/26 showed:-Resident #1 and Resident #2 were arguing about something.-He/She overheard Resident #2 say if you throw that water at me, I am going to whoop your ass.-He/She then told Resident #1 not to throw water on Resident #2.-Resident #1 initially did not throw the water at Resident #2 after the reminder.-All of the sudden Resident #1 threw water at Resident # #2.-He/She called a Code [NAME] when he/she saw Resident #2 get out of his/her seat. During an interview on 4/28/26 at 9:51 A.M. CNA B said:-He/She had checked in with Resident #2 when the argument started but did not really intervene.-He/She had told Resident #1 not to throw the water at Resident #2.-He/She did not think that the altercation was going to escalate at that point, so he/she felt like the reminder was an appropriate response.-There was an opportunity for staff to intervene directly and help Resident #2 with coping skills.-Resident #2 throws tantrums when he/she did not get his/her way.-Resident #2's behaviors mainly involve Resident #1 only and is not directed towards staff or other residents.-Resident #2 liked to talk to staff, take a walk, or get a soda as part of Resident #2's coping skills.-Resident #2's mom had recently passed away and felt that his/her anger could have been related to that. Review of Certified Medication Technician (CMT) B's witness statement dated 4/24/26 showed:-Around 4:37 P.M. he/she had been at his/her medication cart.-He/She heard a voice from one of the staff members.-The staff member was shouting and telling the residents to stop it.-He/She then ran to the altercation and saw Resident #2 hitting Resident #1 in the face.-He/She then separated the residents. During an interview on 4/28/26 at 10:13 A.M. CMT B said:-He/She had overheard a staff person say stop it to Resident #1 and Resident #2 before the altercation became physical. -The altercation could probably have been prevented if staff had intervened differently.-He/She was unsure of the specific trigger that started the altercation.-Resident #2 was always coming up with issues.-Resident #2 would get angry if his/her past was brought up.-He/She felt that in general if more staff were in the building, then resident behaviors could be managed easier. During an interview on 4/28/26 at 12:23 P.M. the Assistant of Director of Nursing (ADON) said:-The altercation could possibly have been prevented.-The staff should have done more than just remind Resident #1 not to throw the liquid at Resident #2.-Resident #2 escalated to anger quickly, which the staff were aware of.-It could be hard to keep Resident #2 calm at times.-Resident #2 had a lot of triggers for behaviors.-Resident #2 being bored is one of his/her main triggers.-Resident #2 needed meaningful activities to prevent behaviors.-Staff could have gone on a walk with Resident #2 or taken the cup away from Resident #1 to prevent the altercation. During an interview on 4/28/26 at 1:14 P.M. Nurse Practitioner (NP) B said:-Resident #2 had told him/her that he/she acted in self-defense to the situation.-He/She felt that if staff thought the altercation could have been prevented by managing Resident #2's behaviors better, then he/she agreed with staff.-Staff should always err on the side of resident safety. During an interview on 4/28/26 at 2:37 P.M. the Director of Nursing (DON) and Regional Nurse Consultant (RNC) said:-Resident #1's and Resident #2's altercation was triggered behavior.-Staff did not report to them that they felt like the altercation could have been prevented with better intervention.-The staff should have been more active in the situation.-If staff felt that the altercation could have been prevented with better behavioral management, then it probably could have been prevented.-Resident #2 was very self-aware and they thought the resident would be a good candidate for an anger management behavior contract.-Resident #2 liked to be involved in activities and was assigned to help the Activities Assistant to help manage his/her behaviors. 2991969

Based on interview and record review, the facility failed to ensure professional standards were met related to the documentation of blood glucose (sugar) checks (measures the amount of sugar in blood) and insulin (a hormone produced by the pancreas that regulates blood sugar levels) for three sampled residents (Resident #10, Resident #14, and Resident #15) out of 15 sampled residents. The facility census was 104 residents.Review of the facility's policy titled Administration of Insulin Policy dated 5/14/24 showed:-All insulin would be administered in accordance with physician orders.-Insulin administration will be coordinated with mealtimes and bedtime snacks unless otherwise specified in the physician order.-Staff were to review the insulin order which included:--Resident name.--Medication name.--Medication dosage.- Time to be administered.--Route of administration.-Staff were also to administer insulin at appropriate times.-After administering the insulin staff were to document the dosage, site, and time in the medication along with nurse signature. Review of Transcription Orders/Following Physician's Orders dated 5/18/24 showed:-The licensed nurse would review electronic Medication Administration Records (MARs) and electronic Treatment Administration Records (TARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etcetera.-If a medication was marked as not given, the reasoning for not being given should be explained in the progress notes, and the Director of Nursing (DON)/Assistant Director of Nursing (ADON)/Registered Nurse (RN), and Administrator should all be notified.-The Physician and legal guardian (if applicable) must also be notified.-The nurse's progress notes must document the plan/solution because of the medication not being administered and any adverse reactions that the resident may have.-For electronic MARs/TARs, the medication would be documented as not given by selecting the corresponding chart code for the reason why it was not given, and a progress note would be written.-The nurse or Certified Medication Technician (CMT) in charge of medication administration must review all their designated MARs and TARs prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shift were administered according to the physician's order and that all necessary interventions were taken in the event of an omission. 1. Review of Resident #15's admission Record showed he/she admitted to the facility with a diagnosis of Diabetes Mellitus (DM II- a metabolic disease). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 2/23/26 showed:-The resident was cognitively intact.-The resident received no injections within the seven day look back period. Review of the resident's Order Summary Report dated April 2026 showed:-An order for Humalog (Insulin Lispro- a fast-acting insulin) Injection Solution, inject as per sliding scale.-An order for Insulin Glargine (a long-acting insulin) Solostar Subcutaneous Solution Pen-Injector 100 unit/milliliter (ml), inject 25 units subcutaneously at bedtime, hold for blood glucose level less than 70 milligrams (mg)/deciliters (dL).-An order for blood sugars to be checked before meals and at bedtime. Review of the resident's MAR/TAR dated April 2026 showed:-The resident missed six out of 27 opportunities of administration related to his/her insulin glargine injection.-The resident missed seven out of 81 opportunities of administration related to his/her insulin lispro injection.-The resident missed 11 out of 108 opportunities related to his/her blood sugar checks. During an interview on 4/28/26 at 11:30 A.M. the resident said:-Sometimes the staff would forget to check his/her blood sugar and give him/her insulin.-Sometimes he/she would need to ask staff to do his/her blood sugar checks or insulin administration if he/she was not checked as ordered.-He/She thought that the staff could be doing the checks and administration outside of the scheduled time, so maybe that was why they were not documenting the blood sugar checks or insulin administration. 2. Review of Resident #10's admission Record showed he/she was admitted to the facility with a diagnosis of DM II. Review of the resident's quarterly MDS dated [DATE] showed the resident received insulin injections seven days out of the seven day look back period. Review of the resident's Order Summary Report dated April 2026 showed:-An order for blood sugars to be checked before meals and at bedtime.-An order for Lantus (Insulin Glargine) Solostar Subcutaneous Solution Pen-Injector 100 unit/ml, inject 12 units subcutaneously two times a day. Review of the resident's MAR/TAR dated April 2026 showed:-The resident had an order for Insulin Lispro Injection Solution 100 units/ml, inject per sliding scale from 4/1/26 which was discontinued on 4/21/26.-The resident had an order for Lantus Solostar Sub cutaneous Pen-Injector 100 unit/ml, inject 13 units subcutaneously two times a day from 4/1/26 that was discontinued on 4/21/26.-The resident had an order for Lantus Solostar Subcutaneous Pen-Injector 100 unit/ml, inject 10 units subcutaneously two times a day, which was ordered on 4/21/26 and discontinued on 4/24/26.-The resident missed nine out of 36 opportunities of administration related to his/her insulin lispro injection.-The resident missed one out of seven opportunities of administration related to his/her insulin glargine inject 10 units subcutaneously two times a day injection.-The resident missed seven out of 18 opportunities of administration related to his/her insulin glargine inject 13 units subcutaneously two times a day injection.-The resident missed 10 out of 66 opportunities related to his/her blood sugar checks. 3. Review of Resident #14's admission Record showed he/she admitted to the facility with a diagnosis of DM II. Review of the resident's quarterly MDS dated [DATE] showed received insulin injections seven days out of the seven day look back period. Review of the resident's MAR/TAR dated April 2026 showed:-An order for blood sugar to be checked before meals and at bedtime.-An order for Insulin Aspart (a fast-acting insulin) Subcutaneous Solution Pen-Injector 100 unit/ml, inject per sliding scale.-An order for Insulin Aspart-szjj (a fast-acting insulin) Subcutaneous Solution Pen-Injector 100 unit/ml, inject eight units subcutaneously before mealtimes and at bedtime.-An order for Insulin Degludec (a long-acting insulin) Subcutaneous Solution Pen-Injector 100 unit/ml, inject four units subcutaneously at bedtime. Review of the resident's MAR/TAR dated April 2026 showed:-The resident missed nine out of 109 opportunities of administration related to his/her insulin aspart injection.-The resident missed 10 out of 109 opportunities of administration related to his/her insulin aspart-szjj injection.-The resident missed four out of 27 opportunities of administration related to his/her insulin degludec injection.-The resident did not have any documentation records related to his/her blood sugar checks. 4. During an interview on 4/28/26 at 12:21 P.M. the ADON said:-He/She had not noticed any issues with documentation related to blood sugar checks and insulin administration.-He/She has had residents inform him/her that they didn't have their blood sugars checked at times.-All CMTs were able to check resident's blood sugars.-Some of the CMTs were certified to be able to administer insulin.-The majority of the time nurses were responsible for blood sugar checks and insulin administration.-He/She felt like staff were not very good about documenting refusals of blood sugar checks and insulin administration.-He/She had been doing daily audits of medication administration but had been assigned to work on the floor and was unable to perform the audits.-He/She had been assigned to work the floor for about three to four weeks.-He/She thought that documentation could also be getting missed if staff had to respond to behavioral emergencies.-Staff should be documenting all blood sugar checks and insulin administration regardless of issues that may occur on the shift.-If a resident refused for their blood sugar to be checked or have insulin administered then the staff were responsible for documenting the refusal and progress note.-Staff should also be communicating with nurse management if there were issues during the shift that prevented documentation to be completed. During an interview on 4/28/26 at 1:08 P.M. Nurse Practitioner (NP) A said:-He/She expected staff to follow all physician orders.-If a resident refused to have their blood sugar checked or their insulin administered then it needed to be documented.-He/She expected the staff to follow the facility's policy related to blood suage checks and insulin administration.-He/She expected staff to notify the provider if the order indicated to do so.-He/She had not heard residents complain to him/her about blood sugar checks or insulin administration. During an interview on 4/28/26 at 2:37 P.M. the DON and Regional Nurse Consultant (RNC) said:-All staff were expected to chart in real time.-There was no excuse for staff not to document blood sugar checks or insulin administration.-The ADON had been performing medication administration audits but had been assigned to work on the floor more frequently and had been unable to perform the audits.-There was no other person assigned to perform the medication administration audits since the ADON had been working on the floor.-He/She expected the staff to follow all physician orders.-He/She felt that staff were doing the blood sugar checks and insulin administration but were not documenting it.-Id residents refused their blood sugar checks and insulin administration then it needed to be documented too. 2986541

Based on interview and record review, the facility failed to prevent physical abuse for three sampled residents (Resident #6, #7 and #8) out of 16 sampled residents. On [DATE] Resident #6 hit Resident #7 and he/she fell to the ground. Resident #6 hit Resident #7 two more times while he/she was on the ground. Resident #7 was sent to the hospital and received a dissolvable suture to his/her bruised lip and swelling to the forehead. On [DATE] Resident #8 was standing in the hallway when Resident #6 approached Resident #8. Resident #6 then threw multiple closed fist punches at Resident #8's face then Resident #8 hit Resident #6. Resident #8's left cheek had swelling and redness. The facility census was 105 residents. Review of the facility's Abuse policy, revised [DATE] showed:-Physical abuse was purposefully striking, wounding, or injuring any resident in any manner whatsoever, including hitting, slapping, punching, biting, and kicking.-On a regular basis the supervisors will monitor the ability of the staff to meet the needs of the residents. 1. Review of Resident #6's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves.-Paranoid personality disorder (a mental health condition characterized by a long-term pattern of pervasive distrust and suspicion causing misinterpretations).-Restlessness and agitation. Review of Resident #6's Pre-admission Screening and Resident Review (PASARR), Level II (an in-depth evaluation triggered when a Level I screen indicates a potential serious mental illness or intellectual disability (ID) or related condition. The Level II determines if a nursing facility is appropriate and identifies needed specialized services), dated [DATE], showed:-The resident had a history of mental illness beginning in his/her late teens to early 20's which required inpatient psychiatric treatment. The resident heard voices, thought he/she was being poisoned, thought he/she received personal messages from the TV, and thought he/she had special powers to control others or make things happen. He/She also has a history of crystal meth substance abuse (a highly addictive, illegal central nervous system stimulant). -The resident could be guarded, suspicious, irritable, and easily frustrated and agitated. He/She avoided interpersonal interactions and had difficulty adapting and concentrating.-If admitted to a nursing facility the resident could benefit from medication management and a structured environment and plans for changing inappropriate behaviors and crisis intervention. Review of Resident #6's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE], showed the resident:-Was moderately cognitively impaired.-Had no verbal or physical behaviors with others during the review period. Review of Resident #7's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Traumatic Brain Injury (TBI - damage to the brain resulting from external mechanical force).-Mild cognitive impairment.-Mood disorder (a mental health condition characterized by long-term emotional disturbances that disrupt daily life).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety). Review of Resident #7's Care Plan Report showed the following individual care plans: -The resident's Schizophrenia care plan, initiated [DATE], showed the resident required medications for anxiety and hallucinations. Interventions were for staff to monitor closely for signs of anxiety and help the resident reduce anxiety by offering opportunities to listen to music and relax in bed.-The resident's TBI care plan, initiated [DATE] showed the resident had deficits in attention and inability to manage time and get things done. Interventions were for keeping routine consistent and watch closely for signs of agitation, impulsivity, and/or anger.-The resident's Negative Behaviors care plan, initiated [DATE], showed the resident sometimes slammed doors. Triggers were identified as people being rude. Interventions included counseling, a structured environment, and coping skills training. Review of Resident #7's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact.-Had no verbal or physical behaviors involving others during the review period. Review of the facility's internal investigation, dated [DATE], showed:-On [DATE] at 7:40 P.M. an incident of physical aggression occurred involving the head between Residents #6 and #7. -On [DATE] at approximately 7:40 P.M during a smoke break Resident #6 came into the smoke room and got into line behind Resident #7. Resident #6 didn't like being behind another resident who he/she believed would steal money so he/she went in front of Resident #7 and Resident #7 said he/she couldn't cut in front of him/her. Resident #6 told Resident #7 not to touch him/her and then hit Resident #7 which caused Resident #7 to fall to the ground. Resident #6 proceeded to hit Resident #7 two more times. Staff redirected Resident #6 to walk to his/her own room. Staff provided medical care to Resident #7 who had a busted lip and slight bruising to the forehead. Due to Resident #7's past history of a TBI, he/she was sent to the hospital. Resident #6 received a Telehealth visit with the Psychiatric Nurse Practitioner (Psych NP) who recommended Resident #6 be sent to the hospital for an evaluation. Education was started for resident rights. Interventions were for the Interdisciplinary Team to review the smoke policy and procedures. Abuse was defined as the purposeful infliction of physical, sexual, or emotional injury or harm. Review of the Resident #7's hospital record, dated [DATE], showed:-The resident presented from his/her nursing facility after he/she was punched in the face causing an inner lip laceration and facial abrasions.-The resident has a one centimeter (cm) internal lip laceration. One dissolvable suture placed to keep together. Educated on suture care. Review of the Police Report, dated [DATE], showed:-On [DATE] at 10:35 P.M. officers were dispatched to the facility regarding a call.-Upon arrival they met with the nurse who had not witnessed the physical altercation but was able to look at video footage which showed Resident #6 punch Resident #7 multiple times. From what the nurse gathered the altercation occurred because Resident #7 cut Resident #6 in line.-Officers were unable to gather information on the extent of Resident #7's injury due to the party not being on location. -The nurse said his/her supervisor stated the police incident needed to be documented due to their policy.-The police incident status was closed. The report was inactivated pending further development. Review of Resident #6's incident and progress notes, dated from [DATE] to [DATE], showed:-On [DATE] at 7:35 P.M., a Code [NAME] (it is used to designate a secure, rapid response to an aggressive or combative person) was called and Resident #7 sat on the smoke room floor with active bleeding from his/her mouth. An assessment was completed with the resident found alert and responsive. The resident said he/she had been struck by Resident #6. Resident #6 became agitated and struck Resident #7 in the face because he/she believed the other resident cut in line during the smoke break. The residents were immediately separated and Resident #6 was placed on 1:1 monitoring for safety. The Administrator, medical provider, psychiatric provider, and guardians were notified.-On [DATE] at 12:50 A.M., Resident #6 completed a Telehealth evaluation visit with Psych NP A who ordered a transfer to the hospital for a comprehensive psychological evaluation and x-ray of the resident's right hand due to complaints of pain and visible swelling to the right knuckles. -On [DATE] at 3:33 A.M., following hospital evaluation Resident #6 was provided with a splint with instructions to not remove it. Review of Resident #6's Psychosocial Post-Incident notes, dated [DATE], showed:-A note written at 7:00 P.M. showed: Resident #6 was involved in an incident. He/She didn't want to talk to staff about any incident and stated he/she wanted to smoke. -A note written at 7:01 P.M. showed: Staff observed the resident's right outer ear bleeding. Provider and legal representative notified. Resident refused skin check. -A note written at 8:16 P.M. showed: A Code [NAME] was called. Upon arrival observed Resident #6 in hallway. Staff informed the nurse that Resident #6 was involved in a fight. Resident #6 said he/she asked another resident to stay out of his/her room from getting water and stated the other resident hit him/her. The resident refused to talk further and walked into the dining room. Observed Resident #6's right ear was bleeding. The resident was taken off the unit, and his/her right ear was cleaned. The resident said he/she was okay. Vital signs (heart rate, respirations, and blood pressure) were stable. The NP, Director of Nursing (DON), and Administrator were notified. Observation and interview on [DATE] at 3:25 P.M. showed Resident #7 had a visible cut approximately one-third to one-half inch long and his/her right ear was slightly reddish tented. Resident #7 said:-On [DATE] Resident #6 hit him/her at smoke break time. -He/She was in line to smoke and Resident #6 cut in front of him/her and two other residents. -He/She told Resident #6 he/she couldn't do that. Resident #6 cussed him/her out and he/she cussed Resident #6 out. Resident #6 called him/her a stupid white cracker derogatory name bitch. -He/She told Resident #6 he/she couldn't talk to him/her like that, and Resident #6 hit him/her on his/her lip.-Resident #6 punched him/her two or three times in the mouth and also on the right side of his/her stomach. -Resident #6 hit his/her right ear.-He/She never before had problems with Resident #6 so he/she didn't expect to be attacked by him/her. Review of Certified Nurse Assistant (CNA) F's written statement, dated [DATE], showed:-He/She had residents in the smoke room for the 7:00 P.M. smoke break.-While waiting in line to receive their cigarette he/she heard Residents #6 and #7 get into a disagreement over who was in line first the conversation escalated very quickly into a loud back and forth over who was going to be first.-Resident #6 began to elevate his/her voice and CNA F told the resident to relax and reminded him/her everyone gets to smoke. After that statement Resident #7 said, yeah, that's right. Resident #6 immediately hit Resident #7 twice in the face so hard the blows knocked Resident #7 backwards into the soda machine which caused the resident to fall onto the floor.-Residents #6 and #7 were surrounded by at least five other residents.-He/She moved as fast as he/she could to get Resident #6 off of Resident #7. Before he/she could position himself/herself to do so, Resident #6 threw two more quick punches to the face of Resident #7.--The charge nurse arrived to the unit to assess Resident #7.--He/She explained to the nurse that Resident #7 should remain on the floor because Resident #7 had tried to get up on his/her own and fell hard once again to the floor.--Resident #6 kept hitting Resident #7 in his/her head and temple and his/her nose was bleeding. During an interview on [DATE] at 4:15 P.M., CNA F said:-On [DATE] he/she was passing out cigarettes in the smoke room and saw Resident #6 cut in line. He/She got there late but told Resident #6 all residents would get to smoke. Resident #7 then said yeah, all residents will get a cigarette. -Resident #6 didn't like that and hit Resident #7 in the face. Then Resident #6 hit Resident #7 a second time in the face by Resident #6's cheek and mouth, but he/she didn't remember which side.-Resident #7 fell down and Resident #6 got on top of him/her and hit Resident #7 a couple more times in the face.-Resident #6 was in another world. It looked like the resident would hit CNA F as well so he/she put his/her hands up with palms toward the resident and the resident stopped. -He/She grabbed Resident #6 off Resident #7. -Resident #6 was definitely the aggressor. Resident #7 was too dazed to do anything. Review of Resident #1's quarterly MDS, dated [DATE], showed the resident was moderately cognitively impaired. During an interview on [DATE] at 4:25 P.M., Resident #1 said:-He/She was in the smoke room when Resident #6 attacked Resident #7, who didn't deserve it. -Resident #7 turned around and Resident #6 just clocked him/her and knocked Resident #7 down in two hits to the face.-CNA F looked very concerned and staff called a Code Green. -Resident #7 got hit bad. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on [DATE] at 4:35 P.M., Resident # 10 said:-He/She turned around and #6 was punching Resident #7 while he/she was standing and Resident #7 landed on the ground.-It happened in the smoke room. -He/She only knew Resident #6 was trying to get his/her cigarette and get out of the smoke room. During an interview on [DATE] at 11:46 A.M., with the Administrator, Regional Nurse Coordinator (RNC) A and RNC B -The Administrator said video coverage of the incident between Resident #6 and #7 was no longer available. After a certain number of hours the video gets taped back over.-RNC A said physical abuse included hitting, punching, slapping, spitting, kicking, and grabbing. -Resident #6 abused Resident #7.-RNC B said Resident #6 abused Resident #7. 2. Review of Resident #8's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Mild intellectual disabilities.-Oppositional defiant disorder (a behavioral conditions most common in children and teens characterized by a persistent pattern of angry and irritable moods, argumentative behaviors, and defiance towards authority figures).-Persistent mood disorder.-Autism spectrum disorder (a neurodevelopmental condition affecting brain development, characterized by social and communication challenges, restricted interests, and repetitive behaviors). Review of Resident #8's PASARR Level II Evaluation, dated [DATE] showed the resident:-Had a history of significant psychomotor agitation, opposition to all cares, verbal and physical aggression directed toward staff, cursing and threatening to harm others, and refusing to speak to staff or take medications as scheduled. -Was impatient/demanding, intrusive/invasive with others, and was suspicious of others.-Required 24 hour nursing supervision and oversight to assure he/she and others are safe and he/she had consistent access to psychiatric follow-up and psychotropic medications (drugs that affect mood, perception, and/or behaviors).-Required a plan to address physical aggression directed toward others to include how to firmly redirect while maintaining dignity. Include steps to reduce agitation and anger by use of quiet time in room, 1:1 interactions, distraction through activity, and use of medications as needed.-Required ongoing assessment of mood, thought processes, and behaviors to identify signs of worsening anxiety, fear, depression, and anger that could precipitate harm to self/others.-The resident's plan should include clear steps to take to support the individual during a crisis situation, specify who to contact for assistance, how staff will work together during a crisis and identify when the physician, EMS, and/or law enforcement should be contacted. Review of Resident #8's annual MDS, dated [DATE], showed the resident: -Was cognitively intact.-Had no verbal or physical behaviors involving others during the review period. Review of Resident #8's progress notes, dated [DATE], showed:-Resident #8 was the aggressor in an incident.-New skin issue. Front left earlobe abrasion one cm wide.-Left side of face apparent swelling at cheek, left ear small pen sized scratch. Review of the facility's internal Investigation, dated [DATE] showed:-There was an incident on [DATE] of physical aggression involving the head.-At approximately 6:50 P.M. on [DATE] the DON was notified that according to Resident #6 he/she told Resident #8 to stay out of his/her room and Resident #8 asked what he/she was going to do about it. Resident #6 said Resident #8 hit him/her first, but Resident #8 said he/she did not.-Because the incident happened inside Resident #6's room there was no camera footage to confirm the allegation. -Resident #8 had a bloody nose that was cleaned up with first aid and a scratch on his/her ear.-Resident #6 refused to be evaluated by the nurse.Resident #6 left the facility with the police to a local hospital at 10:46 P.M. for a 96 hour hold after Resident #8 pressed charges. Review of the Police Report, for the [DATE] incident, showed:-Upon arrival the police officer made contact with the Assistant Manager who stated two residents got into a fight and there was video coverage of the incident. -He/She observed Resident #6 assault Resident #8. The video showed Resident #8 stood in the hallway when Resident #6 came into the frame. Resident #6 shoulder checked Resident #8 and proceeded to throw multiple closed fist punches to Resident #8's face. Staff broke up the fight shortly thereafter.-Resident #8 said he/she was going down the hallway to get water when he/she saw Resident #6 walking down the hallway towards him/her. Resident #6 then pushed Resident #8 with his/her shoulder and proceeded to throw punches. -He/She observed swelling and redness to Resident #8's left cheek. Resident #8 said he/she wanted to press charges.-Resident #8's statement was consistent with what he/she observed on the video.-Resident #6 had a previous encounter with Emergency Medical Systems (EMS) a few days prior and proceeded to fight EMS. Resident #6 was a danger to others due to his/her violent behavior and mental health diagnoses.-Resident #6 was taken into custody without incident and transported to the hospital to be placed on a 96-hour hold for a mental evaluation. Resident #6 was issued an assault charge. Due to city level charges Resident #6 was booked and released at the hospital and an affidavit was completed. Review of Certified Medication Technician (CMT) C's written statement dated [DATE] showed:--He/She sat at the table charting medications when he/she heard the noise. --When he/she went to see what was going on he/she saw Residents #8 and #6 fighting. --He/she called a Code [NAME] and tried to break up the fight along with CNA F and CNA G. Review of CNA G's written statement, dated [DATE], showed:--Residents #6 and #8 were fighting in the hallway near the dining area.--He/she saw Residents #6 and #8 throwing punches. Then they fell down which caused Resident #6 to hit his/her head.--He/She and the other CNAs held the residents' hands until we were able to get them apart. During an interview on [DATE] at 3:45 P.M., CMT C said:-He/She was working when Resident #6 bloodied Resident #8's nose.-He/She didn't know until later that Resident #8 kept going into Resident #6's room to get water. Resident #6 never told staff until later.-Resident #8 told Resident #6 he/she was going into Resident #6's room whether Resident #6 wanted him/her to or not.-CMT C was charting his/her medications and heard a commotion. Resident #8 grabbed Resident #6 around the body like he/she was going to take him/her down. -He/She called a Code [NAME] and he/she and two other staff tried to break it up. It happened around 6:30 P.M. or so.-He/She and another CNA put Resident #8 in the dining room, and another aide took Resident #6 to the other end.-Resident #8 bullied his/her way into Resident #6's room according to Resident #6.-He/She thought Resident #6 hit Resident #8 because Resident #6 was frustrated. Resident #6 said he/she was just tired of Resident #8 coming into his/her room. Review of Resident #8's written statement, dated [DATE], showed:-He/She went to get water from Resident #7's room because that room had good water. Resident #7 was in the bathroom, so he/she went to the other resident room who had the second-best water.-Resident #6 rushed him/her and stopped and looked and then hit him/her in the face. Resident #6 hit him/her in the head a couple of times.-He/she took Resident #6 down. -By the time he/she had Resident #6 on the ground CMT C and CNA F tried to pull him/her off of Resident #6, but it was kind of a struggle. because for one, when I'm mad and I get ahold of you, trust that my strength is very strong. It usually takes four to five people just to get me off that person. During an interview on [DATE] at 4:00 P.M., Resident #8 said:-He/She had tried to go to another resident's bathroom to get water, but someone was in there. His/Her room didn't have cold water.-He/She walked into Resident #6's room without knocking and went to the bathroom to get water. He/She drank the water and went back into Resident #6's room to get more water. Resident #6 told him/her not to come in.-He/She told Resident #6 he/she didn't have cold water at his/her sink and Resident #6 punched him/her on the left cheek with a closed fist.-He/She thought about hitting Resident #6, but then Resident #6 punched him/her on his/her nose with a closed fist.-Resident #6 tried to hit him/her in the head and he/she grabbed Resident #6 around his/her body, but he/she might have ended up grabbing Resident #6's head instead.-He/She thought Resident #6 hit his/her head on the floor. He/She got on top of Resident #6 and tried to punch him/her, but the aides stopped him/her from hitting Resident #6. Review of CNA F's written statement, dated [DATE], showed:--He/she was coming out of the supply room when he/she heard CMT C screaming you all stop!--When he/she made it to the doorway of the dining area, he/she saw Residents #6 and #8 fighting.--He/she immediately went to assist CMT C and CNA F to separate the two residents.--The time of the Code [NAME] was around 6:48 P.M. During an interview on [DATE] at 4:15 P.M., CNA F said:-He/She came out of the supply closet room around 6:50 P.M. to get ready to start his/her shift and saw an alarmed look on CMT C's face. CMT C said oh, my God! You guys stop!-Residents #8 and #6 were both swinging and fighting.-Resident #6 grabbed Resident #8's hoodie and pulled it over his/her face and swung Resident #8 around while Resident #8 was trying to get out of his/her grip.-They were entangled and went down together. -He/She couldn't tell if either had made contact before they were on the ground. -Once they were exhausted, he/she talked Residents #6 and #8 into letting go and told them OK, you all are tired. Let each other go and they did. -He/She saw the Administrator taking pictures of Resident #8's face.-Resident #6 was taken out of the facility to the hospital a couple of hours after the incident. -Resident #8 pressed charges. -Resident #6 had handcuffs on when he/she left the faciity on [DATE]. During an interview on 4/14 at 10:10 A.M., Psych NP A said:-He/She didn't think Resident #8 struck back until the end of the altercation.-On [DATE] Resident #6 said he/she told Resident #8 not to go into his/her room. -Resident #8 said Resident #6 bumped into him/her hard in the hallway.-Resident #8 said he/she had been going in there because he/she had no cold water and said Resident #6 told him/her not to go into his/her room, but Resident #8 went into Resident #6's room anyway and then Resident #6 purposely bumped into him.-He/She thought Resident #8's nose looked swollen on [DATE], but Resident #8 didn't want to go to the hospital and denied he/she had a swollen nose.-Staff said the water faucet in Resident #8's room worked. -He/She did a Telehealth visit with Resident #8 the night of [DATE] and learned Resident #8 bit Resident #6's ear. During an interview on [DATE] at 9:56 A.M., CNA G said:-On [DATE] he/she heard a noise and turned around and saw Residents #6 and #8 fighting. It was after supper around shift change and staff were meeting in the dining room.-When he/she first saw the altercation Residents #6 and #8 were swinging at each other and they hit each other, but he/she couldn't tell where because they were swinging so fast.-They both slipped and were holding and grabbing each other by the clothes and hitting each other.-They moved so fast she couldn't tell where they hit each other.-Staff had to physically grab them to separate them. They wouldn't stop.-Someone took Resident #8 and someone took Resident #6 to be checked by the nurse. -He/She checked them one at a time. Resident #8 was bleeding from his/her nose.-Resident #6 had a little blood on the outside of his/her ear. He/She left soon after that. During an interview on [DATE] at 10:26 A.M. Licensed Practical Nurse (LPN) A said:-Resident #6 said he/she was upset because Resident #8 kept going into his/her room and getting water and he/she doesn't want anyone in there.-Resident #6 said Resident #8 called him/her a curse word. He/She told Resident #6 he/she needed to tell the staff.-He/She told Resident #8 to stay out of Resident #6's room and leave him/her alone after the incident happened.-He/She could have gotten water from his/her own room. They keep an ice chest on the unit for cold water and he/she can get it there.-What set Resident #6 off was the intrusion. Resident #8 told Resident #6 what you gonna do about it. Resident #6 had told Resident #8 for a couple of nights not to come into his/her room. During an interview on [DATE] at 11:46 A.M., with the Administrator, RNC A and RNC B:-The Administrator said: --The facility goes over all types of abuse during abuse trainings, no matter the type of abuse that has occurred for a refresher. -Video footage of the altercation between Resident #6 and #8 was no longer available. It lasts a certain number of hours and then gets taped back over.Resident #8 said he/she kept going into Resident #6's room because his/her faucet didn't come on full-stream. -RNC B said he/she encouraged Resident #8 to get water from the kitchen water dispenser. What Resident #8 was doing was a boundary issue which is an ongoing behavior of his/hers. What happened between Residents #6 and #8 was abuse.-RNC A said physical abuse included hitting, punching, slapping, spitting, kicking, and grabbing. -What happened between Residents #6 and #8 was abuse. 2978191, 2973781

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #9) right to maintain his/her personal property out of 16 sampled residents. The facility census was 105 residents.Review of the facility's Resident Rights policy, revised 9/21/25 showed:-Residents have the right to voice grievances without discrimination or reprisal. -Prompt efforts will be made by facility to resolve grievances residents may have, including those with respect to the behavior of other residents. 1. Review of Resident #16's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Bipolar disorder (Mood disorder that can cause intense mood swings).-Psychosis (Mental disorder involving loss of contact with reality) not due to substance or known physiological condition.-Paranoid Schizophrenia (Serious mental illness that affects how a person thinks, feels, and behaves characterized by intense delusions (false beliefs), hallucinations (sensory perceptions that are not real), and distrust of others). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 2/10/26 showed the resident was moderately cognitively intact. Review of the resident's progress note, dated 4/6/26 at 2:05 P.M. showed a Code [NAME] (behavioral emergency response) was called for the resident at approximately 11:00 A.M. The resident threw another resident's cell phone and broke it and then paced through the medical unit. Review of the resident's internal incident investigation for behavioral events that took place on 4/6/26 and 4/7/26 showed Resident #9 turned in a grievance on 4/6/26 about his/her phone being broken by Resident #16. Review of Resident #9's admission Record showed the resident was admitted to the facility on [DATE] with a primary diagnosis of a stroke. Review of the resident's Inventory Form, signed and dated by the resident on 2/7/26, showed:-The resident had an Apple i-pad.-The resident had a Samsung Galaxy phone. Review of the resident's admission MDS, dated [DATE] showed the resident was cognitively intact. Review of the Resident Grievance Form, dated 4/6/26 and signed by the resident, showed: -His/her phone was broken by Resident #16. -The facility is responsible for the actions of the other resident and needs to replace or pay for his/her phone As Soon As Possible (ASAP). During an interview on 4/9/26 at 11:20 A.M. Resident #9 said:-On 4/6/26 Resident #16, who was his/her roommate, was throwing his/her phone at the window along with throwing other stuff at the window while trying to break the window. -He/She left the room to tell staff what Resident #16 was doing. Resident #16 broke his/her phone at around 10:00 A.M. on 4/6/26 and it was unable to be used. Resident #16 cracked the screen of his/her i-pad as well, but the device could still be used. -The window ended up getting broken by Resident #16 the evening of 4/6/26.-His/Her family member gave him/her the phone that had been broken for Christmas, 2025 and gave him/her another cell phone to use temporarily.-The Administrator told him/her the facility wasn't responsible for his/her phone. Observation on 4/9/26 at 11:40 A.M. showed: -The resident had two phones, one of which the resident was observed using. The other phone had a shattered screen which the resident said was broken by Resident #16. The phone that was shattered was not a Samsung Galaxy.-An i-pad was observed with a crack running from the top left of the screen to the bottom right. During an interview on 4/9/26 at 2:05 P.M. the Activities Director said he/she learned from Resident #9 about his/her broken phone and tablet when he/she came to work on 4/7/26. The resident said Resident #16 had smacked his/her phone out of his/her hand on 4/6/26 causing it to shatter. During an interview on 4/10/26 at 2:05 P.M. Certified Medications Technician (CMT) A said: -On 4/6/26 Resident #9 said Resident #16 broke his/her phone.-He/She had seen the resident using two different phones recently and knew both phones worked.-He/She didn't notice the brand of either phone. During an interview on 4/10/26 at 2:57 P.M. CMT B said on 4/6/26 Resident #9 said Resident #16 busted his/her smart phone and broke their room window. During an interview on 4/10/26 at 4:35 P.M. the Social Services Director (SSD) said Resident #9 told him/her Resident #16 broke his/her phone and filled out a grievance form related to his/her complaint. During an interview on 4/14/26 at 9:15 A.M. Receptionist A said:-He/She and the other receptionist were responsible for doing resident inventories when residents are new to the facility. They use an electronic form to document the resident's possessions. -He/She wasn't working the day Resident #9 came into the facility so the other receptionist would have filled it out.-The receptionists were supposed to indicate on the inventory form if a device like an i-pad screen is cracked and the form didn't show the i-pad to have been cracked at the time. -The receptionist always makes a copy of the inventory they fill out and has the resident sign it. During an interview on 4/14/26 at 11:46 A.M. with the Administrator, Regional Nurse Coordinator (RNC) A and RNC B:-RNC A said:--On 4/6/26 a Code [NAME] was called at 11:00 A.M. because Resident #16 was restless and pacing the halls and pacing around the dining room tables.--Around 2:00 P.M. on 4/6/26 Resident #9 said Resident #16 had broken his/her phone earlier in the day.-The Administrator said:--The resident filled out a grievance with the SSD related to a broken phone. --Staff have mentioned the resident has been seen with multiple phones, so he/she didn't know why all the resident's devices weren't on his/her inventory sheet.--He/She notified the corporate office of the resident's grievance but didn't know what the office did about property that might have been broken by another resident. 2975515

Based on interview and record review, the facility failed to provide appropriate, necessary behavioral health services for two sampled residents (Resident #2 and Resident #10) out of 10 sampled residents to maintain the highest practicable physical, mental and psychosocial wellbeing of each resident with supervision and the use of Crisis Prevention Intervention (CPI- behavioral techniques for de-escalation). On 3/25/26, Certified Nurse Aide (CNA) A failed to implement Resident #1's care plan for behavioral interventions on the smoke deck including supervision and the use of CPI with Resident #1 and Resident #2 which resulted in a resident to resident altercation where Resident #1 received a black eye. On 3/31/26, CNA B failed to utilize CPI and provide supervision, when CNA B left the smoke room unattended after Resident #10 had already become agitated with verbal outbursts and Resident #10 threw an ashtray and hit Resident #9 in the face,. which resulted in a bruise to the left eye and a swollen left check for Resident #9. The facility census was 106. Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed:-The purpose of the policy was to ensure all residents received necessary behavioral health services to assist them in reaching and maintain their highest level of mental and psychosocial functioning.-The facility staff were to ensure the residents were receiving necessary behavioral health care which were person-centered and reflect the resident's goals for care while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.-Behavioral health care and services were to be provided in an environment that was conducive to mental and psychosocial well-being. -The facility staff were to monitor the resident closely for expressions or indications of distress.-If the resident showed signs of distress, the staff were to evaluate if those changes in behavior were unavoidable.-The facility staff were to develop person-centered care for any concerns identified with the resident.-The staff were to maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety.-The facility staff were to have interventions that were person-centered, evidence-based, culturally competent, trauma-informed, and in accordance with professional standards of practice. Review of the CPI Facility Training, dated 2023, showed the goal of CPI training is to equip employees with the necessary skills to prevent and safely manage crisis situations, ensuring a safe and supportive environment for everyone. Review of the facility's undated handbook for CPI showed: -Safety interventions range from verbal and environmental non-restrictive interventions to non-restrictive disengagements and restrictive interventions. The goal is to choose the safety intervention that is a last resort, reasonable, and proportionate. -Disengagements and restrictive interventions are not risk-free and are highly traumatic for everyone involved. It can affect a person physically and mentally. These effects can be long-lasting or even life-threatening. -Many individuals in your care might have already been through traumatic experiences. A disengagement or restrictive intervention can trigger previous traumatic experiences. -Holding. A restrictive safety intervention necessary to restrict a person's range of movement to prevent the infliction of harm to self or others. -Standing Hold: Medium Level Restriction - Staff begin in the low-level restriction. Apply the Outside Principle by placing the palm of your furthest hand at the resident elbow. Apply the Inside Principle, bringing your nearest arm underneath and resting your arm over the person's forearm. Cup your hand to avoid gripping and squeezing. Stand close, adjusting your furthest leg so you remain balanced and stable. Use your body to maintain contact at the shoulder, hip, and thigh. Encourage the person to keep their arms in front of their body. Review of the facility Smoking Safety Regulations, dated 4/6/17 and revised on 6/29/23, showed:-The purpose of this policy was to ensure that all staff and residents were following the safety regulations for smoking.-The facility would provide direct supervision for smoking residents classified as not responsible. Review of the employee training records showed:-Licensed Practical Nurse (LPN) A was trained in CPI on 3/12/26. -LPN B was trained in CPI on 2/1/26.-Director of Nursing (DON) was trained in CPI on 6/24/25. -Assistant Director of Nursing (ADON) was trained in CPI on 6/30/25.-Certified Nursing Aide (CNA) A was trained in CPI on 2/19/26.-CNA B was trained in CPI on 5/20/25. 1. Review of Resident #1's Preadmission Screening and Resident Review (PASARR - A preadmission screening used to help ensure individuals with serious mental disorder and/or developmental disabilities are not inappropriately placed in nursing homes for long term care and receive the services they need in their residential setting), dated 2/26/23, showed the following diagnosis:--Schizophrenia Paranoid Type (a chronic mental disorder characterized by intense, irrational paranoia (distrust and suspicion of others), delusions (false beliefs), and auditory hallucinations (hearing voices).--Schizoaffective Disorder (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions) with mood disorder symptoms (mania or depression).--Psychotic Disorder (severe mental health condition that cause a loss of touch with reality, characterized by hallucinations, delusions, and disorganized speech/behavior).--Dependent Personality Disorder (a chronic, excessive need to be cared for, leading to submissive, clingy behavior and intense fear of abandonment).--Adjustment Disorder, with mixed Disturbance of emotions and conduct.--Bipolar II Disorder (a mental health condition characterized by alternating patterns of major depressive episodes and hypomania, a less severe form of mania).--Anxiety Disorder.--Major Depressive Disorder (MDD) (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), recurrent severe without psychotic features.--Traumatic Brain Injury (TBI) (damage caused by an external force that disrupts brain function, ranging from temporary concussion to permanent disability).-The resident's symptoms include stealing from other residents, withdrawn, depressed, suicidal ideations, poor insight and judgement, attention seeking, paranoid, poor hygiene, sexually inappropriate, and refusing medications.-He/She had a history of verbal and physical threats to staff and other residents.-He/She hallucinated (tell him/her to hurt himself/herself, hearing voices telling him/her to kill his/her spouse).-The resident had a history of multiple psychiatric admissions and had attempted suicide multiple times. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff and used for care planning), dated 1/21/26, showed he/she was cognitively intact and had no behaviors. Review of Resident #1's undated Care Plan showed he/she:-Will have decreased signs and symptoms of the diagnosis of traumatic Brain Injury (TBI), Schizophrenia, Suicidal Ideations (SI), Anxiety, Dependent Personality Disorder, and Bipolar Disorder. -Avoid confrontation.-Do not argue or get defensive with him/her.-Keep a routine as much as possible.-Provide a comforting and homelike environment.-Remember his/her personal space.-Watch him/her closely for signs of agitation and work with the residents to reduce impulse feelings of anger.-Decrease stimulation around him/her when displaying signs of anxiety.-Implement plans to change inappropriate behavior.-Was taught the importance of not lining up at the door and waiting to let staff members take other residents when assigned out to smoke. Review of Resident #2's PASARR showed the resident did not have a Level II screening, but did have a Level I screening, dated 6/20/25, showed he/she: -Had Major Depressive Disorder.-Experienced one psychiatric treatment episode that was more intensive than routine follow-up care.-Had a substance related disorder.-Diagnosis of dementia with behaviors, Major Depressive Disorder, and Bipolar Disorder.-Behavioral symptoms were withdrawn/depressed controlled with medications.-Received in patient treatment at psychiatric hospital. Review of Resident #2's undated admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:-Bipolar Disorder.-Anxiety.-Major Depressive Disorder.-Dementia with behaviors (a decline in mental ability such as memory, reasoning, and communication which can cause confusion and negative behaviors such as anxiety, aggression, agitation, and delusions). Review of Resident #2's quarterly MDS, dated [DATE], showed he/she was cognitively intact and had no behaviors. Review of Resident #2's undated Care Plan showed he/she:-If resident was disturbing others, encourage him/her to go to a more private area to voice concerns/feelings to assist in decreased episodes of disturbing others.-Had potential to be physically aggressive related to poor impulse control.-When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response was aggressive, staff to walk calmly away, and approach later. -Provide physical and verbal cues to alleviate anxiety.-Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion.-Do not get into a power struggle with him/her.-He/She would be assessed per smoking policy to smoke in the designated areas and clothing checks. Review of the facility Administrator/Registered Nurse Investigation (RNI), dated 3/25/26, showed:-Physical aggression involving the head between Resident #1 and Resident #2 witnessed by CNA A.-At approximately 8:00 A.M. on 3/25/26, the Administrator was notified when residents were lining up at the smoke room door for smoke break, Resident #2 walked in front of Resident #1 and Resident #1 told Resident #2 you cannot cut the line. Resident #2 hit Resident #1 in the eye and Resident #1 hit Resident #2 back on top of the head. -LPN A re-educated CNA A, Resident #1 was to have solo smoke breaks before the scheduled time as of 3/22/26. -Resident #1's left eye was noted to be watery, with mild redness and slight bruising on the under-eye area.-Staff shall not permit residents to line up to smoke door; this creates anticipation and could increase anxiety for some residents. During an interview on 3/31/26 at 4:11 P.M., LPN A said:-He/She was the charge nurse working the day the intervention was put in place for Resident #1 to smoke alone before the other residents.-The intervention was a result of prior resident to resident altercation, when Resident #1 had placed his/her hands on another resident's neck.-The care plan was not updated at the time of the incident.-3/22/26 was the date the intervention started.-He/She did not know CNA A was not told about Resident 1's smoking at a different time. Just figured CNA A knew.-The Director of Nurses (DON) and Assistant Director of Nurses (ADON) were responsible for training the staff on any new changes with the residents or policy/procedures including Resident #1 being permitted to smoke prior to smoking times alone. Review of Resident #1's Incident Note, dated 3/25/26 at 9:01 A.M., showed:-A code green was called, upon arrival LPN A observed Resident #1 near the smoke door.-Resident #1 said Resident #2 cut the line.-Resident #1 told Resident #2 he/she could not cut in line and that was when Resident #2 hit Resident #1 in his/her left eye.-Resident #1 then hit Resident #2 in his/her jaw.-Resident #1's right eye was slightly watery no redness noted and the resident denied any pain.-Resident #1 and Resident #2 were reminded ofn the importance of not lining up at the door and to wait to let staff members smoke him/her. Review of Resident #2's incident note, dated 3/25/26 at 9:48 A.M., showed:-Resident #2 had cut the line and Resident #1 told him/her he/she can't do that.-Resident #2 was hit on top of his/her head and kicked in his/her left leg.-Resident #2 was educated to not hit other residents/staff. Review of Resident #1's social Service Progress Note, dated 3/25/26 at 10:02 A.M., showed:-He/she was escorted to the Social Service Office in regards of a resident to resident this morning.-Resident #1 told Resident #2 that he/she cut the line and needed to move.-Resident #1 nudged Resident #2. Resident #2 turned around and punched Resident #1 in the eye and Resident #1 hit Resident #2 back.-Resident #1 was not trying to harm Resident #2.-Resident #1 was just trying to help staff direct Resident #2 to smoke break, because it was Resident #1's turn to smoke. Review of Resident #2's Social Service Progress Note, dated 3/25/26 at 10:50 A.M., showed:-Resident #2 said, It was all my fault, but Resident #1 should not have hit me.-He/She should not have gotten ahead of the line, had he/she gone to the back of the line then they would not have this problem.-Resident #1 asked Rresident #2 to get out of the line and when Resident #2 did not move Resident #1 hit Resident #2 in the head and Resident #2 hit Resident #1 back.-Resident #2 fell because he/she was wearing slippers and lost balance.-Resident #2 was not hurt and feels fine. During an interview on 3/31/26 at 3:32 P.M., Resident #2 said:-He/she had cut in line and did not go to the back of the line.-Resident #1 hit him/her. -He/she was angry and hit Resident #1 on the head. Observation and interview on 3/31/26 at 3:38 P.M. showed Resident #1 had a bruise under his/her left eye by the nose and he/she said: -Resident #2 cut in line at smoke break time.-Resident #1 told staff but Resident #2 told staff he/she did not cut in line.-Resident #1 bumped into Resident #2 and Resident #2 turned around and punched him/her in the left eye.-Resident #1 said he/she hit Resident #2 back.-The incident upset him/her and that was why he/she punched Resident #2 back.-He/she felt safe with no problems and tried to stay away from Resident #2. During an interview on 3/31/26 at 3:57 P.M., CNA A said:-Did not know the interventions Resident #1's smoke breaks had changed since he/she had been off work for a couple of days.-Interventions can be found on the resident's care plan and CPI.-CPI was kept in a notebook at the Nurse's Station.-He/She did not remember what happened for sure.-Resident #2 cut line said F you.-He/she told Resident #2 to get into line. -It happened so fast.-He/she had not separated Resident #1 from the group when Resident #1 had complained Resident #2 had cut in line. -He/She called for a code to get help.-He/She tried to separate the residents.-He/She stayed with Resident #2.-Resident #2 had no injuries. During an interview on 4/1/26 at 1:26 P.M., Medical Nurse Practitioner (MNP) said he/she:-Was notified of the incident between Resident #1 and Resident #2 on 3/25/26 due to Resident #1 being punched in the left eye by Resident #2, no new orders were given.-Would have expected CNA A to separate Resident #1 and Resident #2 when Resident #1 told resident #2 he/she could not cut in line instead of just telling Resident #2, he/she cannot cut in line and left Resident #2 there. -Would expect facility staff to follow the facility policies and separate the residents when residents started to escalate with residents. During an interview on 4/1/26 at 1:32 P.M., Psychiatric Nurse Practitioner (PNP) said he/she:-Was notified of the incident between Resident #1 and Resident #2 on 3/25/26.-Staff did not follow Resident #1's care plan and smoke Resident #1 before the other resident due to several incidents with peers in or around the smoke room. -Would have expected staff to separate the residents when Resident #1 told staff about resident #2 cutting in line.-Staff need to follow facility policies and procedures; staff are to intervene before the residents get physical with each other. -It was reported to them by the DON that CNA A just told Resident 2 to get in line and did not redirect Resident 2 to the end of the line to respond to Resident #1's concern of Resident #2 cutting the line. During an interview on 4/1/26 at 2:31 P.M., ADON said:-Would have expected the staff to have separated Resident #1 and Resident #2 prior to the incident before the residents escalated to physical abuse per facility policy and procedures for Behavior Management.-CNA A reported that he/she just told Resident 2 to get in line and did not redirect Resident 2 to the end of the line. During an interview on 4/2/26 at 4:36 P.M., the Administrator and the DON said:-The altercation was inside the smoke room. -The residents know the smoke break times as they were posted around the facility.-The residents see the staff go to the closet on the other end of the hallway to get out the smoke box and walk by the residents going to the smoke room on each unit.-The staff do not line up the residents; they know when it was time to smoke and start to gather outside the smoke room, getting the residents to enter the smoke room.-Residents can come in late and go out early during the smoke breaks.-The resident to residentincident on 3/25/26 between Resident #1 and Resident #2 happened because Resident #1 was to smoke before the other residents due to behaviors in the smoke room with other residents.-This was put in place for Resident #1 on 3/22/26 due to another resident-to-resident in the smoke room.-Resident #1 must be reminded of this intervention at smoke break times.-CNA A did not know of this intervention and thought Resident #1 was to smoke with the other resident. They forgot to educate him/her.-Not all the staff members were not educated about this intervention at the time of the incident, CNA A was off. -Resident #2 walked faster to get in front of Resident #1 to get into the smoke room sooner.-When Resident #1 brought this to CNA As attention and no corrective measures were taken to move Resident #2 to the back of Resident #1 who was not scheduled to smoke at that time.-Resident #1 got upset and bumped into Resident #2 per Resident #1, Resident #2 turned around and punched Resident #1 in the left eye.-Staff should read the person-centered care plans of each resident involved in incidents or be informed by the charge nurse before or during the shift. The prior shift should have told CNA A on report of the changes to Resident #1's smoke plan; but CNA A was off for a couple of shifts and the staff were no longer giving the Resident #1's change for smoking in report.-Staff knew where to find the resident care plans but only if they had time to read it. Changes were given off in report to the next shift per discipline. -CNA A did not utilize CPI when he/she did not separate Resident #1 from the group and acknowledge Resident #2 had cut in line. CPI provided instruction for verbal de-escalation. 2. Review of Resident #9's PASARR dated 5/31/16, showed the following diagnosis:--PTSD.--Depression.--Anxiety.--Adjustment Disorder.--Panic Attacks (a sudden, intense episodes of fear or discomfort, often peaking within 5 to 20 minutes, featuring symptoms like a racing heart, chest pain, dizziness, and feelings of doom).--Histrionic Personality Disorder (a mental health condition marked by a pervasive pattern of excessive emotionality and an overwhelming desire to be the center of attention).--Anti-Social Behavior (a mental health condition defined by a long-term pattern of manipulating, exploiting, or violating the rights of others).--Low Intellectual Functioning.--Mild Intellectual Disability. -The resident's symptoms included poor impulse control, poor insight, poor judgement, irritability, boundary issues, difficulty with appropriate interactions, problems with authority, manipulative, excessive emotionality and attention seeking behaviors.-The resident had a history of multiple psychiatric admissions. Review of Resident #9's undated admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis:-Major Depressive Disorder.-Adult Antisocial Behavior.-Bipolar Disorder. Review of Resident #9's quarterly MDS, dated [DATE], showed the resident was cognitively intact with no behaviors. Review of Resident #9's undated Care Plan showed he/she:-Will have decreased signs and symptoms of the diagnosis of PTSD, depression, anxiety, Adjustment Disorder, Intellectual Disabilities, Antisocial Behavior, and Impulse Disorder.-Administer medications and monitor for side effects.-Providing a calm, relaxing environment can help lessen or relieve anxiety and promote a feeling of safety.-Was at risk for peer-to-peer conflict and psychosocial distress related to a lack of social nuance and boundary awareness associated with Mild Intellectual Disabilities and Adult Antisocial Behavior.-Tends to assume helper or staff-like roles (managing trash in the dining room), which creates negative power dynamics and triggers aggressive responses from cognitively impaired peers.-The resident will defer questions regarding facility rules/schedules to staff rather than attempting to enforce them with peers.-Educate and gently remind the resident of appropriate peer-to-peer boundaries.-Instruct him/her that if a peer asks him/her a question about the schedule, he/she should reply, Let's go ask the nurse/staff.-Staff to check in with the resident daily to ensure he/she continued to feel safe on the unit and allow him/her to verbalize any lingering anxiety regarding the incident. -Staff to monitor the resident's proximity to peers with known episodes of impulse control.-Ensure the residents were seated away from high-traffic areas where peer friction was likely to occur.-Had a behavior problem where he/she attempts to be helpful with staff maintaining environment and helping peers, will try to tell peers what to do, can trigger peers at times resulting in conflicts will hurt the resident's feelings as he/she only wants to help.-Assist the resident to develop more appropriate methods of coping and interacting with his/her peers.-Encourage the resident to express feelings appropriately.-Educate resident on not involving his/herself in other people's affairs.-Intervene as necessary to protect the rights and safety of others.-Approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed.-Decrease stimulation around him/her when displaying signs of anxiety.-Educate the residents on boundary setting; redirect away from performing staff-oriented tasks in common areas. Review of Resident #10's PASRR, dated 9/2/24, showed the following diagnosis:--Schizophrenia.--Psychotic disorder.--Anxiety.--Bipolar Disorder.--Mood Disorder.--Developmental Disability.--Psychosis.--Schizoaffective Disorder.-The resident's symptoms included feelings of sadness and agitation with aggressive behaviors with hitting head against.-Place on a 96 hour hold due to attempts to elope and hitting head against the wall.-The resident had a history of multiple psychiatric admissions, and 16 emergency room visits in two and a half months.-The resident had difficulty understanding and following directions, memory was impaired, and thought process was circumstantial and nearly totally focused.-Affective development such as interest and skills involved with expressing emotions, making judgments, and making independent decisions were poor judgement, poor response to redirection, becomes easily agitated, uncooperative and defiant, concrete, judgement quite impaired, and unable to make informed decisions regarding his/her care.-The resident had a history of disorganized behavior worsening psychosis, inability to care for his/herself.-Reports paranoid delusions like having a rat in his/her stomach that needs to be removed, staff poising him/her with red meat. States a dangerous man had control of me. The voice will not leave him/her alone. Review of Resident #10's undated admission Record showed he/she was admitted to the facility on [DATE] and readmitted [DATE] with the following diagnosis:-Restlessness and agitation.-Mood Disorder.-Bipolar Disorder. Review Resident #10's quarterly MDS, dated [DATE], showed he/she was cognitively intact with no behavior. Review of Resident #10's undated Care Plan showed he/she:-Will have decreased signs and symptoms of the diagnosis of Anxiety, Schizophrenia, Psychotic Disorder, Bipolar Disorder, Mood Disorder, Suicidal Ideations (SI) and Intellectual Disabilities.-Administer medications as ordered by physicians.-Closely watch him/her for signs of anxiety and act before he/she loses control.-Will work on coping skills on how to walk away from someone's aggression.-Had aggression with Resident #9. Resident #9 had intervened when the resident requested a cigarette from a peer. -Educated staff and residents on smoking policy. -Give residents five minutes to understand processes with activities. -Offer rewards program to assist with buying personal cigarettes. -Triggers are being yelled at, not smoking, and voices in his/her head.-Staff must actively monitor the residents during smoke breaks and intervene immediately at the first sign of peer conflict or rule disputes. -Staff will consistently and calmly remind the resident of the facility's strict no sharing, trading, or borrowing cigarette policy, ensuring enforcement comes from staff, not peers. Review of the facility RNI, dated 3/31/26 at 10:10 P.M., showed:-At 8:12 P.M., the Administrator was notified of an incident involving Resident #10 and Resident #9, where Resident #10 was the aggressor.-Resident #10 was receiving a white (personal) cigarette from another peer when Resident #9 interjected and told the peer he/she was not supposed to do that, it was against the rules.-CNA B already made this clear to Resident #10 before Resident #9 interjected.-CNA B told Resident #10 if he/she was going to be aggressive he/she would have to leave.-Resident #10 ignored redirection and threw the ashtray hitting Resident #9.- Resident #9 telling the peer to not give Resident #10 a cigarette upset Resident #10 because Resident #10 felt Resident #9 was bossy in nature.-Resident #10 told Resident #9 to shut up and threw the ashtray across the room hitting Resident #9's left cheek.-According to Resident #9, he/she was not paying attention to move out of the way.-Nothing more than first aide administered. -Initial skin assessment of Resident #9 noted swelling then about an hour or more later, bruising was observed.-Resident #10 had been moved and placed on continuous monitoring for the rest of the shift.-CNA B was expected to call the code green at the first sign of verbal aggression and Resident #10s refusal to leave area prior to Resident #9s interjection, to potentially prevent occurrence. This behavioral emergency required corrective action for CNA B. Review of Resident #9's Incident Note, dated 3/31/26 at 7:50 P.M., showed:- CNA B reported Resident #10 threw an ashtray at Resident #9, striking Resident #9 in the face.-Resident #9 was assessed and noted to have a small abrasion under the left eye.-Resident #9 stated At smoke break, I was talking to a peer about not giving out his/her cigarettes to Resident #10. Resident #10 yelled at him/her in my face; I told CNA B to come here because Resident #10 was going to hit me. Then Resident #10 yelled some more about me being bossy when I was cleaning the dining room earlier. After Resident #10 sat down in the chair, Resident #10 picked up a black ashtray and threw, and it hit me on the left side of my face. Review of Resident #10's Incident Note, dated 3/31/26 at 7:50 P.M., showed:-CNA B reported Resident #10 threw an ashtray at Resident #9, striking him/her in the face.-Multiple de-escalation interventions were attempted, including verbal redirection and environmental modification; however, these interventions were unsuccessful. Review of Resident #10's Behavior Note, dated 3/31/26 at 7:35 P.M., showed: - Resident #10 and Resident #9 had what started as a verbal altercation in the smoke room that lead to Resident #10 throwing an ashtray at Resident #9 hitting Resident #9 in the face. Observation and interview on 4/1/26 at 3:36 P.M., Resident #9 showed he/she:-Had a bruise under his/her left eye and swelling to the left side of his/her face and temple.-Told another resident to not share cigarettes.-Was not paying attention to Resident #10 when talking to other residents.-Resident #10 yelled Resident #9 needed to stay out of his/her F business.-Resident #10 got close to his/her face when yelling.-Called for CNA B and LPN B came in the smoke room and told Resident #10 to give the cigarette back to peer.-Resident #10 said that bitch always wants to be bossy.-CNA B told Resident #10 to leave the smoke room if he/she was not going to calm down.-Resident #19 picked up the ashtray and threw it hitting him/her on the left side of the face.-His/Her pain was rated a 9 out of 10 being the highest pain level.-CNA B was in the hallway at that time.-There were no staff in the smoke room monitoring the residents at the time of the incident.-During the day staff monitor the residents when smoking.-At night some staff stay in the hallway, and some will stay in the smoke room monitoring the residents smoking.- It scared me, had dream about the incident thinking someone was coming in the room.-Feels safe around others except Resident #10. During an interview on 4/1/26 at 1:54 P.M., Resident #10 said:-Resident #9 was bossy and a tattle tale.-He/She can only have two of the facility cigarettes.-He/She wanted a white cigarette to smoke during the smoke break.-He/She was out of his/her own cigarettes and had no money to buy some.-He/She had enough of Resident #9 being in his/her business.-First, he/she stomped his/her foot to get Resident #9 to stop talking about him/her.-He/She picked up the ashtray and threw it at Resident #9.-Resident #9 had pissed him/her off.-He/She aimed for Resident #9's left eye. During an interview on 4/1/26 at 8:02 A.M., LPN B said:-He/She was at the medication cart checking blood sugars down the hallway from the smoke room when he/she heard arguing. -He/She put blood sugar checking supplies.in the med cart and went to see what was going on.-He/She asked CNA B what was going on and was told Resident #10 did not want a house cigarette but wanted a white cigarette. -Resident #10 was upset with CNA B.-LPN B told Resident #10 to leave the smoke room, Resident #10 said he/she did not want to leave the smoke room.-He/She told CNA B to not give Resident #10 a cigarette.-Resident #10 did not seem upset and went to [TRUNCATED]

Based on observation, interview, and record review the facility failed to protect three sampled residents (Resident #1, Resident #2, and Resident #9) from physical abuse out of ten sampled residents. On 3/25/26 Resident #2 punched Resident #1, Resident #1 then punched Resident #2 which resulted in bruise to Resident #1's left eye. On 3/31/26 Resident #10 picked up an ashtray, threw it across the room and hit Resident #9 on the left eye which resulted in a bruise to the left eye and a swollen left check for Resident #9. The facility census was 106 residents.Review of the facility Abuse and Neglect Policy, dated 11/28/16 revised on 6/12/24, showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.--Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. 1. Review of Resident #1's Preadmission Screening and Resident Review (PASRR - A preadmission screening used to help ensure individuals with serious mental disorder and/or developmental disabilities are not inappropriately placed in nursing homes for long term care and receive the services they need in their residential setting), dated 2/26/23, showed the following diagnosis:--Schizophrenia Paranoid Type (a chronic mental disorder characterized by intense, irrational paranoia (distrust and suspicion of others), delusions (false beliefs), and auditory hallucinations (hearing voices).--Schizoaffective Disorder (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions) with mood disorder symptoms (mania or depression).--Psychotic Disorder (severe mental health condition that cause a loss of touch with reality, characterized by hallucinations, delusions, and disorganized speech/behavior).--Dependent Personality Disorder (a chronic, excessive need to be cared for, leading to submissive, clingy behavior and intense fear of abandonment).--Adjustment Disorder, with mixed Disturbance of emotions and conduct.--Bipolar II Disorder (a mental health condition characterized by alternating patterns of major depressive episodes and hypomania, a less severe form of mania).--Anxiety Disorder.--Major Depressive Disorder (MDD) (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), recurrent severe without psychotic features.--Traumatic Brain Injury (TBI) (damage caused by an external force that disrupts brain function, ranging from temporary concussion to permanent disability).-The resident's symptoms include stealing from other residents, withdrawn, depressed, suicidal ideations, poor insight and judgement, attention seeking, paranoid, poor hygiene, sexually inappropriate, and refusing medications.-He/She had a history of verbal and physical threats to staff and other residents.-He/She hallucinated (tell him/her to hurt him/herself, hearing voices telling him/her to kill his/her spouse).-The resident had a history of multiple psychiatric admissions and had attempted suicide multiple times. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff and used for care planning), dated 1/21/26, showed he/she was cognitively intact and had no behaviors. Review of Resident #2's undated admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:-Bipolar Disorder.-Anxiety.-Major Depressive Disorder.-Dementia with behaviors (a decline in mental ability such as memory, reasoning, and communication which can cause confusion and negative behaviors such as anxiety, aggression, agitation, and delusions). Review of Resident #2's quarterly MDS, dated [DATE], showed he/she was cognitively intact and had no behaviors. Review of the facility Administrator/Registered Nurse Investigation (RNI), dated 3/25/26, showed:-Physical aggression involving the head between Resident #1 and Resident #2.-Witnessed by Certified Nursing Aide (CNA) A.-At approximately 8:00 A.M., the Administrator was notified that residents were lining up at the smoke room door for smoke break.-Resident #2 walked in front of Resident #1 and Resident #1 told Resident #2 you cannot cut the line.-Resident #2 hit Resident #1 in the eye and Resident #1 hit Resident #2 back on top of the head according to Resident #1.-Resident #1's eye noted to be watery, with mild redness at the time.-Resident#1's left eye had slight bruising on the under-eye area.-Resident #2 had no bruising, red marks or swelling Review of Resident #1's Skin Check, dated 3/25/26 at 8:00 A.M., showed the resident: -Had a new skin issue to the left eye with redness, the eye was watery and had bruising. -Acquired in-house on 3/25/26. Review of Resident #2's incident note, dated 3/25/26 at 9:48 A.M., showed:-A code was called, upon arrival staff informed Licensed Practical Nurse (LPN) A.-Resident #2 had cut the line and Resident #1 told Resident #2 he/she can't do that.-LPN A observed Resident #2 get up off the ground.-Resident #2 stated that he/she was hit on top of his/her head and kicked in his/her left leg.-Resident #2 had no visible injury. Review of Resident #2's Social Service Progress Note, dated 3/25/26 at 10:50 A.M., showed:-Resident #2 was escorted to Social Services office due to a resident to resident this morning.-Per the resident's own admittance, It was all my fault, but Resident #1 should not have hit me.-He/she should not have gotten ahead of the line, if he/she had gone to the back of the line then they would not have this problem.-Resident #1 asked resident #2 to get out of the line and when Resident #2 did not move Resident #1 hit Resident #2 in the head and Resident #2 hit Resident #1 back. Review of Resident #1's social Service Progress Note, dated 3/25/26 at 10:02 A.M., showed:-Per the resident he/she noticed at smoke break Resident #2 had cut the smoke line.-CNA A had asked Resident #2 to get in front of other residents as they walked into the smoke room. -Resident #2 refused to move per Resident #1.-Resident #1 told Resident #2 that he/she cut the line and needed to move.-Resident #2 proceeded to move toward the smoke room.-When Resident #1 nudged Resident #2. Then Resident #2 turned around and punched Resident #1 in the eye.-Per Resident #1 he/she hit Resident #2 back. Review of Resident #2's written statement, dated 3/25/26, showed:-He/She cut in line.-Resident #1 hit him/her and he/she hit Resident #1.-He/She should not have cut the line.-Resident #1 said sorry to the staff but not to him/her. During an interview on 3/31/26 at 3:32 P.M., Resident #2 said:-He/She had cut in line.-Resident #1 hit him/her, because he/she did not go to the end of the line.-He/she was angry and hit Resident #1 on the head. -He/she had no injuries to the head. Review of Resident #1's written statement, dated 3/25/26, showed:-He/She was in line to smoke.-Resident #2 butted in front of him/her and everyone else.-He/she told CNA A about it.-Resident #2 said he/she was up in front of Resident #1.-He/She bumped Resident #2, Resident #2 turned around and hit Resident #1 in the eye, so Resident #1 hit Resident #2 back. Observation and interview on 3/31/26 at 3:38 P.M., with Resident #1 showed:-Resident #1 had a bruise under his/her left eye by the nose.-Resident #1 said Resident #2 cut in line at smoke break time.-Resident #1 told staff but Resident #2 said he/she did not cut in line to the staff.-Resident #1 bumped into Resident #2 and Resident #2 turned around and punched Resident #1 in the left eye.-Resident #1 hit Resident #2 back because Resident #1 was upset. -Resident #1 tried to stay away from Resident #2. Review of CNA A's written statement, dated 3/25/26, showed:-Resident #2 jumped the line.-Resident #1 told Resident #2 to go back.-He/She did as well, but Resident #2 just looked at Resident #1 and said F you.-He/she was not sure who hit who first.-Resident #2 fell and Resident #1 kicked Resident #2.-He/she called a code green, and it was over. During an interview on 3/31/26 at 3:57 P.M., CNA A said:-He/she does not remember what happened for sure.-Resident #2 cut line said F you.-It happened so fast.-He/she called for a code to get help.-He/she tried to separate the residents.-He/she stayed with Resident #2.-Resident #2 had no injuries. During an interview on 4/1/26 at 1:26 P.M., Medical Nurse Practitioner (MNP) said he/she:-Was notified of the incident between Resident #1 and Resident #2 on 3/25/26 due to Resident #1 being punched in the left eye by Resident #2, no new orders were given. During an interview on 4/1/26 at 1:32 P.M., Psychiatric Nurse Practitioner (PNP) said he/she:-Was notified of the incident between Resident #1 and Resident #2 on 3/25/26. During an interview on 4/2/26 at 4:36 P.M., the Administrator said:-The resident-to-resident incident on 3/25/26 between Resident #1 and Resident #2 happened because Resident #1 was to smoke before the other residents due to behaviors in the smoke room with other residents.-Resident #2 walked faster to get in front of Resident #1 to get into the smoke room sooner.-When Resident #1 brought this to CNA As attention and no corrective measures were taken to move Resident #2 to the back of Resident #1 who was not scheduled to smoke at that time.-Resident #1 got upset and bumped into Resident #2 per Resident #1, Resident #2 turned around and punched Resident #1 in the left eye.-CNA A tried to get in-between the residents to separate them and called for a code green for more staff to help.-No one saw Resident #1 push or hit Resident #2. 2. Review of Resident #9's PASRR, dated 5/31/16, showed the following diagnosis:--PTSD.--Depression.--Anxiety.--Adjustment Disorder.--Panic Attacks (a sudden, intense episodes of fear or discomfort, often peaking within 5 to 20 minutes, featuring symptoms like a racing heart, chest pain, dizziness, and feelings of doom).--Histrionic Personality Disorder (a mental health condition marked by a pervasive pattern of excessive emotionality and an overwhelming desire to be the center of attention).--Anti-Social Behavior (a mental health condition defined by a long-term pattern of manipulating, exploiting, or violating the rights of others).--Low Intellectual Functioning.--Mild Intellectual Disability. -The resident's symptoms included poor impulse control, poor insight, poor judgement, irritability, boundary issues, difficulty with appropriate interactions, problems with authority, manipulative, excessive emotionality and attention seeking behaviors.-The resident had a history of multiple psychiatric admissions. Review of Resident #9's undated admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis:-Major Depressive Disorder.-Adult Antisocial Behavior.-Bipolar Disorder.-PTSD. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact with no behaviors. Review of Resident #10's PASRR, dated 9/2/24, showed the following diagnosis:--Schizophrenia.--Psychotic disorder.--Anxiety.--Bipolar Disorder.--Mood Disorder.--Developmental Disability.--Psychosis.--Schizoaffective Disorder.-The resident symptoms included feelings of sadness and agitation with aggressive behaviors with hitting head against.-The resident had a history of multiple psychiatric admissions, and 16 emergency room visits in two and a half months. Review of Resident #10's undated admission Record showed he/she was admitted to the facility on [DATE] and readmitted [DATE] with the following diagnosis:-Restlessness and agitation.-Intellectual Disabilities. Review of Resident #10's quarterly MDS, dated [DATE], showed he/she was cognitively intact with no behaviors. Review of the facility RNI, dated 3/31/26 at 10:10 P.M., showed:-At 8:12 P.M., the Administrator was notified of an incident involving Resident #10 and Resident #9, where Resident #10 was the aggressor.-Resident #10 was receiving a white (personal) cigarette from another peer when Resident #9 interjected and told the peer he/she was not supposed to do that, it was against the rules.-CNA B already made this clear to Resident #10 before Resident #9 interjected.-CNA B told Resident #10 if he/she was going to be aggressive he/she would have to leave.-Resident #10 ignored redirection and threw the ashtray and hit Resident #9.-This upset Resident #10 because Resident #10 because she feels the Resident #9 was bossy in nature.-Resident #10 told Resident #9 to shut up and threw the ashtray across the room hitting Resident #9's left cheek.-Initial skin assessment on Resident #9 noted swelling then about an hour or more later, bruising was observed. Review of Resident #9's Incident Note dated 3/31/26 at 7:50 P.M., showed:-Late Entry.-The Director of Nursing (DON) responded immediately to code green.-Upon arrival CNA B reported Resident #10 threw an ashtray at Resident #9, striking him/her in the face.-Resident #9 was assessed and noted to have a small abrasion under the left eye.-Resident #9 stated At smoke break, I was talking to a peer about not giving out his/her cigarettes to Resident #10. Resident #10 yelled at me in my face; I told CNA B to come here because Resident #10 was going to hit me. Then Resident #10 was yelling some more about me being bossy when I was cleaning the dining room earlier. After Resident #10 sat down in the chair, Resident #10 picked up a black ashtray and threw, and it hit me on the left side of my face. Review of Resident #10's Incident Note, dated 3/31/26 at 7:50 P.M., showed: -upon arrival CNA B reported Resident #10 threw an ashtray at Resident #9, striking him/her in the face. Review of Resident #9's Neurologic Focused Evaluation, dated 3/31/26 at 7:49 P.M., showed: - the resident's left eye pain rated a 9 on a scale of zero being the lowest pain to 10 being the highest pain and was aching, intermitted cool compresses applied, and as needed pain (PRN) medication was given per physician's order. Review of Resident #9's written statement, dated 3/31/26, showed he/she:-At 7:30 P.M. smoke break talking to a peer about not giving out his/her cigarettes to Resident #10.-Resident #10 yelled at Resident #9 in his/her face.-Told CNA B to come in the smoke room because Resident #10 was going to hit Resident #9.-Then Resident #10 yelled at Resident #9 being bossy when he/she cleaned the dining room.-Resident #10 picked up a black ashtray and threw it across the room and hit Resident #9 in the left face real hard.-Resident #9 wants to press charges against Resident #10 for assault. Review of Resident #9's Social Service Progress Note, dated 4/1/26 at 10:00 A.M., showed:-Resident #9 was escorted to the Social Service Office due to the resident to resident overnight.-Per Resident #9 he/she was conversing but (whispering) with one of his/her peers at the evening smoke break. -Resident #9 stated Resident #10 got in his/her face calling him/her a tattle tale.-Resident #9 yelled for staff.-Resident #10 threw an object and hit Resident #9 in the face. Review of Resident #9's Skin Issue, dated 4/1/26 at 4:59 P.M., showed:-Left face had bruising.-Stable; previously deteriorating wound characteristics plateaued, was acquired in-house.-Wound pain medication as needed; ice pack applied relief from interventions. Observation and interview on 4/1/26 at 3:36 P.M., Resident #9 had a bruise under his/her left eye and swelling to the left side of his/her face and temple and said:-He/She told another resident to not share cigarettes.-He/She did not pay attention to Resident #10 when talking to other residents.-Resident #10 yelled Resident #9 that he/she needed to stay out of his/her F business.-Resident #10 got close to his/her face when yelling.-Called for CNA B and LPN B came in the smoke room and told Resident #10 to give the cigarette back to peer.-Resident #10 said, that bitch always wants to be bossy.-CNA B told Resident #10 to leave the smoke room if not going to calm down.-Resident #10 picked up the ashtray and threw it hitting him/her on the left side of the face.-His/Her pain was rated a 9 out of 10 being the highest pain level.-CNA B was in the hallway at that time.-No staff were in the smoke room monitoring the residents.-During the day staff monitor the residents when smoking.-At night some staff stay in the hallway, and some will stay in the smoke room monitoring the residents smoking.-He/She had dreamt about the incident thinking someone was coming in the room, the incident had scared him/her.-Feels safe around others except Resident #10. Review of Resident #10's written statement, dated 3/31/26, showed he/she wrote he/she refused to give a statement for the investigation. During an interview on 4/1/26 at 1:54 P.M., Resident #10 said:-Resident #9 was bossy and a tattle tale.-He/She could only have two of the facility cigarettes and he/she wanted a white cigarette to smoke during the smoke break.-He/She was out of his/her own cigarettes and had no money to buy some.-He/She had enough of Resident #9 being in his/her business.-First, he/she stomped his/her foot to get Resident #9 to stop talking about him/her.-He/She picked up the ashtray and threw it at Resident #9.-Resident #9 had pissed him/her off.-He/She aimed for Resident #9's left eye. Review of CNA B's written statement, dated 3/31/26, showed:-Resident #10 called Resident #9 some names.-CNA B told Resident #10 to give the cigarette back to their peers.-Resident #10 resisted for a little bit then gave the cigarette back to the peer.-Resident #10 was calm and went to the far-right window seat while CNA B was in the doorway monitoring.-Resident #10 then turned around and threw the metal ashtray across the room hitting Resident #9 in the face. During an interview on 4/2/26 at 3:21 P.M., CNA B said he/she:-Was in charge of the 7:30 P.M. smoke break.-Resident #10 did not have any of her own cigarettes.-Offered Resident #10 a house cigarette, but he/she refused did not want a house cigarette wanted a white cigarette.-Explained to Resident #10 he/she was out of his/her own white cigarettes.-While passing out cigarettes to the other residents, Resident #10 borrowed a white cigarette from another resident behind CNA B's back.-Resident #9 told the other unidentified resident that they were not to borrow cigarettes from each other, it was against the rules.-Resident #10 started yelling at Resident #9 calling him/her names.-He/She made Resident #10 give the white cigarette back.-Resident #10 was told to calm down or leave the smoke room.-Resident #10 went to the other side of the smoke room and sat down and did not say anything.-He/She stepped out of the smoke room doorway for a second and Resident #10 threw an ashtray at Resident #9 hitting Resident #9 in the face. During an interview on 4/1/26 at 1:26 P.M., Medical Nurse Practitioner (MNP) said he/she:-Was notified of the incident between Resident #9 and Resident #10 on 3/31/26 due to Resident #9 being hit in the face with an ashtray. -A order was given to apply ice pack to Resident #9's left eye and side of face as needed for swelling. During an interview on 4/1/26 at 1:32 P.M., Psychiatric Nurse Practitioner (PNP) said he/she:-Was notified of the incident between Resident #9 and Resident #10 on 3/31/26.-Staff need to follow facility policies and procedures. During an interview on 4/1/26 at 2:31 P.M., ADON said:-Residents buy their own cigarette with the money they receive monthly, families buy them, or the residents earn points at the facility to buy them.-A white cigarette was the resident's own personal cigarette and are not allowed to give to another resident at any time.-The facility (house) cigarette was brown in color and was flavored,-Residents who do not have any can have a house cigarette during smoke breaks.-Some residents just want their own cigarettes or do not like the house cigarettes due to them being flavored.-Resident #10 was out of his/her own cigarettes and refused a house cigarette.-Resident #10 was caught borrowing a white cigarette from another resident during the 7:30 P.M. smoke break.-Resident #9 chimed in saying Resident #10 cannot borrow a cigarette from another resident.-This upset Resident #10 because Resident #9 was in his/her business.-Resident #10 picked up the ashtray and threw it at Resident #9 hitting him/her in the face.-Resident #9 was assessed for injuries to the left eye and face was puffy and starting to bruise under the left eye.-Would have expected the staff to have separated Resident #9 and Resident #10 incident before the residents escalated to physical abuse per facility policy and procedures. During an interview on 4/2/26 at 4:36 P.M., the Administrator said:-On the resident-to-resident incident between Resident #9 and Resident #10. CNA B should have called a code green when the residents started yelling at each other per facility policy.-LPN B should have made Resident #10 leave the smoke room due to aggression towards Resident #9 before the ashtray was thrown.-Resident #10 threw an ashtray at Resident #9 while in the smoke unattended by staff, hitting Resident #9 in the face.-MNP was notified of the injury, and order was given to place an ice pack to the injured area as needed for swelling, monitor resident for a change in condition and call back if needed.-Resident #9's left eye and cheek changed condition overnight and the MNP was notified of the change, and an order was given for mobile x-ray to come to the facility and take x-rays of Resident #9's left side of his/her face. 2963701, 2970175

Based on observation, interview, and record review, the facility failed to ensure residents were provided with activities to meet the residents' psychosocial well-being for two sampled residents (Resident #2 and Resident #16 out of 22 sampled residents. The facility census was 104 residents.Review of the facility's policy, Activities, dated 7/19/23 showed:-The purpose of this policy was to ensure that all residents in the facility were provided an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interests and their physical, mental and psychosocial well-being.-The Life Enhancement Director coordinates the comprehensive assessment and ensures that activities were designed to promote and enhance the emotional health, self-esteem, pleasure, comfort, education, creativity, success and independence for all residents, based on interview and assessing the resident's likes and dislikes. -The activity calendar would have been posted on each unit.-Under the direction of the Life Enhancement Director/Activities Director documentation would have been completed on each resident's activity within the facility daily. -Documentation would note participation in activities. 1. Review of Resident #2's face sheet showed he/she was admitted to the facility with the following diagnoses:-Schizophrenia (a severe mental disorder characterized by loss of touch with reality).-Anxiety.-Bipolar (a mental health condition characterized by intense mood swings, ranging from extreme highs to lows).-He/She had a legal guardian. Review of the resident's progress notes dated 1/7/26 showed he/she was cognitively intact. Review of the resident's undated care plan showed:-He/She had a behavior problem related to Schizophrenia, dated 7/16/24.-Staff was to provide a program of activities that was of interest and accommodates the resident. No documentation of which activities.-He/She had a behavior problem and went out to the hospital for Suicide Ideation (SI- wanting to end one's life) and upon return stated he/she went to the hospital because he/she was bored.-Staff was to assist the resident to develop more appropriate methods of coping and interacting, offer different activities and resident choice with staff, dated 2/26/26. -He/She was at risk for Anxiety.-Staff was to offer activities to keep him/her from getting bored and provide an opportunity to release energy in a healthy way, dated 6/4/24.-No documentation of which activities the resident enjoyed. Review of the resident's Physician's Order Sheet (POS) dated February 2026 showed an order to send him/her to the emergency room (ER) for evaluation related to suicidal and self-harm threats and refusal to take as needed (PRN) medication, dated 2/16/26. Review of the facility's investigation dated 2/16/26 showed:-The resident overheard staff asking another resident if they were trying to kill themselves.-The resident raised his/her hand and said yes. -The resident was assessed by the nurse and redirected for suicide ideation.-The resident said he/she was hearing voices.-The Nurse Practitioner (NP) was contacted, and an order was received to send the resident to the hospital for evaluation.-The resident was sent out to a nearby hospital.-The resident told the staff that he/she was just bored and wanted to get out of the building. -Conclusion: The resident was not engaged in meaningful activities. Review of the resident's Social Service notes dated 2/18/26 showed:-The Social Service Director (SSD) spoke with the resident about his/her suicidal ideations.-The residents need something to do as this is there home and many of them cannot leave the facility.-They need to interact with each other and maybe make some friends. During an interview on 2/25/26 at 2:10 P.M. the resident said:-He/She had heard voices which told him/her to do something bad to him/herself.-He/she would have liked to do something besides coloring or BINGO.-He/she would like to do something outside of the building. During an interview on 2/25/26 at 2:40 P.M. Certified Nurse's Aide (CNA) F said:--There were not many activities for the residents to do. -They have a social hour in the dining room where the Activity Director plays music or a movie on the TV. -He/She did not remember seeing an Activity Calander. -He/She would not know where to look to find which activities a resident would like to do. -He/she was not educated on the resident's preferred activities. During an interview on 2/26/26 at 2:30 P.M. Licensed Practical Nurse (LPN) D said:-There was not much for the residents to do at night only watch TV.-If the resident did not smoke, they don't go outside the building.-Some of the residents can't leave the building for safety reasons.-A lot of the residents are young and need to go outside to play basketball or do something to get fresh air.-There was nothing for the residents to do on the weekends. -He/she may have seen an activity calendar in the past but not recently.-The Activity Director should ask the residents what kind of activities would interest them, and that interest should be on their care plans. -Residents say they would have liked to do something on the weekend, but they did not know what was available.-He/She was busy with other duties, and it was the Activity Director's job to find things the resident's liked to do to keep them busy and out of trouble. Review of the facility's Action Plan dated 2/26/26 showed:-Staff was to monitor behaviors and attempt to determine underlying cause.-Staff was to provide a program of activities that was of interest and accommodated the resident's status.-Staff was to provide activities that promote exercise and strength building where possible.-There was no documentation of any activities set up. During an interview on 3/2/26 at 2:00 P.M. CNA A said:-If the resident starts to act out, he/she gave them a snack.-He/She did not know where to look for which activities any of the residents would like to go to. -A lot of the residents were in their 30's and need something more than TV or BINGO to do especially on the weekends. During an interview on 3/9/26 at 1:30 P.M. CNA G said:-The residents need more activities to do. -He/She did not know where to look to see which activities the residents would be interested in.-He/She had not seen any Activity Calanders on the walls for a while.-If the residents had more to do then maybe there would have been less problems with the residents. During an interview on 3/9/26 at 9:00 A.M. the SSD said:-The resident told him/her when he/she came back from the hospital that he/she wanted to go to an all-female facility. -There was not much for the residents to do at night.-He/She has seen the resident color as an activity. -There should have been some activities where the residents could have interacted with each other. During an interview on 3/9/26 at 9:44 A.M. the Activity Director said:-The resident went to all the scheduled activities. -The resident was in his/her mid 20's and liked to color and play BINGO. -The resident was not specifically asked what type of activities he/she would have liked. 2. Review of Resident #16's face sheet showed he/she was admitted to the facility with the following diagnoses:-Psychosis (a loss of contact with reality, characterized by symptoms like hallucinations (seeing or hearing things not there), delusions (false, firm beliefs) and disorganized thinking).-Bipolar.-The resident had a legal guardian. Review of the resident's undated care plan showed:-The resident was at risk for signs and symptoms of anxiety disorder.-Staff was to offer activities to keep him/her from getting bored and provide an opportunity to release energy in a healthy way, dated 7/25/24.-Staff was to ensure that the activities the resident attended were compatible with physical and mental capabilities, compatible with known interests and preferences.-Adapt as needed (such as large print, holders if resident lacks hand strength and were age appropriate. -Invite the resident to scheduled activities. -The care plan did not address which activities that were of interest to the resident. Review of the resident's Pre admission Screening and Resident Review PASRR (a comprehensive, person-centered assessment triggered by a positive Level 1 screening, determining if an individual with suspected serious mental illness, intellectual disability, or related conditions needed specialized services) Level II evaluation dated 5/16/25 showed:-Provision of a structured environment.-Staff was to provide schedule of daily tasks or activities. Review of the resident's progress notes showed his/her BIMS score was 12 indicating he/she was moderately cognitively impaired. During an interview on 3/2/26 at 2:00 P.M. the resident said:-There was nothing to do here and he/she went to his/her family's home over the weekend. -He/She would go home whenever it was possible to get out of the facility and do something different.-The staff had never asked him/her what kind of activities he/she would like to participate in.-He/She would have like to do something 1:1 not in a large noisy group, more than BINGO and more activities on the weekends. -He/She said that he/she spends a lot of time sitting in his/her room and would have liked to had someone to talk to or do an activity together. Review of the resident's Action Plan dated 3/9/26 showed staff was to provide him/her with diversional activities. Review of the resident's Activity Sheet from 1/1/26 to 3/9/26 showed the resident attended activities on the following dates:-1/5/26 and 2/1/26. -There was no documentation of the resident attending any activities after 2/1/26. During an interview on 3/9/26 at 9:44 A.M. the Activity Director said:-He/She did not know what kind of things the resident liked to do.-He/She tried to write down who attended activities but did not always do that. 3. During an interview on 3/9/26 at 9:44 A.M. the Activity Director said:-He/She would go around to the residents and ask them what they would like to do. -They put up Activities Calendars and sometimes the residents tear it down.-There was no current Activity Calendar on the wall. -He/She did not fill out a form for each individual resident showing what kind of activities they were interested in. -The residents were not specifically asked what type of activities they would like to attend. -He/She had a sheet that was filled out for attendance to the activities. -The residents have board games available to play at night. -There was a Church service the residents watched on TV on Sundays. -They did not have many activities on the weekends. Residents usually watched TV. -During the week there was a social hour. -Recently the residents had ice cream. During an interview on 3/9/26 at 2:30 P.M. the Administrator said:-A lot of the resident were younger and needed something to occupy their time.-Many of the residents were not able to leave the facility as they have guardians and did not have permission to leave. -They did not have many outside activities for the residents to do.-His/Her expectation was the Activity Director should have interviewed each of the residents when they first came into the facility and documented on their care plan which type of activities were of interest to them. -The Activity Director should have provided activities to meet the needs of the residents whether the resident was in a group or 1:1.-There should have been activities scheduled in the evening and on the weekends. -Residents become bored then they start to act out. -The Activity Director should have had documentation daily of which residents attended the activities and did not think that had been done. During an interview on 3/9/26 at 3:00 P.M. the Director of Nursing (DON) said:-The Activity Director should ask each resident which activities would be of interest to them, and it should have been documented on an assessment.-The assessment should have been completed when they first came into the facility. -There were activities on the weekends like cards, board games, bowling, crosswords, and watching movies on the TV.-A resident's choice of activities should have been documented in their care plan. During an interview on 3/9/26 at 2:28 P.M. the Psych Nurse Practitioner said:-It was important to have activities as they decrease resident behaviors. -The residents should have been evaluated for the things they liked to do as this was their home.-It was important to have activities in the evenings and on the weekends.

Based on observation, interview and record review, the facility failed to ensure two sampled residents (Residents #14 and #18) were free from abuse when on 2/26/26 Resident #8 struck Resident #14 on the back of the head and on 3/1/26 Resident #17 struck Resident #18 with a chair out of 22 sampled residents. The facility census was 104 residents. Review of the facility Abuse and Neglect Policy dated 6/12/24 showed:-It is the policy of the facility to report all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. -Physical abuse is purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. -Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, Facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.-The facility will identify events, patterns and trends that may constitute abuse and investigate thoroughly, notifying the Administrator and the proper authorities. 1. Review of Resident #8's Preadmission Screening and Resident Review (PASRR, DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; this includes dually certified beds both Medicare and Medicaid), dated 5/8/2020 showed: -Diagnoses including schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), bipolar disorder (mood disorders characterized usually by alternating episodes of depression and mania), and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen) without behavioral disturbances. -He/She had to be given medications, told to shower, change clothes, etcetera.-Significant memory issues are the main problem, with a retention time of 10-15 minutes, each day is a new day. -History of mood swings, depression, and trouble with sleep. -Tended to stay away from others, not much interaction and verbal responses were slow. Review of Resident #8's Referral Packet dated 1/12/26 showed the resident displayed exit-seeking behaviors and aggressive behaviors with staff and peers at a prior placement. Review of Resident #8's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/10/26 showed the resident was severely cognitively impaired. Review of Resident #14's PASARR dated 5/31/16 showed:-Diagnoses including Post-Traumatic Stress Disorder (PTSD is a mental health condition triggered by witnessing or experiencing terrifying, life-threatening events, such as abuse, war, or natural disasters), depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), adjustment disorder (a mental health condition where an extreme emotional or behavioral reaction to a stressor, such as divorce, job loss, or illness, disrupts daily life), and panic attacks.-He/She had poor impulse control, poor insight, poor judgement, and irritability. -Needed medical, behavioral, medication and safety provided within the nursing facility.-Required more supervision due to poor decision making, behaviors and would be considered an elopement risk in a less restrictive setting. Review of Resident 14's MDS dated [DATE] showed he/she was cognitively intact. Review of the facility Incident Report dated 2/27/26 showed:-On 2/26/26 an incident of physical aggression occurred involving Resident #14 and Resident #8.-Resident #8 walked up to staff and stated he/she wanted to smoke, staff advised it was not time to smoke. -Resident #14 also said it was not time for smoke break.-As Resident #14 was walking away from the table outside of the dining room, Resident #8 hit Resident #14 in the back of the head.-Resident #8 backed away on his/her own and walked towards his/her room.-Resident #14 expressed having a headache and was offered pain relief medication. -According to Resident #8, Resident #14 hit him/her on the cheek, so he/she hit Resident #14 back in the stomach while inside the smoke room. During an interview on 3/9/26 at 1:30 P.M. Certified Nurses Aide (CNA) G said: -One of the resident's called out and Resident #8 was in Resident #14's room beating him/her head. -When he/she got in the room Resident #14 was in bed and Resident #8 was standing. -He/She got Resident #14 out of the bed and behind him/her, Resident #8 was coming towards them. -He/She told Resident #14 to count to 3, then they backed up and ran out of the room to get away from Resident #8. During an interview on 2/26/26 at 11:00 A.M. the Administrator said:-The facility had an incident of abuse. Resident #8 struck Resident #14 in the back of the head. During an interview on 2/26/26 at 12:33 P.M. Resident #14 said: -Resident #8 hit him/her several times on his/her head, face and arm. -He/She was trying to help Resident #8 out, trying to help explain smoke breaks since Resident #8 couldn't quite get it.-He/She complained of pain to the back of head and forearm. -He/She screamed for help and would tell Resident #8 this wasn't his/her room and redirected him/her out of the room. -He/She was glad Resident #8 was gone and didn't want to deal with him/her again. -He/She felt scared when around Resident #8. 2. Review of Resident #17's PASARR dated 12/17/24 showed:-No known family support, under court ordered guardianship.-Diagnoses included schizophrenia, psychosis, bipolar with psychotic features, and borderline personality disorder.-History of mood lability, paranoid delusions, easily agitated, grandiosity, flight ideations, increased psychosis, and refusal of compliance with medications. -History of polysubstance abuse, including hallucinogenic.-History of delusions and talking to unseen persons. -Significant and ongoing fixed delusional ideation of grandiose, religious and persecutory nature leading to functional impairment and disability. -Preoccupied with idea that he/she is being continuously raped. -Other symptoms include labile mood, agitation, intrusiveness, rapid pressured speech, paranoia, internally preoccupied, history of medication non-compliance, and denial of illness.-Nursing Facility services recommended for a period of psychiatric stabilization following a period of medication non-compliance and elopement from previous RCF placing self in a dangerous situation in the community.-Requires ongoing cueing for ADLs as needed, diabetes management due to denial of illness, medication administration and monitoring. -Needs mental health and behavioral services, medication therapy and monitoring, structured environment, and crisis intervention services. Review of Resident #17's MDS dated [DATE] showed he/she was severely cognitively impaired. Review of Resident #18's PASARR dated 1/9/13 showed:-Diagnoses including schizophrenia, chronic paranoid schizoaffective disorder, alcohol dependence and polysubstance abuse.-Suffers from a chronic psychiatric condition, has had multiple in-patient psychiatric treatment episodes and multiple placements in long-term care facilities beginning in the early 1980's.-Significant history of legal problems usually associated with substance use/abuse.-History of homicidal ideation, of threatening behaviors.-History of lability of mood, mild agitation at times and some depression.-History of polysubstance abuse and alcohol use with treatment. -He/She tends to respond almost continually to unseen or unheard others.-Mental status exam was difficult due to paranoia and delusion system.-Suspicious of others, believes he/she is being watched, that others can read or hear his/her thoughts.-Conversation was disorganized, a word salad and interspersed with neologisms. -Continual auditory and visual hallucinations, many of which appear to be command. -Required verbal direction for personal care, monitor what the voices are telling him/her to do, and needed supervision due to disorganization.-Unable to take care of him/herself due to chronic illness, inability to distinguish real from not real, and not treatment compliant without structure. -Was his/her own guardian and needed to be placed under public administration.-Needed guardianship, monitoring for how he/she manages in an unlocked setting very closely. Review of Resident #18's Brief Interview for Mental Status dated 3/2/26 showed the resident was severely cognitively impaired. Review of Resident #17's Progress Note dated 3/01/26 at 2:00 A.M. showed:- It was reported the resident walked into the dining room, picked up a chair, and hit Resident #18 with it, causing Resident #18 to have a small pen-sized scratch on the right side of his/her eye. Review of Resident #17's Incident Report dated 3/1/26 showed:-On 3/1/26 at 2:02 A.M. there was an incident involving Resident #17 and Resident #18.-Resident #18 was sitting in the dining room with other staff nearby. -Resident #17 was observed pacing in the dining room with no clear evidence of anticipated aggression.-Without provocation, Resident #17 quickly picked up a dining room chair and threw it at Resident #18.-Resident #18 raised his/her arm to block the chair while staff verbally directed Resident #17 to stop .-Resident #18 had a scratch on the right eyebrow about the size of a pinhole and difficult to determine if it came from the chair or his/her hand when blocking. -The bleeding stopped after being cleaned, some swelling was noted by the charge nurse.-Pain relief administered, and ice pack offered. Observation of Resident #18 on 3/2/26 at 12:00 P.M. showed: -He/she had a laceration above his/her right eye. -No dressing noted, laceration was well approximated with redness and swelling noted. -He/she was alert to self and unable to interview. Observation of Resident #17 on 3/2/26 at 12:15 P.M. showed:-The resident was displaying behaviors and was unable to be interviewed.-The resident believed the state agency oniste was the feds coming after him/her. -The Assistant Administrator did not feel it was safe to be around the resident at that time due to the resident's behaviors. During an interview on 3/9/26 at 12:04 P.M. the Regional Care Plan Coordinator said:-Resident #17 throwing chairs is a new behavior. -He/She believed Resident #17 hitting Resident #18 was classified as abuse. During an interview on 3/9/26 at 2:30 P.M., the psychiatric Nurse Practitioner:-He/She expected the staff to keep the residents safe.-He/She felt the incident met the criteria for abuse. 3. During an interview on 3/6/26 at 1:00 P.M. the Director of Nursing (DON) said:-Resident #17 struck Resident #18 with a chair. -Resident #18 had a small cut above his/her eye.-The incident met the criteria for abuse. During an interview on 3/2/26 at 3:01 P.M. the Assistant Administrator said:-Resident #17 did not release the chair and kept it in his/her hand when striking Resident #18. -The incident met the criteria for abuse. 2789854, 2791189

Based on observation, interview, and record review, the facility failed to provide a functional and comfortable environment for residents by not maintaining inside resident room temperatures within acceptable parameters (71 to 81 degrees [ ] Fahrenheit [F] year-round) during outdoor temperature extremes in the event of a power outage and/or HVAC (heating, ventilation, and air conditioning) failure during those extremes; failed to develop a facility-specific, comprehensive climate control system outage policy and procedure; and failed to notify the proper agencies and entities of a failure in a timely manner, in accordance with State of Missouri rules and federal regulations. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 109 residents at the time of the investigation.Review of past Kansas City, Missouri outdoor temperatures on the Weather History website https://www.wunderground.com/history/daily/us/mo/kansas-city, showed the following:-Weather temperatures for Friday, 11/28/25, between 12:00 A.M. and 11:59 P.M. fluctuated from 26 F to 36 F.-On Saturday, 11/29/25, between 12:00 A.M. and 11.59 P.M., they were anywhere from 45 F to 25 F.-Sunday, 11/30/25 between12:00 A.M. and 11.59 P.M., temperatures ranged from 18 F to 28 F.-On Monday, 12/1/25, between 12:00 A.M. and 11.59 P.M., they were anywhere from 23 F to 25 F.-Tuesday, 12/2/25, between 12:00 A.M. and 11.59 P.M., they were from 15 F to 40 F.Review of the facility's 9-page indoor air temperature documentation, dated from 11/29/25 through 12/1/25 and provided by the Administrator, showed the following:-The documentation consisted of copies of handwritten blank paper and preprinted Air Temperature Log forms that were filled out by night nurses, CNA's (Certified Nursing Assistant), and the Maintenance Department.-The overnight temperatures from 11/29/25 at 7:00 P.M. to 11/30/25 at 7:00 A.M. were recorded as having been as low as 67.1 F in resident room [ROOM NUMBER], 67.0 F in room [ROOM NUMBER], and 64.0 F in room [ROOM NUMBER].-The temperatures on 11/30/25 between 8:00 A.M. to 10:00 A.M. were recorded as having been as low as 65.4 F in room [ROOM NUMBER], 60.7 F in room [ROOM NUMBER], 63.7 F in #204, 65.2 F in #208, 63.7 F in room [ROOM NUMBER], and 66.2 F in #211.-On 11/30/25 at 4:00 P.M. the temperature was logged at 62.1 F in room [ROOM NUMBER], 63.6 F in #202, 64.2 F in room [ROOM NUMBER], and 66.0 F in room [ROOM NUMBER].-The overnight temperatures from 11/30/25 at 8:00 P.M. to 12/01/25 at 4:00 A.M. were recorded as having been as low as 66.7 F in room [ROOM NUMBER], 66.7 F in #202, 65.8 F in #203, and 66.5 F in #204.-Most of the pages had no names or signatures, only two had initials, and three were undated.1. During an interview on 12/1/25 at 7:00 A.M., the Administrator said:-One of the residents noticed the QR (Quick Response) code, which went to the Maintain-X website for maintenance work order requests, located on their door's header and scanned it to notify them that their individual heating unit was not working. -The affected rooms found afterward were #201, 202, 203, and 210.-room [ROOM NUMBER] was fixed on 11/28/25 but he/she found out on 11/30/25 it was still malfunctioning.Observations on 12/1/25 from 7:40 A.M. to 8:13 A.M., showed:-The temperature in room [ROOM NUMBER] was 68.6 F.-The temperature in room [ROOM NUMBER] was 69.0 F.-The temperature in room [ROOM NUMBER] was 70.5 F.-The temperature in room [ROOM NUMBER] was 70.1 F.During an interview on 12/1/25 at 8:44 A.M., the Maintenance Director said:-On Friday night, 11/28/25, he/she was notified via a QR maintenance request that resident room [ROOM NUMBER] had an issue with the individual heating unit. -The software sent him/her a work order saying their room was cold at 6:13 P.M.-He/She called the heating company, and a technician came to the facility.-The technician said the unit was airlocked with sediment at 8:42 PM. -There was no indication to take temperatures in other rooms that night.-Parts were not available that evening and the resident room temp was still above 72 -73 F; the radiant heat was working, but the fan motor was not moving.-They started taking room temps on Saturday 11/29/25 as there was no other heat related complaints at that time.-Friday night room [ROOM NUMBER]'s heat was working.-On Saturday morning he/she took the air temperature in room [ROOM NUMBER] and it was over 72 and the unit was off.-That day he/she was notified other rooms were also having heating unit issues.-At 10:36 A.M. Saturday morning 11/29/25 he/she started checking all resident rooms, no other issues were indicated.-He/She started hourly room temps on Sunday morning 11/30/25 at approximately 10:30 A.M. to 11:00 A.M.-He/She was not aware of any cold rooms or individual heaters issues between Saturday and Sunday.-He/She found out Sunday morning there were three other rooms that were below 70 degrees #201, 203, and 210.-Staff were given thermometers and they kept temperature logs.Review of Resident #6's quarterly Minimum Data Set (MDS, dated [DATE], showed the resident was moderately cognitively impaired.During an interview on 12/1/25 at 10:11 A.M., the resident said:-He/She thought his/her room was chilly over the weekend.-He/She covered up and dressed warm.-He/She told two CNA's and the Maintenance Director.Review of Resident #8's quarterly MDS, dated [DATE], showed the resident was cognitively intact.Interview attempted on 12/1/25 at 10:16 A.M., but he/she refused to be interviewed.During an interview on 12/1/25 at 10:20 A.M., Resident #8's Guardian C said: -There was an afterhours emergency phone number but felt this situation rose to the level of being an emergency.-He/She expected the facility staff to offer to move the resident to a different room.-In that case she expected the staff to offer more blankets and warm clothing.During an interview on 12/2/25 at 6:20 A.M., Assistant Director of Nursing (ADON) A, said:-The heat started acting up in resident room [ROOM NUMBER] on Friday, 11/28/25.-The heating repair company came and looked at it that evening, but they did not have the parts and could not fix the unit.-Four units in four rooms were not functioning well #201, 202, 203, and 210.-Their unit were heating up, but no hot air was coming out. -They were taking hourly temps in residents' rooms on that unit.-On Saturday the same issues continued. During an interview on 12/2/25 at 1:07 P.M., the Administrator said:-Any time a person needed to be moved due to a utility being out would be the time to notify state.-He/She felt it was necessary to contact the regional state office on Sunday due to falling outside temperatures, but Friday was not as cold.-He/She was not aware they were supposed to contact the DHSS (Department of Health and Senior Services) disaster line for those four individual PTAC (Packaged Terminal Air Conditioners are a type of ductless cooling and heating unit) units as several units is not a complete utility outage, like a boiler outage.-They have no policy addressing when to contact the disaster line.-Their utility failure policy does not mention calling the state.-The disaster policy should have a time frame for when to start steps for notification and making a resident(s) more comfortable. Review of the facility's binder entitled Emergency Disaster Manual - Administrator's Copy, showed the following:-At Annex G: Utility Failure, under II. Emergency Response Procedures - Overview, a. Utility Failure, at point i.5. HVAC was listed.-Under g. HVAC, at ii. it read, In cases of extreme heat or cold, resident comfort and safety shall be top priority.--4. In cold weather interior temperatures will not fall below 71 F.--5. In the emergency of temperatures below 71 F, the facility will offer more blankets and even a room move if necessary.--8. In addition to current daily temperature checks, during HVAC outages staff shall perform hourly facility temperature checks and document for tracking.

Based on interview and record review, the facility failed to provide adequate supervision, when the facility staff did not provide ordered 1 on 1 supervision in direct line of sight per policy for one sampled resident (Resident #2) who had a known history of self-harm. On 9/19/25, the resident was able to self-harm by cutting him/herself on the left arm with scissors which resulted in a 7cm x 3-centimeter (cm) laceration. The resident was afraid because he/she could not get the bleeding to stop and the laceration required 8 sutures. The facility census was 108 residents.The Administrator was notified on 10/8/25 at 11:30 A.M. of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 9/19/25. The facility immediately completed education on one-to-one staff observations, documentation for one-to-one, including where to be in relationship to the resident and never closing resident doors while outside the resident's room, and implemented audits to ensure compliance. The deficiency was corrected on 9/24/25. Review of the facility's Intensive Monitoring Policy, revised 4/30/24, showed:-The purpose of the policy was to ensure a system was in place for residents who required increased monitoring for crisis, behavioral, and/or psychiatric issues.-Residents who required more intensive monitoring due to crisis, behavioral/psychiatric symptoms were to be monitored by the facility staff.-Intensive monitoring was defined as periodic (hourly, every two hours, or every shift) check completed on a resident by a facility staff member.-One-to-one monitoring was completed by a designated employee assigned by a Facility Supervisor for residents who required intensive monitoring of a dedicated staff member within eyesight of the resident.-Residents who were showing poor impulse control including crisis, behavior and/or psychiatric issues may be placed on intensive monitoring or one-to-one/two-to-one monitoring at the discretion of the administrative staff or Facility Supervisor.-Based on the assessment of the resident, either intensive monitoring or one-to-one/two-to-one monitoring was to be implemented.-Resident on any type of intensive monitoring was to have an assigned employee within eyesight of the resident until the resident stabilized or returned to prior level of function.-Education on the reasoning of the intensive monitoring, including resident triggers and interventions.-The employee was to therapeutically interact with the resident while monitoring the resident.-The facility's Interdisciplinary Team was to address the resident's behavioral concerns and ensure interventions were in place to address the resident's needs including psychiatry follow-up, counseling, and any medical needs.-Once the resident stabilized and/or returned to prior level of function, the facility's Interdisciplinary Team was to meet and discuss whether to continue or discontinue the intensive monitoring.-The facility staff was to document all completed intensive monitoring. 1. Review of Resident #2's Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 12/19/24, showed:-He/she had the following diagnoses:--Schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self).--Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety).--Schizoaffective Disorder (a mental condition that causes loss of contact with reality and mood problems).--Bi-Polar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).--Borderline Personality Disorder (BPD - a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior).--Mood Disorder (a variety of conditions characterized by a disturbance in mood as the main feature).--Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).--Obsessive Compulsive Disorder (OCD, an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions).--Autism or Autism Spectrum Disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave).-He/she had behavioral difficulties and/or mental illness symptoms requiring 24-hour monitoring/management.-He/she had a history of hitting the wall in his/her last facility, breaking his/her hand, as well as taking a razor to his/her arm and making a deep laceration.-The resident had a history of numerous placement situations and hospitalizations usually for self-harm or threatening harm to others.-He/she also had multiple suicide attempts including overdosing and cutting himself/herself.-The resident's family voiced concerns the resident would kill himself/herself while cutting.-He/she had a long history of medication non-compliance along with his/her self-harming behaviors, erratic behaviors with multiple psychiatric hospitalizations.-The resident had shown that his/her cutting were not suicidal, but instead to relieve emotional pain, irritability, and agitation.-He/she had cut as recently as December 2024.-He/she had behaviors of running down a hallway and slamming himself/herself into walls and doors at the previous placement as well as jumping into the Mississippi River in order to self-harm.-He/she had one-to-one supervision as well when inpatient.-The resident showed poor insight and poor decision-making skills, difficulty with expressing his/her emotions, as well as difficulty with interpersonal relationships.-The final determination stated the resident required close supervision and monitoring to maintain his/her safety due to his/her long history of self-harm and suicidal ideations.-He/she remained at a high risk for self-injury requiring 24-hour monitoring and staff intervention to prevent self-harm, monitor eating, mutism, limited overstimulation, providing a quiet, supervised space away from others to de-escalate in times of increased anxiety/agitation.-The resident was to have a structured environment with low stimulation, minimum visual/auditory distractions, a level of supervision required to prevent harm to himself/herself or others, personal space with a daily schedule of tasks and activities. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 9/8/25, showed he/she:-Was cognitively intact.-Had moderate issues with his/her mood.-Had shown no negative behaviors throughout the look-back period. Review of the resident's Physician's Order, dated 9/13/25, showed the resident was to be placed on one-to-one staff monitoring 24 hours per day until behaviorally stable per the Interdisciplinary Team (IDT) decision. Review of the resident's Individualized Service Care Plan (ICSP), dated 9/13/25, showed:-The facility staff was to begin behavior monitoring.-The resident became upset when he/she felt no one was listening to him/her.-The facility staff was to stop and listen to him/her when he/she was trying to speak.-He/she enjoyed animals, especially dogs.-When the resident felt anxious, the facility staff was to discuss with him/her dogs/animals, show him/her videos; have him/her watch a dog movie and speak with him/her about his/her pets.-The facility staff was to engage in conversation and let him/her speak and tell his/her story. -The resident had a history of cutting himself/herself with sharp objects, so the staff was to supervise him/her when he/she had sharp objects like razors and ensure he/she gives it back and it is disposed of properly.-The facility staff was to never leave him/her alone with a razor or any other sharp objects. -He/she was to remain on one-to-one staff observation to attempt to prevent any self-harm until further notice. Review of the resident's one-to-one staff observation documentation, dated 9/18/25 to 9/19/25 from 7:00 P.M. to 7:00 A.M., showed Certified Nurse Aide (CNA) A had been assigned as the resident one-to-one and had marked the sheet every 15 minutes with his/her initials. Review of the resident Nurse's Notes, dated 9/19/25 at 2:30 A.M., completed by Licensed Practical Nurse (LPN) A, showed:-Resident #2 came out of his/her room and went to the far end of the hallway.-LPN A asked the resident if he/she was okay and the resident said he/she was fine.-A few minutes later, Resident #2 requested an as needed (PRN) medication when LPN A noticed the resident had what appeared to have been a pillowcase over his/her left arm.-LPN A further investigated, a 7 cm by 3 cm laceration on the resident's left forearm. Review of the resident's self-harm Registered Nurse Investigation (RNI), dated 9/19/25 at 2:30 A.M., showed: -The resident had a self-inflicted injury.-The facility had placed the resident on one-to-one staff observation on 9/13/25 during an IDT after Licensed Counselor (LC) A raised a concern over future possible self-harming incidents. -The resident had been seen by the Psychiatric Nurse Practitioner (NP) on the day leading up to the incident.-The Psych NP had directed the resident to reach out to facility staff when feeling overwhelmed or when having thoughts of self-harm.-The resident did not say anything to the person doing the one-to-one or any other staff the night of the incident.-Although staff were present for the resident, he/she self-harmed while speaking with LC A, not telling LC A what he/she was doing. Review of the resident's hospital emergency room (ER) note, dated 9/19/25 at 4:08 A.M., showed:-He/she presented to the ER with a laceration approximately 7 cm by 3 cm on his/her left forearm.-The laceration was cleaned and eight staples were placed to close the wound, covered by gauze. -The resident was to keep the dressing dry for the next seven to ten days when the staples could be removed. Review of the written statement, dated 9/19/25 completed by CNA A , showed: -At around 2:00 A.M., the resident came out of his/her room and went to the nurse's station, never saying anything to him/her.-CNA A was sitting outside the resident's room so the next thing he/she knew, LPN A asked him/her to keep an eye on the resident.-At that point, he/she noticed the resident had a cut on his/her arm.-He/she was asked by the Director of Nursing (DON) why he/she was not sitting in the room with the resident, to which he/she responded that he/she had been off a couple of days and when he/she returned, he/she asked if he/she was supposed to sit inside the room and he/she was told no, so that was why he/she sat outside the room.-He/she could not recall who told him/her that he/she did not have to sit inside the resident's room. Review of the Mental Status Exam, dated 9/25/25 completed by the Psych NP, showed:-The resident was seen for changes in mood, anxiety, psychosis, cognition, sleep, appetite, motivation, energy, and safety, including both suicidal and homicidal ideations.-The resident had stitches in place to left wrist from self-harm.-The resident would not disclose where he/she got the scissors that caused the self-harm. His/her mood was flat and down, but he/she was writing hopeful quotes on his/her board.-The resident was encouraged to use his/her coping skills and report any changes in his/her mood to the staff as well as if he/she was experiencing any increase in anxiety.-The staff were encouraged to actively monitor the resident for changes in condition and worsening behaviors. Review of the resident's Focus Interview, dated 9/29/25 at 4:47 P.M. completed by the facility Social Worker, showed:-He/she did not intend to hurt himself/herself, but he/she needed an emotional release as he/she was upset with his/her roommate who had been watching his/her TV and using his/her personal items.-The resident was also upset as his/her roommate had also used his/her tablet and had been communicating and playing on-line games with the resident's closest family member. During an interview on 10/7/25 at 11:00 A.M., the resident said:-He/she had been out with his/her family for his/her birthday and everything went well.-He/she had gotten a birthday gift from a family member that had very small, sharp scissors in it and the scissors were stored in the very bottom of the box under a hard plastic cover, so no staff would find the scissors.-During the night of 9/19/25 he/she had been talking to his/her closest family member who had been the one to give him/her the birthday present.-He/she had also had a lot of issues with his/her roommate taking his/her things which really agitated him/her.-His/her roommate had taken his/her tablet and was playing games on it with his/her closest family member which hurt his/her feelings as the tablet and playing games was one of his/her coping skills. -When he/she started feeling triggered, he/she texted LC A around midnight that he/she was distressed.-LC A did not reply due to the time of night.-He/she was very upset the night of 9/19/25 and remembered the scissors were in the box, so before he/she could really think about it, he/she cut his/her arm.-He/she got scared when he/she couldn't get the bleeding to stop, so around 1:30 A.M. he/she called LC A but didn't tell him/her what happened, only that he/she was distressed.-He/she then went out to get a PRN from LPN A and that was when LPN A found the cut.-He/she had CNA A doing the one-to-one, but he/she was sitting outside the door and the room door was closed. During an interview on 10/7/25 at 12:20 P.M., CNA A said:- He/she had been employed by the facility for four months and he/she was sitting as the one-to-one staff observation for Resident #2 on the night of 9/19/25.-He/she was sitting outside the resident's room during the night of the self-harming incident which occurred inside the resident's room.-The door was kept shut throughout the night of 9/19/25.-He/she was told by an unknown staff member that it was okay to sit outside the room and that the resident wanted the door closed at night, so it was okay to keep the door closed even though the resident required one-to-one staff observation.-He/she was told by the DON after the incident on 9/19/25 there was some education done prior to him/her sitting one-to-one with the resident, but he/she was a night shift staff person and did not know when the education was so he/she missed it.-He/she was told to open the door and check on the resident every 30 minutes and document it.-He/she had never seen the resident's door open during one-to-one staff observations. During an interview on 10/7/25 at 1:30 P.M., LPN B said:-He/she was called by LPN A from another unit to assist as a resident had self-harmed.-When he/she got to the unit, he/she saw Resident #2 sitting in a wheelchair with blood dripping from his/her arm down onto his/her legs.-The resident appeared to be alert and oriented, but had obviously self-harmed by cutting his/her left arm.-He/she called 911 to have the resident transported to the hospital while LPN A tended to the wound on the resident's arm. Review of the written statement completed on 9/19/25 at 1:18 P.M., by Licensed Counselor (LC) A showed:-On 9/19/25 at 12:44 A.M., the resident sent LC A a text saying, I'm breaking.-As it was a text message and so early in the morning, LC A did not respond as he/she did not hear the message.-At 2:19 A.M., Resident #2 called LC A and stated he/she had not reached out to any staff letting them know he/she was in distress.-The resident did not share with LC A that he/she had self-harmed.-LC A told the resident to reach out to the Charge Nurse to get help with his/her distress he/she was feeling, per his/her safety plan, which the resident did while on the phone with LC A.-It was then, that LPN A discovered the resident had self-harmed. During an interview on 10/7/25 at 5:40 P.M., LC A said:-He/she had been seeing the resident for a couple of months.-He/she believed the resident's family was a trigger for the resident; however, the resident had also shown escalation when unable to speak with them or see them.-The staff was aware of the resident's family member could have been a trigger for the resident.-He/she had no idea the resident had already harmed himself/herself when the resident called the night on 9/19/25.-The resident only said he/she was in distress.-He/she was so glad the resident followed directions to go to the nurse for help as he/she was afraid the resident could have bled out had the resident not gotten scared of the bleeding.-He/she would have expected the CNA sitting as the one-to-one staff observation to have known to keep the resident in sight the entire time and never close the door. During an interview on 10/7/25 at 12:30 P.M., CNA B said:-When sitting as one-to-one staff observation, he/she was to be within arm's length with the resident always in his/her sight.-He/she was never to close the resident's door unless he/she was in the room with the resident. -If the resident got up and walked around, he/she was to follow the resident wherever they went.-He/she was to converse with the resident, encourage the resident to use their coping skills if escalating and interact with the resident. During an interview on 10/7/25 at 2:07 P.M., CNA C said:-He/she had sat one-to-one with the resident in the past.-The staff was to always keep the resident close, preferably within arm's length.-Staff were to at least keep them within close sight, close enough that if the resident tried to harm themselves or escalated to the point of self-harm they were to have been able to stop the resident.-The staff were never to close a resident's door unless they were in the room with the resident and close by the resident.-If the resident acted like they wanted to talk, the staff was supposed to talk with them, engage them in activities to keep them busy.-If the resident did not want to talk, the staff was not to force them. During an interview on 10/7/25 at 3:36 P.M., the Psych NP said:-Resident #2 had been doing so well for so long, he/she was really upset that the resident self-harmed.-He/she had not been working with the resident for long as he/she just picked up the facility in August 2025, but he/she had seen him/her recently and the resident was very proud of going so long without self-harming.-The resident had a small behavior and the Psych NP saw him/her on 9/19/25 briefly, just to let the resident vent.-The resident had been using his/her coping mechanisms well, drawing and voicing his/her feelings to staff.-He/she did not see anything alarming when they spoke the day of 9/19/25.-He/she did not make a note that day as they just spoke briefly, and things seemed to be good.-The staff did notify him/her of the incident.-He/she was not aware the CNA sitting one-to-one with the resident on 9/19/25 kept the door shut during the night.-He/she would have expected the CNAs keep the door open and be able to see the resident at all times, documenting per the policy. During an interview on 10/8/25 at 1:45 P.M., the facility Administrator and DON said:-CNA A was sitting with the resident on the night he/she self-harmed and knew better than to keep the door closed.-CNA A should have followed the resident out of the room when he/she left the room to go get help from LPN A.- LPN A and CNA A did not handle the situation or the resident as expected and were both terminated. -The expectation was that CNA A remained inside the resident's room at all times during one-to-one staff observation, followed the resident out of the room when he/she left the room, and that LPN A would have shown more urgency when the resident stated he/she was in distress, including asking questions of the resident, providing non-pharmacological interventions and more closely assessing the resident's physical state. -Given the resident had told LPN A he/she was in distress, the DON and Administrator would have expected LPN A to have noticed the resident had a pillowcase wrapped around his/her arm and immediately intervened instead of preparing a PRN medication.-CNA A had been educated on staying with the resident inside the room and never closing the door when on one-one staff observation. There was no reason CNA A should have closed the door and/or not had the resident within his/her sight at all times. MO002621570

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #2) out of 16 sampled residents was free from abuse; when on 10/27/25 at approximately 12:00 P.M., Resident #1 approached Resident #2 from behind and struck Resident #2 in the head and neck areas. Resident #2 was knocked to the floor from the hit when Resident #1 then kicked Resident #2 multiple times in the head and body; resulting in bruising on his/her forehead and minor swelling on the back of his/her head and neck and a small scratch on his/her left cheek. The facility census was 106 residents.Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident to resident altercations.-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.-Purposefully beating, striking, wounding or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner.-Physical abuse included, but was not limited to, hitting, slapping, punching, biting and kicking. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Disorganized schizophrenia (a mental disorder characterized by disorganized thinking, speech and behavior).-Major depressive disorder, recurrent, (a mood disorder characterized by persistent feelings of sadness). Review of Resident #1's Level II Pre-admission Screening/Resident Review ((PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 11/21/22 showed:-He/she had a history of disorganized schizophrenia; psychotic disorder, (a severe mental health condition that affects the mind causing the person to have a distorted sense of reality); generalized anxiety disorder, (a mental health disorder characterized by excessive, persistent and uncontrollable worry about everyday things); methamphetamine (meth) abuse; marijuana abuse.-He/She had a history of disorganized thoughts, thought blocking, responding to internal stimuli, being withdrawn and depressed, being suspicious, paranoid (feeling suspicious and distrustful), wandering, hallucinations and delusions, and abnormal thought processes. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff and used for care planning), dated 6/20/25, showed he/she was cognitively intact. Review of Resident #1's Care Plan Report dated 4/1025 showed the resident had a history of behavioral challenges that required protective oversight. Interventions included: pharmaceutical interventions as needed; 1:1 observation intervention as needed. Review of Resident #2's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Paranoid schizophrenia, (a type of schizophrenia with paranoia and delusions being prominent symptoms). -Anxiety disorder.-Alcohol dependence.-schizoaffective disorder (a chronic mental health disorder that combines symptoms of schizophrenia with symptoms of a mood disorder). Review of Resident #2's Level II PASSR dated 11/21/22 showed he/she was not able to care for him/herself due to chronic illness and inability to distinguish real from not real. Review of Resident #2's MDS dated [DATE], showed the resident was cognitively impaired. Review of Resident #2's Care Plan Report dated 4/12/25 showed:-He/she was at risk for the following signs/symptoms related to anxiety disorder: cursing, hollering, leg shaking, moving around in or frequently getting up and down from the chair, nail biting, nervousness, pacing on the unit, restlessness, shaky voice, toe tapping, sweating. -Interventions included: being aware of body and facial expressions when approaching the resident; watching for signs of anxiety and acting before he/she lost control; do not argue or tell him/her was wrong while he/she was upset; do not getting a power struggle with the resident; offer medication before he/she had a behavioral outburst; do not get close and remember personal space; offer non-invasive coping mechanisms to reduce anxiety; assist with finding the cause of the anxiety. Review of Resident #1's Progress Notes dated 10/27/25 at 2:32 P.M. showed:-The resident became angry at another resident and hit him/her in the back of his/her head and kicked the resident in the head several times.-A Code Green, (a behavioral emergency or aggressive incident) was called.-The resident went to his/her room when the nurse arrived.-911 was called to have the resident arrested related to assault.-The resident did not have a guardian. Review of Resident #2's Progress Notes dated 10/27/25 at 1:27 P.M. showed:-He/She went to the dining area and was sitting in a chair when Resident #1, came from the back and hit him/her in his/her head and stomped his/her head several times.-A Code [NAME] was called; upon assessment, the resident was found to be sitting in the dining room in a chair. Review of Resident #2's Neurologic Focused Evaluation, dated 10/27/25 at 2:08 P.M. showed:-His/her vital signs were within normal limits.-His/her pain level was 0, and he/she denied any pain.-He/she was able to follow commands and denied weakness, tremors, numbness or tingling.-The resident was alert and oriented x 3, communicated verbally, speech was clear and was able to understand and be understood when speaking.-His/her mood was alert with some cognitive impairment at baseline.-His/her mood was pleasant; no unwanted behaviors witnessed.Review of the Facility Admin/RN Investigation dated 10/27/25 showed:-The incident occurred on 10/27/25.-It was physical aggression involving the head.-Persons involved were Resident #1 and Resident #2.-Action taken was notifying Resident #2's guardian and the local law enforcement. Resident #1 was in police custody.-At approximately 12:05 P.M., shortly before lunch was served on the men's unit, Resident #1 was seated in a chair by him/herself.-Resident #1 proceeded down the hallway into the dining room, approached Resident #2 from behind and struck him/her, knocking him/her out of his/her chair.-At that time, Resident #1 stood over Resident #2 and with his/her foot and began hitting Resident #2's head. -Staff responded immediately, removing Resident #1 from the situation, and Certified Medication Technician (CMT) provided aid to Resident #2. -The Assistant Director of Nursing (ADON) and Assistant Administrator interviewed Resident #1 about his/her actions; he/she stated he/she did it because he/she needed to.-Resident #1 was charged with assault and was currently in the custody of law enforcement. Review of the local Police Department report dated 10/27/25 at 1:08 P.M. showed:-Resident #1 was arrested; suspect charged.-Resident #2 was the victim.-Business Office Manager (BOM) A was a witness.-The facility reporter was the Assistant Manager of the facility.-Upon arrival, Police Officer A contacted the Assistant Manager at the facility, who stated he/she was advised by staff that a physical altercation occurred which saw Resident #1 assault Resident #2.-The assault occurred in the downstairs common area.-The Assistant Manager contacted Resident #1 who told him/her, If I see him/her again, I'll stomp on him/her until I kill him/her. -Resident #1 was apparently angry at Resident #2 for coming into his/her room sometime prior to their physical altercation.-The Assistant Manager advised that Resident #2 was under guardianship of Guardian A.-Guardian A advised he/she would press charges on behalf of Resident #2.-Resident #1 was self-responsible, meaning he/she was not under any guardianship.-BOM A was contacted and stated the assault occurred in the downstairs locked unit in the common room.-Resident #2 was sitting in a chair minding his/her own business when Resident #1 came up to him/her from behind and struck him/her with a closed fist two times to the face/head area.-This caused Resident #2 to fall to the floor where Resident #1 proceeded to stomp on Resident #1's head three times with his/her right foot before he/she was finally separated by staff.-Nurses employed by the facility administered aid to Resident #2 who did not have any major injuries.-Officer A observed Resident #2's injuries. He/she had bruising on his/her forehead and minor swelling on the back of his/her head and neck and a small scratch on his/her left cheek.-Due to department camera not working, no photos were taken of his/her injuries, however they were captured by Police Officer A's body camera.-Resident #1 was taken into custody without incident and transported to detention for booking.-Resident #1 was issued a summons for assault. During an interview at 10:00 A.M. Resident #2 said:- Resident #1 was trying to punk (bully) him/her, but it did not work. -When Resident #1 hit him/her, he/she put his hands up to shield his face. During an interview on 11/5/25 at 11:00 A.M. the BOM said:-He/She witnessed the altercation between Resident #1 and Resident #2 around lunch time. -He/ She didn't know what started it.-He/She was passing out money to the residents that day.-He/She heard the altercation; his/her back was turned, so he/she saw out of the corner of his/her eye Resident #1 had walked up. -He/She thought Resident #1 was going to get in line. -Then Resident #1 hit Resident #2 from behind. -Resident #2 fell to the floor and Resident #1 started kicking Resident #2. -Resident #2 laid there and covered his/her face. During a telephone interview on 11/6/25 at 11:45 A.M. the former Activities Director said:-He/She was at the facility; it was his/her first day and the first thing he/she had to do was pass out money to people. -Resident #2 was sitting at the table and Resident #1 came and attacked Resident #2. -It was a violent attack on someone who wasn't doing anything. -He/She had never witnessed anything like that before. -Resident #1 was stomping Resident #2. -The attack happened about five feet from him/her. -Some employees ran out of the kitchen and pulled the Resident #1 off Resident #2. -During the attack Resident #2 urinated on him/herself. Review of Resident #13's MDS dated [DATE] showed he/she was cognitively intact.During an interview on 11/6/25 at 1:00 P.M. Resident #13 said:-He/She saw Resident #1 kick Resident #2 and they had words. -He/She thought Resident #1 kicked at Resident #2's body. During a telephone interview on 11/7/25 at 1:00 P.M. the Nurse Practitioner said:-Resident #1 assaulted Resident #2. -There was a suspicion Resident #1 could have been on a recreational drug.-Any time anyone got struck, that would be abuse. -He/She would personally not consider being high an excuse for hitting and kicking. During an interview on 11/7/25 at 1:20 P.M. the Director of Nursing (DON) said:-He/She did not consider Resident #1 hitting or kicking Resident #2 in the head as abuse. -He/She considered abuse to be intentional and Resident #1's behaviors were out of his/her norm and could not be intentional. -He/She felt it was an opportunity; if Resident #1 had wanted to do something, why did Resident #1 wait until they were in the dining room. -The two residents were roommates at the time. -It was a resident-to-resident aggression. During an interview on 11/7/25 at 1:30 P.M. the Regional Nurse Consultant said:-He/She was not at the facility when the incident happened. -He/She felt like abuse was malicious intent to cause harm. -He/ She knew the two residents were roommates.-He/She did not know if anything happened between them. -He/She did not know if Resident #1 was under the influence. -The people who were witnesses said head stomping happened, but there was no physical injury. -Resident #1 had other opportunities to hit Resident #2 prior to when Resident #1 hit Resident #2.-Resident #1 was usually respectful and not aggressive, something had to have happened to provoke Resident #1. During an interview on 11/10/25 at 11:09 A.M. Resident #1's family member said:-Resident #1 was his/her own person. -The situation had been escalating between the residents. -Resident #2 had been taking Resident #1's food and clothes. During a telephone interview on 11/10/25 at 11:20 A.M. Resident #1 said:-Resident #2 used to take and put on his/her clothes, shoes and eat his/her food. -That day, Resident #2 said he/she didn't want to be his roommate anymore and closed the door on Resident #1. -Resident #2 would come to Resident #1's side of the room and say weird things. -The Social Worker was going find Resident #1 another room. -He/she attacked Resident #2 when he/she saw Resident #2 in the dining room. -He/She just snapped and he/she did not know why he/she was so mad. He/she had never snapped like that before. -He/She only hit Resident #2 two times. Then he/she stomped Resident #2. He/she was trying to hurt Resident #2. He/she would have done it again. During an interview on 11/10/25 at 12:58 A.M. Guardian A said:-He/She was not aware of issues between Resident #2 and Resident #1.-Resident #2 was one of their newer clients. -Resident #2 had schizophrenia and typically did not have normal conversations with people and would say things that don't make sense.-Had he/she known the full extent of what had happened he/she would have requested Resident #2 to have been assessed in the emergency room. -Resident #2 was assaulted. During an interview on 11/10/25 at 12:10 P.M. the ADON said:-He/She was at the facility when Resident #1 assaulted Resident #2.-Resident #2 did not show injury to his head or face area. Resident #2 had wet and soiled himself/herself because of the altercation and refused to be cleaned up. Resident #2 did not want to be touched or changed, which was his/her baseline. During an interview at on 11/10/25 at 2:30 P.M. the Administrator said:-He/She defined abuse as the willful infliction of injury.-He/She didn't know how much the things said by Resident #1 could be relied on.-They did not have enough information, because the police took the resident.-He/She did not know if the definition of assault was abuse as their industry might have different definitions of events than those of law enforcement in relation to the charge of assault.-He/She felt Resident #1 hitting and kicking Resident #2 was not a willful action; because Resident #1's state of mind was unusual for Resident #1. #2652434

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and behavioral health services for one sampled resident (Resident #204) who had a known history of self-harm. The resident admitted to the facility on [DATE], with a history of self-harm and recommendation of intensive monitoring. The facility staff failed to consistently implement recommendations made in the resident's Pre-admission Screening and Resident Review (PASRR) assessment and the plan of care related to behavioral health services to ensure highest practicable well-being. The facility failed to ensure the interdisciplinary team reviewed, updated, and implemented individualized approaches to care after incidents of self-harm including: hitting a wall until his/her hand was swollen and greenish on 3/21/25; using broken glass from an overhead light to cut his/her left inner arm on 3/22/25; punching the wall with his/her right fist causing it to be swollen and bruised on 3/23/25; using a razor blade to cut the top of his/her left hand requiring sutures on 3/27/25; banging his/her head on a dresser resulting in a bruise over the left eye on 3/31/25; breaking into the smoking room and being found with his/her head in the ceiling and then slamming his/her body into a door three times, requiring the use of Zyprexa (an antipsychotic) 10 milligrams (mg) intramuscular injection (IM) a medication for self-harming behaviors as an intervention on 4/1/25; and threatening to cut him/herself and banging his/her head on the dresser resulting in two black eyes on 4/5/25. The facility failed to ensure staff had knowledge of resident care needs, including history of self-harm, interventions or resident triggers for behaviors. Facility policy showed residents who have self-harming behavior should have a staff person assigned to them within eyesight. The facility had no documentation or plan for intensive monitoring or oversight. As a result of the facility failure to provide treatment and services the resident was sent the emergency roiagnom on multiple occasions for x-rays and treatment. The census was 115. The Administrator was notified on 4/10/25 at 5:20 P.M. of the Immediate Jeopardy (IJ) which began on 4/8/25. The IJ was removed on 4/10/25, as confirmed by surveyor onsite verification. Review of the facility's Intensive Monitoring Policy, revised 4/30/24, showed: -The purpose of the policy was to ensure a system was in place for residents who required increased monitoring for crisis, behavioral, and/or psychiatric issues. -Residents who required more intensive monitoring due to crisis, behavioral/psychiatric symptoms were to be monitored by the facility staff. -Intensive monitoring was defined as periodic (hourly, every two hours, or every shift) check completed on a resident by a facility staff member. -One-to-one monitoring was completed by a designated employee assigned by a Facility Supervisor for residents who required intensive monitoring of a dedicated staff member within eyesight of the resident. -Residents who were showing poor impulse control including crisis, behavior and/or psychiatric issues may be placed on intensive monitoring or one-to-one/two-to-one monitoring at the discretion of the administrative staff or Facility Supervisor. -Based on the assessment of the resident, either intensive monitoring or one-to-one/two-to-one monitoring was to be implemented. -Resident on any type of intensive monitoring was to have an assigned employee within eyesight of the resident until the resident stabilized or returned to prior level of function. -Education on the reasoning of the intensive monitoring, including resident triggers and interventions. -The employee was to therapeutically interact with the resident while monitoring the resident. -The facility's Interdisciplinary Team was to address the resident's behavioral concerns and ensure interventions were in place to address the resident's needs including psychiatry follow-up, counseling, and any medical needs. -Once the resident stabilized and/or returned to prior level of function, the facility's Interdisciplinary Team was to meet and discuss whether to continue or discontinue the intensive monitoring. -The facility staff was to document all completed intensive monitoring. Review of Resident #204's Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 12/19/24, showed: -He/she had the following diagnoses: --Schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self). --Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). --Schizoaffective Disorder (a mental condition that causes loss of contact with reality and mood problems). --Bi-Polar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). --Borderline Personality Disorder (BPD - a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). --Mood Disorder (a variety of conditions characterized by a disturbance in mood as the main feature). --Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). --Obsessive Compulsive Disorder (OCD, an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions). --Autism or Autism Spectrum Disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). -He/she had behavioral difficulties and/or mental illness symptoms requiring 24-hour monitoring/management. -He/she had a history of hitting the wall in his/her last facility, breaking his/her hand, as well as taking a razor to his/her arm and making a deep laceration. -The resident had a history of numerous placement situations and hospitalization s usually for self-harm or threatening harm to others. -He/she also had multiple suicide attempts including overdosing and cutting himself/herself. -The resident's family voiced concerns the resident would kill himself/herself while cutting. -He/she had a long history of medication non-compliance along with his/her self-harming behaviors, erratic behaviors with multiple psychiatric hospitalization s. -The resident had shown that his/her cutting were not suicidal, but instead to relieve emotional pain, irritability, and agitation. -He/she had cut as recently as December 2024. -Along with his/her history of self-harm and non-compliance, he/she also showed a history of hallucinations, delusions, seclusiveness, destroying property, wandering, OCD, uncooperation with medications, eating, activities, hygiene, along with recently selectively muting himself/herself. -He/she had been on an inpatient psychiatric unit since 12/4/24 on 15-minute suicide watch. -He/she had had behaviors of running down a hallway and slamming himself/herself into walls and doors at the previous placement as well as jumping into the Mississippi River in order to self-harm. -He/she had one-to-one supervision as well when inpatient. -The resident had expressed a coping mechanism of utilizing a seclusion room with the door open and lights tuned low when he/she was overstimulated. -He/she had participated in being in the seclusion room several times during his/her previous psychiatric stay. -The resident showed poor insight and poor decision-making skills, difficulty with expressing his/her emotions, as well as difficulty with interpersonal relationships. -The final determination stated the resident required close supervision and monitoring to maintain his/her safety due to his/her long history of self-harm and suicidal ideations. -He/she required monitoring of behavioral symptoms, trauma informed services, and positive behavioral support services. -He/she remained at a high risk for self-injury requiring 24-hour monitoring and staff intervention to prevent self-harm, monitor eating, mutism, limited overstimulation, providing a quiet, supervised space away from others to de-escalate in times of increased anxiety/agitation. -The resident was to have a structured environment with low stimulation, minimum visual/auditory distractions, a level of supervision required to prevent harm to himself/herself or others, personal space with a daily schedule of tasks and activities. -A crisis plan was to be developed that indicated clear steps that were to be taken to support the resident during a behavioral crisis including knowing who to contact for assistance, how to work together with the resident during the crisis, and how to determine when the crisis was over. -The crisis plan was to identify the physician, emergency medical services, and/or law enforcement who were to be appropriately contacted. Review of the resident's facility Clinical Admission form, dated 2/20/25 at 11:49 P.M., showed: -He/she was admitted to the facility with no family present. -He/she was ambulatory, showed no medical issues, and his/her vital signs were stable. -He/she showed no signs of issues with his/her mood, was pleasant with no noted negative behaviors. -The resident showed issues with his/her skin with previous lacerations/scars to his/her left forearm, right abdomen, and right thigh. -The care planning portion of the form showed no safety concerns, no concerns with harm to himself/herself or others, no behavior management issues, no disturbed sensory perception concerns, no concerns with social interactions, no concerns for risk of injury, no concern with coping, and did not identify any supervision needs. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff and used for care planning), dated 3/16/25, showed he/she: -Was cognitively intact. -Had nearly daily issues with feeling down, hopeless or depressed, having little pleasure in doing things, sleeping too much or too little, having little energy, and feeling bad about himself/herself. -Showed no negative behaviors during the 90-day look-back period. Review of the resident's undated Nursing Care Plan on 4/8/25, showed: -The resident had a problem with his/her psychosocial well-being including ineffective coping, low self-esteem, taking everything personally, an altered perception of reality and at-risk for self-harm. - The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. -On 3/21/25 he/she became angry, hitting the wall and throwing objects causing his/her right hand to swell and bruise. Review of the resident's Nurse's Notes, dated 3/22/25 at 4:38 A.M., showed: -On 3/22/25 the resident had been placed on one-to-one staff observation after he/she cut his/her arm in anger. -Administrator A had spoken to the resident who stated when Licensed Practical Nurse (LPN) A asked two Certified Nursing Assistants (CNAs) to watch him/her, they argued about who would provide the one-to-one staff observations as it was a shitty job which he/she said he/she took very personally as if no one wanted him/her. -It was explained to the resident he/she needed one dedicated person to provide observation. -The resident expressed understanding and felt better after discussing the issue. -The resident stated the cutting was only to make him/her feel better and he/she did not have another outlet. -Administrator A gave the resident his/her contact information telling the resident he/she could call if he/she needed to vent his/her feelings. -The resident stated he/she does not show his/her emotions until they explode. -He/she stated when he/she got manic, he/she got very anxious, his/her thoughts raced and became obsessive over certain thoughts, causing him/her to self-harm. -The resident had five new dissolvable stitches in his/her arm yet denied pain. -The resident remained on intensive monitoring and had been since returning from the hospital. -He/she had cut himself/herself in the past, not trying to kill himself/herself, but instead, cutting made him/her temporarily happy. -He/she provided coping mechanisms such as speaking with his/her family member, coloring and playing his/her Nintendo Switch, which had been damaged by his/her roommate on 3/13/25 and had not yet been replaced by the facility, which he/she had expressed frustration over numerous times. -He/she stated he/she would like his/her service dog to visit him/her, but his/her family with the dog, lived far away. -He/she stated his/her latest self-harming episode was partly, because his/her family member was in the hospital and he/she was worried about that. -He/she stated the family member was his/her best friend and they used to do everything together. -He/she had ordered food that unbeknownst to him/her, had wheat in it, which he/she was allergic to. -He/she then had been made to feel like the allergic reaction was done on purpose and was his/her fault by the Dietary Manager. -He/she broke his/her overbed light and used the casing of the light cover to cut his/her forearm. -He/she felt like a failure and felt overwhelmed as he/she was having issues with his/her roommate and felt punished as the staff was making him/her move rooms, not his/her roommate. -He/she was upset the staff had to remove the food in his/her room which contained wheat or gluten even though he/she knew he/she was allergic and had a bad reaction to those foods. Review of the resident's Nurse's Notes, dated 3/22/25 at 12:38 P.M., showed: -The resident was found sitting on the bathroom floor bleeding from his/her left forearm. -Pressure was applied to the laceration with a towel to stop the bleeding and 911 called. -The resident stated he/she cut himself/herself with the light cover in his/her room. -The resident stated he/she cut himself/herself, because he/she was angry because the staff blamed him/her for an allergic reaction he/she had the night before when he/she ordered food delivery containing wheat and/or gluten, which caused the resident to have to go to the hospital and get medication and fluids for the reaction. Review of the resident's Self-Inflicted Injury Report, dated 3/22/25, showed: -The staff called a code after having found the resident on the bathroom floor bleeding from his/her left forearm. -Pressure was applied to the cut and 911 was called. -The resident stated he/she cut himself/herself with the light cover in his/her room. -He/she was angry because he/she felt the staff blamed his/her for having an allergic reaction to some food he/she had ordered and because his/her close family member was in the hospital. -He/she was taken to the hospital for evaluation and treatment. -The incident was not witnessed. -The injury was to his/her left forearm. -He/she was completely alert and oriented. -There were no predisposing factors prior to the incident. Review of the resident's Nurse's Note, dated 3/22/25 at 3:51 P.M., showed Administrator A documented: -The resident returned from the hospital and was placed on one-to-one staff observation. -He/she was placed on an antibiotic to prevent infection and orders to keep the stitches clean and dry. During an interview on 4/9/25 at 11:45 A.M., CNA T said: -He/she was working the day shift on 3/22/25, but not providing direct care for the resident. -He/she was not aware the resident had a history of self-harming behaviors. -It would be nice to know what the resident's history was so he/she could have paid closer attention to the resident. -He/she was not aware of what the resident's triggers or interventions were, but he/she could probably find them in the care plan. -He/she had not seen the resident much during the day as each time he/she walked by the resident's room, the resident was in his/her room in bed, refusing to do any activities. -He/she happened to go into the resident's room and found the resident on the floor of the bathroom, bleeding from his/her left forearm. -He/she noticed the resident had a lot of old cutting scars on his/her left forearm on the top of his/her arm and underneath his/her arm at the time he/she found the resident. -The resident had both linear scars and X shaped scars on his/her arms. -He/she called for help and the nurse attended to the resident and sent him/her to the hospital. -The resident had broken the light above his/her bed and used the glass shards to curt himself/herself. -The resident had not been on one-to-one staff observation prior to his/her cutting. -He/she did not recall having any de-escalating technique or mental health education at the facility, but he/she had a behavioral health background, having worked in mental health facilities in the past, so he/she felt prepared to work with mentally ill residents. Review of the resident's undated care plan on 4/8/25, showed facility staff did not update the resident's care plan with the incident on 3/22/25 or add any new interventions to prevent self-harm. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. Review of the resident's One-on-One Documentation Form, dated 3/23/25, showed the resident assigned one-to-one staff observation from 9:15 A.M. through 9:00 P.M. Review of the resident's Nurse's Notes, dated 3/23/25 at 9:10 P.M., showed: -The resident became angry and began hitting the wall and throwing objects. -A Code [NAME] (an overhead page indicating a resident had escalated their behavior to a point of needing extra staff assistance to keep the resident safe from harm) was called and upon assessment the resident was standing up in his/her room. -LPN F asked him/her to stop and what was wrong. -The resident stated he/she was angry at his/her guardian, because of his/her dog. -The resident's right hand was swollen and turned a greenish color. -911 was called, the physician and guardian were notified, and the resident was sent to the hospital for assessment and treatment. Review of the resident's Self-Inflicted Injury Report, dated 3/23/25, showed: -The resident became angry and began hitting the wall and throwing objects. -A Code [NAME] was called and staff came to assist. -The staff asked him/her to stop and what was wrong. -The resident stated he/she was angry with his/her guardian related to his/her dog. -Upon assessment, his/her right hand was swollen and greenish in color. -911 was called and the resident went to the hospital for evaluation and treatment. -His/her guardian was notified and stated the resident was angry as he/she did not know where his/her dogs were. -He/she was completely oriented. -There were no predisposing factors. Review of the resident's care plan showed no new interventions put in place after the 3/23/25 incident. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. During an interview on 4/10/25 at 11:40 A.M., LPN F said: -He/she was working 3/23/25. -The resident had not shown any signs of escalation, but had been on his/her phone during the evening. -It appeared that one of the phone conversations the resident had caused him/her to quickly escalate. -The resident was not on one-to-one staff observation as it was only being done during the daytime hours. -No behavioral interventions were put in place after this incident. Review of the resident's Nurse's Notes, dated 3/24/25 at 11:26 A.M., showed: -He/she returned from the hospital with no new orders. -The resident remained on one-to-one staff observation for protective oversight. Review of the resident's Nurse's Notes, dated 3/24/25 at 6:58 P.M., showed: -He/she remained on behavior monitoring with no signs of negative behaviors. -He/she had been in his/her room most of the day, so he/she was discontinued from one-to-one staff observation. Review of the resident's Nurse's Notes, dated 3/27/25 at 1:30 A.M., showed: -It was discovered the resident had a 4.5 centimeter (cm) deep laceration to the back of his/her left hand. -The resident initially stated he/she had fallen and cut his/her hand, however, later disclosed he/she cut himself/herself with a razor blade. -His/her hand was dressed with gauze and 911 was called to transport the resident to the hospital for treatment. -The resident's guardian, Administrator A, and Nurse Practitioner (NP) were all notified. Review of the Registered Nurse Investigation (RNI), dated 3/27/25 at 8:31 A.M., showed: -The resident cut himself/herself with a razor blade he/she had hidden in a box of tissues. -He/she cut the top of his/her left hand. -The incident was not witnessed. -Pressure was applied to the cut and the resident was sent to the ER. -All appropriate individuals were notified. -Counseling, a new Nintendo Switch, rubber band therapy, therapy dogs were all discussed as coping skills. -The resident was placed back on one-to-one staff observation while awake and environmental room checks of the room were completed. Review of the resident's undated care plan on 4/8/25, showed facility staff did not update the care plan after the 3/27/25 incident and did not add any new interventions to prevent the resident from self-harm. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. Review of the resident's Nurse's Notes, dated 3/31/25 at 3:25 P.M., showed: -The resident stated he/she fell in his/her room. -LPN A asked how he/she fell . -The resident stated he/she did not know. -LPN A observed a bruise over the resident's left eyebrow area. -The resident's room was checked for any items with which he/she could have harmed himself/herself and none were found. -It was later determined after resident interview that the resident admitted to banging his/her head on his/her dresser instead of falling. -All appropriate persons were notified. During an interview on 4/10/25 at 12:22 P.M., LPN A said: -He/she did not believe the resident was assigned one-to-one staff observation during the incident on 3/31/25. -The resident had not shown any self-harming behavior just prior to the incident. -The resident later told LPN A the resident banged his/her head either on his/her dresser or the sink, causing the bruising and the cut above his/her left eye. -The resident was sent to the hospital for evaluation and treatment. Review of the resident's care plan showed staff did not update the care plan after the 3/31/25 incident or with new intervention to prevent self-harm. Review of the resident's Nurse's Notes, dated 3/31/25 at 8:48 P.M., showed: -A peer of Resident #204 was having a behavior throwing chairs in the dining room. -The peer's behavior caused Resident #204 to trigger and he/she charged at his/her peer. -Multiple staff attempted to keep the residents apart and no blows were exchanged. -The resident got ahold of his/her peer's clothing, but he/she quickly released the clothing. -The resident calmed down after his/her peer was removed from the area. -No further issues occurred, and only superficial scratches were discovered on the resident's chest. Review of the resident's undated care plan on 4/8/25, showed facility staff did not update the care plan after the 3/31/25 incidents, including any new interventions or needs related to the resident's self-harming behaviors or safety concerns. During an interview on 4/10/25 at 10:40 A.M., LPN F said: -The resident had been fine at the beginning of the shift on 3/31/25. -He/she believed the resident's peer becoming escalated caused the resident to escalate as the resident later said the loudness and chaos of the unit made him/her upset. -He/she was not present for the incident until it was over, however, he/she would have expected the staff to remove the resident from the chaos before it caused the resident to escalate. -He/she was not aware loudness and chaos caused the resident to escalate in the past. -He/she did not believe the resident was on one-to-one staff observation at the time of the incident. Review of the resident's Nurse's Notes, dated 4/1/25 at 9:00 P.M., showed: -The resident became agitated and broke into the smoke room. -He/she was found climbing the window bars into the ceiling. Review of the resident's Nurse's Notes, dated 4/1/25 at 9:33 P.M., showed: -The resident was discovered sitting on top of the heater in the smoke room. -Staff were present and at a safe distance. -The resident agreed to go to Administrator A's office. -The resident was noted to run down the hall and into the unit door three times. -No apparent injury noted and an as needed (PRN) medication was given per the resident's request. -The resident calmed down after having been allowed to vent and verbalize his/her feelings. -All appropriate individuals were notified, and the resident was monitored for safety, increased anxiety and agitation. During an interview on 4/9/25 at 11:15 A.M., CNA I said: -He/she worked 4/1/25. -He/she was just ending his/her shift when he/she heard chaos coming from the smoke room. -When he/she got there, Resident #204 was standing up on the heater, holding onto the bars on the windows with his/her head up through the ceiling tile. -The resident had been fine all day and he/she had no signs of escalating. -As far as he/she was aware, the resident did not say why he/she did this or say anything about being upset to anyone. -Administrator A took the resident to his/her office to calm down. -He/she was not aware of what the resident's triggers or interventions were. -He/she was aware of the care plan, but had not looked at it. During an interview on 4/10/25 at 12:22 P.M., LPN A said: -He/she was just finishing up his/her day when he/she heard someone say to come to the smoke room. -On 4/1/25 the resident had broken into the smoke room and was standing on top of the heater, hanging on to the window bars, attempting to put his/her head into the ceiling. -Administrator A arrived and de-escalated the situation, taking the resident to his/her office. -The resident had shown no signs of escalation during the shift and was not on one-to-one staff observation as far as he/she could recall. -The resident did not say what upset him/her or why he/she did it. Further review of the resident's care plan on 4/8/25, showed staff did not update the care plan after the incident on 4/1/25 and no new interventions were put in place for the resident's self-harming behavior. The care plan did not include any interventions related to supervision needs or known triggers/stimuli (loudness or chaos) that could lead to challenging behaviors. The care plan did not include parameters for when pharmalogical interventions could be used. The care plan did not show an order for an intramuscular injection of Zyprexa at 10 mg ordered for an intervention PRN (as needed) medication for self-harming behaviors. Review of the resident's Nurse's Notes, dated 4/4/25 at 11:28 A.M., showed: -The resident was noted at 10:30 A.M., to be pacing back and forth while on the phone. -When he/she got off the phone, he/she began punching the walls, causing a large hole in the wall. -The resident was removed from the unit and escorted to Administrator A's office where he/she quickly de-escalated. -The resident called and spoke to one of his/her guardians who suggested the resident use his/her ear buds to drown out the chaos around him/her. -The resident's right hand was noted to be red and bruised from punching the walls in his/her room. -The NP was notified and ordered x-rays of the resident's hand. -The x-ray showed no fracture. -All appropriate individuals were notified. Further review of the resident's care plan showed staff did not update the care plan after the incident on 4/1/25 or 4/4/25. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. No new interventions were put in place for the resident's self-harming behavior, including the use of ear buds as a coping mechanism. Review of the resident's One-on-One Documentation Form, dated 4/5/25, showed the resident was on one-to-one staff observation, (provided by CNA I) from 7:00 P.M. to 9:45 P.M., when he/she was sent to the hospital for thoughts of self-harm. Review of the resident's Nurse's Notes dated 4/5/25 at 9:30 P.M., showed: -The resident came to CNA H and stated he/she was about to explode and harm himself/herself by cutting. -He/she was shaking significantly and did not appear to have been in control of his/her emotions. -He/she was interviewed by the Director of Nursing (DON) and was sent out to the hospital for further evaluation. Review of the resident's medical record showed it did not contain information the resident received trauma informed services or positive behavioral support services as indicated in the resident's PASRR. The resident's medical record showed no counseling services provided to the resident, daily living skills training, development of a personal support network, drug therapy/monitoring, medically related social services, physician services, a structured environment, and structured socialization as directed by the care plan to prevent self resident's self-harming behavior. Review of the resident's One-on-One Documentation Form, dated 4/9/25, showed the resident was on one-to-one staff observation provided by CNA T from 4:30 P.M., to 5:45 A.M. During an interview on 4/9/25 at 3:45 P.M., Hospital Registered Nurse (RN) A said: -He/she had taken care of the resident on the first day he/she was in theER on [DATE] and he/she was out of control the whole time he/she was there. -They had to keep someone with him/her at all times or they were afraid he/she would harm himself/herself. -Hospital RN A was off the day before and back on 4/9/25. -When he/she came back to work on 4/9/25 the resident was completely different. -The resident was calm and cooperative with no voiced intent to harm. -He/she believed the psychiatrist who saw the resident may have changed up some of the resident's medications, but he/she was not sure about that. -The resident told him/her that when he/she had these urges to self-harm, he/she had to do it or someone would have to physically stop him/her as the urges were too great for him/her to stop on his/her own. During an interview on 4/10/25 at 12:28 P.M., CNA H said: -He/she was not aware of what triggered the resident at any point in time when he/she self-harmed, or what interventions were in place other than one-to-one staff observation. -The resident had been on one-to-one staff observation during the day off and on throughout his/her stay at the facility. -A little while after the one-to-one caregiver left 4/5/25, the resident came and said he/she was getting upset and was about to explode and harm himself/herself. -CNA H immediately notified the charge nurse who called the NP and had the resident sent to the hospital. -He/she stayed with the resident until the resident left for the hospital. During an interview on 4/9/24 at 3:32 P.M., the resident said: -They had taken him/her off one-to-one staff observation prior to this last hospitalization on [DATE]. -He/she had been in the ER for three or four days this time. -Sometimes when he/she was

Based on observation, interview, and record review, the facility failed to ensure staff were using appropriate infection control practices during wound care for three sampled residents, (Resident #19, #1 and #14), failed to ensure Enhanced Barrier Precautions (EBP-strategy to decrease transmission of infections and/or cross-contamination during high-contact care activities for residents in nursing homes that include wearing gowns, gloves and at times a face mask) were used for one sampled resident with open wounds (Resident #19), failed to have appropriate EBP signage on the doors and Personal Protective Equipment (PPE) available near the rooms for three sampled residents (Resident #19, #1 and #14), failed to ensure the medication room on the Men's Locked Unit was kept clean and hand hygiene products were available for staff, and failed to ensure staff preformed hand hygiene during medication pass, out of 23 sampled residents, and failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for five sampled resident (Resident #1, #23, #72, #98 and #108) out of five sampled residents. The facility census was 111 residents. Review of the facility Standard Precautions-Infection Control policy dated 5/14/2024 showed: -Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. --This includes hand hygiene, selection and use of Personal Protective Equipment (PPE-e.g., gloves, gowns, face masks, respirators, eye protection). Respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment. -Hand Hygiene is a general term for cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known alcohol-based hand rub (ABHR). --During the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. -Personal Protective Equipment refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. Review of the facility Hand Hygiene policy dated 6/26/2024 showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. -Alcohol-based hand rub with 60-95% alcohol is the preferred method of cleaning hands in most clinical situations. -Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. -The use of gloves does not replace hand hygiene. -If the task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. -Use ABHR includes but not limited to: --Between resident contacts. --After handling contaminated objects. --Before applying and after removing PPE, including gloves. --Before and after handling clean or soiled dressings, linens, etc. --Before performing resident care procedures. --After handling items potentially contaminated with blood, body fluids, secretions, or excretions. --When, during resident care, moving from a contaminated body site to a clean body site. Review of the facility Clean Wound Dressing Change policy dated 5/18/2024 showed: -Provide wound care in a manner to decrease potential for infection and/or cross-contamination. -Each wound will be treated individually. -When multiple wounds are being dressed, the dressings will be changed in order of least contaminated to most contaminated (i.e. change extremity wounds before wounds contaminated with stool). -Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: --If the table is soiled, wipe clean. --Place a disposable cloth or linen saver on the overbed table. -Place only supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape). --Use no-touch techniques to remove ointments and creams from their containers (i.e. use tongue blade or applicator). Liquid solutions should be poured directly onto gauze sponges. -Establish area for soiled products to be placed. Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. -Loosen the tape and remove the existing dressing. -Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. -Wash hands and put on clean gloves. -Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze. -Measure wound using disposable measuring guide. - Wash hands and put on clean gloves. -Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. -Secure dressing. [NAME] with initials and date. -Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of the facility Enhanced Barrier Precautions dated 5/18/2024 showed: -EBP (gown and gloves) must be used for wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a Multidrug-resistant Organism (MDRO). -Any wound care requiring a dressing including chronic wounds, but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. -Make gowns and gloves available immediately near or outside of the resident's room. -Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). -Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. -EBP are intended to be placed for the resident's entire stay in the facility or until resolution of the wound or discontinuation of the indwelling device that placed them at higher risk. 1. Review of Resident #1's Admission Record showed he/she initially admitted on [DATE] and readmitted [DATE] with the following diagnoses: -Paraplegia (loss of movement of both legs and generally the lower trunk). -Pressure ulcer (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) left buttock, stage III (full-thickness skin loss extending into the tissue beneath the skin, forming a small crater). -PU Right heel stage III. -PU Left heel stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). -Unspecified open wound right foot, subsequent encounter (any encounter after the active phase of treatment). -PU Right buttock stage IV. -Type II Diabetes Mellitus (DM-condition that affects the way the body processes blood sugar (glucose). -Acute Lymphoblastic Leukemia (a type of cancer of the blood and bone marrow that affects white blood cells) not having achieved remission. -Neuromuscular dysfunction of bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Review of the resident's care plan dated 11/25/24 showed: -Limited physical mobility related to diagnosis of Paraplegia. -Area of trauma to the right buttock with potential to get worse due to non-compliance. -Pressure ulcer to left and right buttocks, and accidental puncture & laceration of skin, subcutaneously (the layer of tissue that underlies the skin) during other procedure. -Suprapubic indwelling catheter (a hollow flexible tube that is used to drain urine from the bladder and inserted through the abdominal wall into the bladder) with drainage bag (bag that collects urine) related to a Neurogenic bladder. Observation on 12/16/24, 12/17/24 and 12/18/24 throughout each day showed no EBP signage on the resident's door nor a cart for EBP supplies outside his/her room. During an interview on 12/18/24 at 1:53 P.M., Licensed Practical Nurse (LPN) B said there should be a sign on the resident's door for EBP due to the indwelling catheters and open wounds. Observation on 12/18/24 at 1:56 P.M., of the resident's wound care and dressing changes showed LPN B: -Used EBP of gown and gloves. -Opened wound supply cart in resident's room and removed items and placed on the bedside dresser without cleaning it or placing a clean barrier surface down. -Did not change gloves or wash/sanitize hands. -Cut old dressing off the resident's left foot and touched other objects in room without changing gloves or washing/sanitizing hands. -Another staff brought his/her name badge in and he/she put it in pocket under gown without changing gloves or washing/sanitizing hands. -Placed chux pad (a disposable, absorbent pad used to protect surfaces from incontinence) under the resident's feet and removed old dressing on right foot. -Did not change gloves or wash/sanitize hands. -Cleaned wounds on both resident's feet with wound cleanser and gauze. -Turned resident to right side to clean the left lateral foot better, with same gloves. -Change gloves sanitized hands and re-gloved. -Cut Xeroform (medicated Vaseline gauze) dressing to fit wound area and covered with an abdominal pad (ABD an extra thick primary or secondary dressing used for wounds) dressing on left foot. -Did not change gloves or wash/sanitize hands. -Looked through the wound supply cart for another ABD pad. -Did not change gloves or wash/sanitize hands. -Placed another ABD over top of foot for protection and wrapped with Kerlix wrap (a name brand of gauze wrap). -Changed gloves but did not wash/sanitize hands. -Removed dressing on right lateral foot near heel, two small areas and cleaned with wound cleanser and gauze. -Rubbed lower left leg, dry skin, and bottom of foot with A&D ointment (a Vaseline ointment with vitamins A and D added). -Removed gloves and put on new gloves without washing or sanitizing hands and went through cart again to find items. -Did not change gloves or wash/sanitize hands. -Placed Xeroform dressing on each area. -Searched through cart again for more Xeroform without changing gloves or washing/sanitizing hands. -Searched back through supply cart for an ABD pad without changing gloves or washing/sanitizing hands. -Placed ABD dressings over top and side of left foot. -Turned on call light with same gloves on to have another staff get more ABD pads and Kerlix wrap. -Did not change gloves or wash/sanitize hands before touching bed frame and gathering trash while waiting. -Wrapped self-adhesive ace wrap over the left foot dressing to keep in place still did not change gloves or wash/sanitize hands. -Opened Kerlix package and wrapped right foot, did not change gloves or wash/sanitize hands. -Applied A&D ointment on lower right leg. -Rolled resident to left side with the same gloves on. -Removed old buttocks dressings. -Did not change gloves or wash/sanitize hands. -Cleaned buttock area wounds with wound cleanser and gauze. -Did not change gloves or wash/sanitize hands -Went through cart drawer again to get a Q-Tip to measure depth of opened areas. -Did not change gloves or wash/sanitize hands. -Packed both holes with Dakin's solution (a type of hypochlorite solution that is made from bleach, water, and baking soda it kills most forms of bacteria and viruses and prevents germ growth in wounds) soaked Kerlix and under buttocks fold area. -Placed Xeroform over the small buttocks areas and covered with an ABD pad. -Gathered up supplies and assisted resident to turn to right side with same gloves on. -Removed old dressing and cleansed left buttocks areas with wound cleanser. -Did not change gloves or wash/sanitize hands. -Placed Xeroform over areas. -Turned on call light to get a clean brief for resident. -Did not change gloves or wash/sanitize hands. -Placed ABD pad over buttocks. -Placed clean brief under resident. -Did not change gloves or wash/sanitize hands. -Cleaned peri area with wet wipes. -Did not change gloves or wash/sanitize hands. -Readjusted resident's catheter tubing's (resident had a Foley catheter [a tube with retaining balloon passed through the urethra into the bladder to drain urine] and a Suprapubic catheter) and cleaned both catheter tubing's. -Did not change gloves or wash/sanitize hands. -Fastened the resident's brief pulled up the resident's pants. -Removed gloves, took scissors to the medication room and cleaned scissors with bleach wipes and washed hands. During an interview on 12/19/24 at 10:49 A.M., the wound company Nurse Practitioner said the resident: -Had a history of leukemia and Osteomyelitis (bone infection usually caused by bacteria). -Had gone through multiple rounds of IV antibiotics that had not helped in the wound healing process. -Refused to be admitted to a hospice (end of life) program. -Refused Nephrostomy (a passage way maintained by a thin tube placed through the back into the kidney to temporarily drain urine that is blocked) tubes to help with healing. -Wounds were healing and doing much better then when he/she first started seeing this resident. During an interview on 12/20/24 at 9:57 A.M., Certified Nursing Assistant (CNA) M said when doing catheter care: -Washed his/her hands and gown and glove up. -Clean the catheter tubing with a wet wipe starting at the top insertion area and wipe down several inches. -When finished remove gloves and wash hands. -Change gloves and wash/sanitize hands when going from a dirty area to a clean area. -The nurse usually did the resident's catheter care when doing his/her dressing changes. During an interview on 12/23/24 at 11:13 A.M., CNA N said when doing catheter care: -Washed hands and put on PPE, gown and gloves due to the EBP requirements. -Held the tubing in one hand and wiped down the tubing from the top about 2 inches with the wet wipes. -Changed gloves when going from dirty area to a clean area and sanitized or washed hands and put on new gloves to finish cares. -Don't touch other items in the room during cares. -If did touch something change gloves wash/sanitize hands and re-glove. 2. Review of Resident #14's Admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Osteoarthritis (inflammation of the of the bone with progressive cartilage deterioration). -Paranoid Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, feeling distrustful, suspicious, and fearful of others unable to distinguish reality from fantasy having delusions and hallucinations, to manage emotions, make decisions, and relate to others). -Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Acquired Absence Right leg above knee. Review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 9/20/24 showed: -Re-entry 8/31/24. -Entered from an acute hospital. -Major orthopedic surgery. Review of the resident's care plan dated reviewed on 12/18/24 showed: -Had limited physical mobility related to bilateral amputee utilized a wheelchair for mobility. -Would remove his/her dressing multiple times throughout a 24-hour period. Review of the resident's Treatment Administration Record (TAR) dated December 2024 showed: -Xeroform Oil Emulsion Gauze External Pad (Bismuth Tribromophenate Petrolatum an antimicrobial compound that was the active ingredient in Xeroform). -Apply to Left Above the Knee Amputation (AKA). -Cover with ABD pad topically every day shift for wound care. -Dressings were changed daily. Observations on 12/16/24, 12/17/24, and 12/18/24 throughout each day showed no EBP signage on the resident's door nor a cart for EBP supplies outside his/her room. During an interview on 12/19/24 at 12:00 P.M., the resident said: -He/She did not know what the EBP sign was for on the door. -It was put up last night he/she didn't ask any staff what it was for. -Did not think any nurse put a gown on to change the dressing on his/her knee. Observation on 12/20/24 at 11:36 A.M., of the resident's left knee dressing change showed LPN D: -Knew what EBP was. -Put gown, gloves and mask on. -Did not clean the bedside table or place a clean barrier on the bedside table. -Placed several dressing packages on the resident's bedside table. -Removed gloves. -Sanitized hands and gloved up told res what doing. -Resident was sitting next to bed near the opened door. -Did not close the door. -Removed old dressing from the surgical wound on left knee. -Did not change gloves or wash/sanitize hands. -Cleaned the incision with wound cleanser. -Opened Xeroform package with gloves on. -Did not change gloves or wash/sanitize hands. -Placed Xeroform dressing over surgical site and covered with an ABD dressing. -Placed a bordered gauze over the ABD to secure. -The bordered gauze was too small to cover all edges. -With the same gloves on moved packages of dressings around on bedside table looking for tape. Could not find tape. -Removed gown and gloves without washing/sanitizing hands and left room to get tape. -Returned gowned up did not wash or sanitize hands and put on gloves and taped all edges of the dressing. 3. During an interview on 12/23/24 at 12:07 P.M., LPN B said: -When doing dressing changes supplies should be ready before starting. -Provide privacy for the resident. -Supplies should be on a cleaned surface or clean barrier. -Wash hands, glove up and gown up. -Should change gloves and wash/sanitize hands and re-glove between each wound area. -If need to touch other items in room should change gloves and wash/sanitize hands and re-glove. -When finished remove gown, gloves and place in an EBP red trash bag and wash hands. During an interview on 12/23/24 at 4:02 P.M., the Director of Nursing (DON) said: -The nurse should have all supplies ready before starting dressing changes. -The room door and curtains should be closed for privacy when doing dressing changes. -The nurse should not touch other items during the procedure without changing gloves and washing/sanitizing hands and re-gloving. -Gloves should be changed and hands washed/sanitized between one wound and another. -During catheter care gloves should be changed and hands washed/sanitized if going from a dirty area to a clean area. -Residents with wounds or catheters should have EBP. -There should be an EBP sign on the resident's door. -There should be a cart outside the resident's room with EBP supplies. -There should be a red trash receptacle in the resident's room for soiled wound dressings. 39469 4. Review of the facility's policy, General Medication Administration Process, dated 6/26/24 showed: -Staff was to wash hands prior to administering medication per facility protocol and product. -Staff was to perform hand hygiene and before preparing medication and before and after direct contact with the resident. Observation on 12/19/22 at 8:33 A.M. of medication pass on the Men's locked unit with Certified Medication Technician (CMT) D showed: -CMT D did not perform hand hygiene before starting the medication pass. -He/She did not have hand sanitizer on the medication cart. -He/She went into room [ROOM NUMBER] and administered medication to the resident. -He/She did not perform hand hygiene after administering the medication to the resident. Observation on 12/19/22 at 11:22 A.M. of medication pass on the Men's locked unit with CMT D showed: -He/She did not perform hand hygiene before starting the medication pass. -He/She did not have hand sanitizer on the medication cart. -He/She administered medications to the residents in room [ROOM NUMBER] and 210. -He/She did not perform hand hygiene after administering the medication to the residents. -He/She locked the medication cart to wake a resident up to take their medication. -He/She did not perform hand hygiene after nudging the resident. -He/She did not perform hand hygiene after unlocking the medication cart. -He/She administered medication with a glass of water he/she had poured to the resident in room [ROOM NUMBER]. -He/She took the glass after the resident drank from it and threw it away. -He/She did not perform hand hygiene after taking the glass back from the resident. -He/She administered medication to the resident in room [ROOM NUMBER] which included an inhaler (a handheld device that delivers medication into the lungs). -He/She put the lid back on the inhaler then put the inhaler in a drawer in the medication cart. -He/She did not perform hand hygiene. -He/She administered medication to the resident from room [ROOM NUMBER] along with a glass of water. -He/She did not perform hand hygiene. -He/She administered medication to the resident from room [ROOM NUMBER] along with a glass of water. -He/She pulled his/her phone out of his/her pocket and looked at it then put the phone back into his/her pocket. -He/She did not perform hand hygiene. -He/She had not worn gloves. During an interview on 12/19/22 at 12:12 P.M. CMT D said: -He/She did not have any hand sanitizer on his/her person. -He/She should have performed hand hygiene before, after medication pass, and after administering medication to each resident. -The facility had provided education on hand hygiene during medication pass a couple of months ago. During an interview on 12/20/24 at 10:00 A.M. the DON and Registered Nurse (RN) A said: -Staff should have washed their hands before, during, and after medication pass. -They should have had hand sanitizer on the medication cart. -The staff had education about hand hygiene many times. During an interview on 12/23/24 at 4:10 P.M. the DON said: -He/She expected the nursing staff to cleanse their hands before they start medication pass, after administering medications to a resident, and after they were done with medication pass. -If they pulled something out of their pocket they also should have done hand hygiene. -He/She was ultimately responsible to ensure staff was performing hand hygiene according to protocol. 5. Review of Resident #19's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Non pressure chronic ulcer of the back. -Open wound right upper arm. -He/She had a guardian. Review of the resident's care plan dated 8/11/24 showed: -He/She had actual impairment to skin integrity to right axilla area (armpit). -He/She was to avoid scratching. Review of the resident's annual MDS dated [DATE] showed: -He/She was cognitively intact. -Had unhealed pressure ulcers. -Had an infection of the foot. -Was getting dressings to the foot. Review of the resident's Physician's Order Sheet (POS) dated December 2024 showed the following order: -Cleanse open areas to lower right leg with wound cleanser, pat dry, apply silver alginate (medication used for treatment of infected chronic wounds) and cover with bordered gauze dressing (an absorptive dressing that consists of three layers), every day shift for wounds. Observation on 12/20/24 at 2:55 P.M. of wound care showed: -The resident had 5 wounds on his/her lower right leg. -LPN A used a gauze soaked in normal saline to cleanse the resident's leg. -LPN A swiped down the right side of the resident's leg using one gauze to wipe the three wounds. -LPN A swiped down the left side of the resident's leg using one gauze to wipe the two wounds. -LPN A cleansed his/her hands and changed gloves. -LPN A reached into his/her pocket to pull out a pen. -LPN A pulled the resident's curtain tighter closed with the same gloves on. -He/She applied medication to the residents wounds without changing gloves first. During an interview on 12/20/24 at 2:55 P.M. LPN A said: -He/she should have changed gloves after wiping each wound. -He/She forgot to change gloves and cleanse hands after putting his/her hand in his/her pocket and pulling the curtain shut. During an interview on 12/20/24 at 10:00 A.M. the DON and RN A said: -Staff should wash their hands every time they changed gloves. -Staff should use different gauze for each wound that was cleaned. -If staff touched anything they needed to change gloves and wash their hands. During an interview on 12/23/24 at 4:10 P.M. the DON said: -If the nurse was doing wound care and reached into his/her pocket or pulled the curtain shut they should have changed gloves and cleansed their hands. -When cleansing a wound staff should use new gauze for each wound. -The staff had a lot of education on hand washing. -He/She was ultimately responsible for ensuring staff was doing wound care appropriately. 6. Observation on 12/16/24 at 1:00 P.M. did not show anyone on the Men's locked unit was on EBP. -There were no signs on any of the resident's doors. -There was no isolation cart near any of the resident's rooms. Observation on 12/17/24 at 9:00 A.M. did not show anyone on the Men's locked unit was on EBP. -There were no signs on any of the resident's doors. -There was no isolation cart near any of the resident's rooms. Observation on 12/17/24 at 3:15 P.M. did not show anyone on the Men's locked unit was on EBP. -There were no signs on any of the resident's doors. -There was no isolation cart near any of the resident's rooms. During an interview on 12/19/24 at 8:33 A.M. CMT D said: -He/She had education about EBP provided by the former DON maybe a month ago. -If a resident was on EBP it would have been documented on the Medication Administration Record (MAR). -There would have been a sign on the resident's door stating he/she was on EBP. -There would have been an isolation cart outside the resident's room. -He/She had not seen a sign or isolation cart outside anyone's room this week. -No one at this time on the Men's locked unit was on EBP. -Resident #19 had a wound on his/her leg that nursing had been treating. -The charge nurse was responsible for alerting the staff if someone was on EBP. -If a resident was on EBP staff should have worn gloves, face mask, gown and booties. -There was no physician's order for Resident #19 to have been on EBP. -He/She was not aware that any of the residents were currently on EBP. During an interview on 12/20/24 at 10:00 A.M. the DON and RN A said: -Before this week they had not been using EBP. -Anyone who had an open wound should have been on EBP. -There should have been a sign on the resident's door indicating he/she was to have been on EBP. -There should have been an isolation cart with PPE in it at the resident's door. -The physician should have written an order for EBP. -Staff had education about EBP. -The DON was responsible for ensuring the residents who had open wounds or any kind of tubing were on EBP. During an interview on 12/23/24 at 4:10 P.M. the DON said: -Resident #19 had an open wound and should have been on EBP. -Any resident that had an open wound or any kind of tubing coming out of their body should have been on EBP. -There should have been a sign on the resident's door indicating he/she was on EBP and what kind of PPE staff was expected to wear while caring for that resident. -There should have been an isolation cart outside the resident's room with PPE for the staff to wear while caring for the resident. -There should have been a physician's order stating the resident was on EBP. -It should have been documented in the care plan the resident was on EBP. -It should have been passed on it the shift report the resident was on EBP. -He/She was ultimately responsible to ensure residents were on EBP and that staff was aware of it. -Staff had education from him/her and previously from the form DON about EBP. 7. Observation on 12/17/24 at 9:47 A.M. and on 12/19/24 at 8:33 A.M. of the medication room on 200 locked unit (men's) unit showed: -The only sink in the medication room was dirty with rust. -There were no paper towels in the medication room. -There was no hand soap in the dispenser. -The floor was dirty and sticky. During an interview on 12/19/24 at 8:33 A.M. CMT A said: -He/She did not know who was responsible for cleaning the medication room. -He/She did not clean it. -The medication room should have been cleaned daily. -The floor should have been cleaned daily. -There should have been soap and paper towels in the medication room for staff to wash their hands. -He/She had never seen anyone clean the medication room. -Housekeeping should have cleaned it. Observation on 12/19/24 at 11:00 A.M. showed: -The only sink in the medication room was dirty with rust. -There were no paper towels in the medication room. -There was no hand soap in the dispenser. -The floor was dirty and sticky. During an interview on 12/19/24 at 11:00 A.M. LPN A said: -When they were done with the medication carts they pushed them into the locked nurse's station. -He/She did not know who was responsible for cleaning the medication room, maybe housekeeping. -The medication room should have been cleaned daily. -The floor should have been cleaned daily. -There should have been soap and paper towels in the medication room for staff to cleanse their hands. -He/She had never seen anyone clean the medication room. -Housekeeping should have cleaned it. -The nurse would have to unlock the door as housekeeping didn't have a key to the medication room. During an interview 12/23/24 at 9:50 A.M. Floor Technician A said: -He/She had worked at the facility for several years and had not cleaned the medication rooms. -Cleaning the medication rooms was up to the Nursing staff. During an interview on 12/23/24 at 4:10 P.M. the DON said: -The sink and floor in the medication room should have been cleaned. -There should have paper towels and soap in the medication room for hand hygiene. -Housekeeping should have cleaned and ensured there were supplies in the medication room daily. 42955 8. Review of the facility's Tuberculosis Testing policy, dated 6/29/23, showed: -The purpose of the policy was to ensure each resident of the facility was tested for TB. -Upon admission and readmission each resident received a two-step purified protein derivative (PPD) tuberculin skin test (TST-a test to detect TB completed by injecting a small amount of TB protein under the top layer

Based on observation, interview, and record review, the facility failed to keep one sampled resident (Resident #9) free from abuse. On 12/8/24 Certified Nursing Assistant (CNA) K kicked at Resident #9. Resident #89 grabbed Resident #9 by the neck out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Abuse and Neglect policy dated 1/5/23 showed: -Physical abuse included purposely beating, striking, or injuring a resident. It included but was not limited to hitting and kicking. -Verbal abuse included using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples included yelling at a resident. -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices such as dealing with aggressive residents, and recognizing signs of burnout, frustrations, or stress that may lead to abuse. -On a regular basis, supervisors will monitor the ability of staff to meet the needs of residents and staffs understanding of individual resident care needs. Situations such as inappropriate language, insensitive handling, and impersonal care will be corrected as they occur. Review of the facility's Resident Rights policy dated 7/5/23 showed residents have the right to be free from mental and physical abuse. 1. Review of Resident #9's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Impulse disorder (a psychiatric condition that makes it difficult to control actions or reactions). -Borderline intellectual functioning (below average cognitive functioning). -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Bipolar (mood disorders characterized usually by alternating episodes of depression and mania). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a shocking, scary, or dangerous event). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/26/24 showed the resident was cognitively intact with no behaviors. Review of Resident #89's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems). -Intellectual disabilities. -Schizophrenia. -Bipolar. -Asperger's syndrome (a developmental disorder that makes it difficult to interact with others and understand social cues). Review of Resident #89's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Had verbal behaviors 1-3 days during the look back period. -Had no physical behaviors. Observation of the facility video of the incident on 12/8/24 showed: -The video was undated and not time stamped. -A resident was standing at the nurse's station with his/her back to the camera using the telephone. The charge nurse was in the nurse's station behind the clear partition and CNA K and CNA L were standing at the nurse's station next to the resident on the telephone with their backs to the camera leaning on the medication cart. -CNA L and CNA K appeared to be talking to the nurse behind the partition while the one resident was on the telephone and other residents were walking up and down the hall. -Resident #9 walked up behind CNA K, CNA K turned to face the resident. The resident began pointing to a box (later identified as the cigarette box for the unit) and down the hall. CNA L then turned around to face the resident. -Resident #9 and CNA K's facial expressions and body language demonstrated both were talking in heated, elevated, agitated tones. CNA K was forcefully pointing his/her finger towards the resident. CNA L also began talking in a heated. elevated tone. The nurse remained behind the clear partition in the nurse's station. -Resident #89 is seen walking into frame behind Resident #9, then walks off. -Resident #9 is still talking in an agitated state when the nurse comes out from behind the nurse's station and gets between Resident #9 and CNA K. CNA L walks out of the camera frame. -The resident that was on phone then walked out of camera frame and Resident #89 walks up behind Resident #9. -Resident #9 and CNA K are still talking to each other in elevated agitated tones with the charge nurse standing between them. -Resident #9 rips off his/her jacket and lunges towards CNA K attempting to throw punches at CNA K. -Resident #89 comes up behind Resident #9 and attempts to put his/her forearm around the resident's neck as if to place in a choke hold. -Unidentified staff come into frame to pull Resident #89 off of Resident #9. The nurse was still between Resident #9 and CNA K. -CNA K begins lunging at Resident #9 with the charge nurse between the two, holding onto CNA K. -The charge nurse is then seen physically restraining CNA K to keep him/her from Resident #9 as two unidentified staff are each holding an arm on Resident #9. -CNA K is then seen kicking at Resident #9. Review of the resident's Progress Behavior note dated 12/8/24 showed the resident told the Administrator the staff on his/her unit jumped on him/her. An investigation immediately ensued. Review of the facility investigation dated 12/12/24 showed: -An undated screenshot of a text message at 9:11 P.M. from the charge nurse, Licensed Practical Nurse (LPN) C, indicating the resident took a cigarette from him/her then went to the CNA to get a cigarette. The charge nurse told the resident he/she already had a cigarette from him/her. The CNA and the resident went to the smoke area. When they came back to the nurse's station with other aides, they were talking back and forth and the resident and staff were loud. The resident became aggressive and tried to attack. Two CNAs held the resident's hands while he/she moved the other CNA from the situation. An as needed medication (PRN) was administered to the resident and the resident calmed down. -Resident #9 and Resident #89 were not interviewed. -CNA L and CMT E were not interviewed. Review of LPN C's written statement dated 12/11/24 showed: -On 12/8/24 a CNA L and the resident came to the nurse's station and asked for a cigarette. -The resident was told he/she had already received a cigarette. -On return from the smoke room the resident was agitated, talking loudly, and one of the CNA K was also loudly talking. -The resident tried to attack the CNA K. -Two CNA L and CNA J held the resident while he/she held the other CNA K and moved the CNA K. **NOTE**LPN C was attempted contact for interview on 12/23/24, 12/24/24 and 12/26/24. LPN C did not return the call. Certified letter mailed for contact. During an interview on 12/17/24 at 2:18 P.M., Resident #9 said: -Staff told him/her they were going to take his/her cigarettes away during a recent incident a week or so ago. -He/She pushed the staff with his/her belly. -The staff and two residents were hitting him/her. During an interview on 12/19/24 at 10:59 A.M., Resident #89 said: -Resident #9 was talking and suddenly got mad and attacked a staff member. -The staff member and Resident #9 were both hitting each other. -He/She hit Resident #9 to get the resident off of CNA K. Review of CNA K's written statement dated 12/10/24 showed: -Resident #9 said he/she was allowed to have his/her cigarettes if he/she asked for them. -When Resident #9 had the cigarettes taken away, he/she began making threats towards the staff and fighting the staff. During an interview on 12/20/24 at 3:58 P.M., CNA K said: -Resident #9 was upset about cigarettes. He/She had asked a nurse about getting them when he/she should not have. -He/She told the resident he/she could not have them. -He/She and the resident began arguing verbally about it. -He/She denied the resident attempted to hit him/her and he/she did not attempt to hit the resident. Review of CNA J's written statement dated 12/8/24 showed: -CNA L said to the resident You have to calm down or else we're gonna have to call a Code Green! (Code [NAME] is a signal to other staff to assist with a behavioral episode). -He/She called the Code [NAME] three times on the walkie talkie. By the third call, he/she witnessed the resident start punching CNA K. -He/she then jumped up and as he/she was running to separate everyone, Resident #89 grabbed Resident #9 by the neck as he/she was swinging at CNA K. -He/she separated everyone the best he/she could, telling the other residents to go to their rooms as he/she was attempting to get Resident #9 in a two-man hold. -At this time they were still yelling for a Code [NAME] for extra help. A few minutes passed when he/she yelled for the Certified Medication Technician (CMT) to run for help since no one can hear us! Finally some help came. - Resident #9 made it seem as if he/she was a trigger, so he/she removed him/herself. During an interview on 12/20/24 at 3:27 P.M., CNA J said: -He/She did not normally work back on the secured care unit. -He/She had been in another room with two other residents when another CNA (CNA L) told him/her the nurse was giving Resident #9 cigarettes. -He/She and CNA L went to talk to CNA K in the closed smoke room about the cigarettes. CNA K showed him/her the cigarette box was almost empty. -Resident #9 was outside the smoke door but was able to get into the smoke room and was getting upset. -They were able to calm the resident down and all of them left the smoke room. -Toward the end of the shift, he/she heard staff call for a Code [NAME] he/she went to see what/who it was regarding. -He/She saw CNA K and CNA L were trying to calm Resident #9 down, but then Resident #9 started to hit CNA K. -Resident #89 came up from behind Resident #9 and him/her in a choke hold and he/she had to pull Resident #89 off of Resident #9. He/She did not see CNA K hit or kick Resident #9, but things were happening so fast and he/she was focused on calming Resident #9 down. -Resident #9 was put in a two person hold and Resident #89 was educated to not intervene in the future because it could trigger him/her or other residents. During an interview on 12/23/24 at 12:05 P.M., the Administrator said: -He/She did not feel as though what was on the video was abuse. -The staff were not interacting with the resident appropriately. It appeared both sides were agitated and not talking calmly. -There was no audio to the video, so he/she could not tell what was actually being said. -He/She could not tell if CNA K was kicking at the resident but was giving him/her the benefit of the doubt that perhaps he/she could have been kicking to get the smoke box out of the way. --NOTE: The smoke box was not in view of the camera and was not in between the resident and CNA K at the time CNA K kicked at the resident. -The investigation provided was the complete investigation. During an interview on 12/23/24 at 4:02 P.M., the Director of Nursing (DON) said: -Abuse investigations were completed by him/her and the Administrator. -He/She had seen the video of the altercation between Resident #9 and Resident #89 and CNA K. -The investigation provided was the complete investigation. -Investigations should include interviews with all witnesses, including any staff and residents identified or involved in the incident. During an interview on 12/23/24 at 12:05 P.M., the Administrator said: -The investigation provided was the complete investigation. -No witness statements or interviews were included in the investigation. During an interview on 12/23/24 at 4:02 P.M., the DON said: -Resident to resident altercations should be thoroughly investigated. -A complete investigation would include witness statements from staff and other residents. -Statements from the residents involved in the incident should be included in an investigation. During an interview on 12/17/24 at 2:18 P.M. Resident #9 said: -Staff told him/her they were going to take his/her cigarettes away during a recent incident a week or so ago. -He/She pushed the staff with his/her belly. The staff and two residents were hitting him/her. During an interview on 12/20/24 at 3:27 P.M., CNA J said: -He/she heard Code Green. Staff were trying to calm Resident #9 down when Resident #9 started hitting CNA K. -Resident #89 came up behind Resident #9 and put him/her in a choke hold. -He/she and CNA L were able to remove Resident #89 and educated him/her about intervening in other resident behaviors. -He/She and CNA L put Resident #9 in a two person hold by holding his/her hand and arm. -He/she said the incident happened so fast he/she could not remember who was doing what, he/she was focused on holding onto Resident #9 arm and trying to calm Resident #9 down. During an interview on 12/20/24 at 3:46 P.M., CMT E said: -He/She normally works on the locked unit. -He/She was in the cafeteria area when he/she heard a commotion. -He/She saw Resident #9 and CNA K at the nurse's station. It looked like they were both hitting each other, but he/she was on sure who hit who, it looked like both were swinging from where he/she was at. -He/She called a Code [NAME] and was told to go find staff to assist. During an interview on 12/23/24 at 11:52 A.M., CNA L said: -He/She was doing rounds checking on residents getting ready for the next medication pass time. -He/She came out of a resident room and saw Resident #9 standing at the medication cart with the nurse. -The nurse handed the resident a couple of cigarettes. -He/She asked what was going on since the staff were not supposed to do that (hand out cigarettes when it was not smoke break time). -The nurse said he/she was giving out cigarettes. He/She told the nurse he/she was not supposed to do that. The nurse said he/she had been doing that all day. -He/She took the cigarettes from the resident and walked with him/her to the smoke room. -He/She spoke to CNA K and CNA J about the resident getting extra cigarettes from the nurse. -As they were discussing it, Resident #9 came into the smoke room and started screaming at the staff. -They walked to the front of the unit by the nurse's station. Resident #9 continued to scream at the staff and an altercation broke out. -He/She went to call a Code Green, and that was when the altercation happened. It happened so fast, he/she did not see anyone other than Resident #89 hit Resident #9. During an interview on 12/23/24 at 12:05 P.M., the Administrator said: -He/She did not feel as though what was on the video was abuse. -The staff were not interacting with the resident appropriately. It appeared both side were agitated and not talking calmly. -There was no audio to the video, so he/she could not tell what was actually being said. -He/She could not tell if CNA K was kicking at the resident but was giving him/her the benefit of the doubt that perhaps he/she could have been kicking to get the smoke box out of the way. -Hitting or kicking a resident would be considered abuse. --NOTE: The smoke box was not in view of the camera and was not in between the resident and CNA K at the time CNA K kicked at the resident. During an interview on 12/23/24 at 4:02 P.M., the DON said: -Abuse investigations were completed by him/her and the Administrator. -He/She had seen the video of the altercation between Resident #9, Resident #89 and CNA K. -Staff should not have been yelling or pointing at the residents. -CNA K was being held back by the nursing staff. -CNA K did kick at Resident #9. It was not clear if contact was made. -This incident should have been considered potential abuse by CNA K. MO00246305

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #9) out of seven sampled residents, was free from abuse when on 8/6/24 Licensed Practical Nurse (LPN) G was verbally and physically abusive. LPN G called the resident names, pulled the resident's hair and kicked the resident while the resident was laying on a mattress on the floor which resulted in a contusion to the resident's right hip and pain to his/her left knee. The resident was heard yelling and crying during the altercation and needed an injection to calm his/her agitation after the incident. Multiple staff witnessed the altercation and did not intervene. The facility census was 109 residents. The Administrator was notified on 8/29/24 at 11:29 A.M. of an Immediate Jeopardy (IJ) which began on 8/6/24. The IJ was removed on 8/30/24, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect Policy, reviewed and revised on 6/12/24, showed: -Abuse was defined as a willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. -Physical abuse included handling a resident with any more force than was reasonable for a resident's proper control, treatment, or management. -Mistreatment was inappropriate treatment or exploitation of a resident. 1. Review of Resident #9's undated Face Sheet, showed the resident admitted to the facility on [DATE] with the following diagnoses: -Major depressive disorder (a mental health condition that caused a persistently low or depressed mood and a loss of interest in activities that once brought joy). -Anxiety disorder (a condition in which a person had excessive worry and feelings of fear, dread, and uneasiness). -Post-traumatic stress disorder (PTSD-a mental health disorder that can develop after a person is exposed to a traumatic event). -Bipolar disorder (a mental health condition characterized by extreme mood swings that include emotional highs and lows). -Schizophrenia (a chronic and severe mental health disorder that affects how a person thinks, feels and behaves). -Intermittent explosive disorder (a mental health condition characterized by sudden, intense outbursts of anger or aggression). -Moderate intellectual ability. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 5/20/24, showed he/she was cognitively intact. Review of the resident's care plan, dated 6/28/24, showed: -He/she had a history of being abused as a child and PTSD with no known triggers. -The environment should be free from actual or perceived judgement and physical or perceived danger. -He/She was at risk for displaying signs and symptoms of bipolar disorder, displaying high and low emotions. Interventions included: helping him/her to stay on task; calm redirection; decreasing stimulation; using a firm and calm approach; avoiding getting in a power struggle; keeping his/her routine consistent. -He/She was at risk for displaying signs and symptoms of schizophrenia. Interventions included avoiding arguing or getting defensive with him/her; being respectful, non-judgmental and honest with him/her; respecting his/her personal space. -He/She had a history of behavioral challenges requiring protective oversight, such as being physically aggressive toward staff and peers, frequent elopements, obsessing about things, impulsive thoughts and actions, disordered thoughts. Interventions included: CALM (a communication strategy often used to de-escalate tense or potentially volatile situations) technique if needed; plans to change inappropriate behavior; 1:1 observation; pharmaceutical interventions as needed. -He/She had a long history of mental illness. He/She had a low tolerance for restrictions, becoming physically assaultive and physical and verbal aggressions. Interventions included: psychiatric management and counseling if needed; behavior modification programs as needed; interdisciplinary team and guardian involvement. -He/She had a long history of PTSD and functional impairment from symptoms, including aggressiveness and self-destructive behavior. Interventions included: encouraging the resident to express emotions in a safe environment, assessing the resident for suicidal or homicidal ideation's and ensuring the safety of the resident and others; administering medications as appropriate; assessing for anxiety. Review of the resident's Medication Administration Record (MAR), dated 8/6/24, showed: -At 2:15 A.M., he/she was given an injection of Olanzapine (a medication used to treat conditions such as schizophrenia and bipolar disorder) as ordered 10 milligrams intramuscularly as needed (PRN) for three times a day for increased agitation. Review of the resident's progress note, dated 8/6/24 at 3:45 A.M., showed: -LPN F notified by staff the resident was having a behavior. Upon arrival, he/she noted the resident throwing papers and picking up trash cans to throw at staff. -LPN F notified Certified Medication Technician (CMT) C (who was the house supervisor) for assistance with getting a PRN (as needed) medication and syringe. -While preparing the PRN medication, the resident was approached by LPN G and was told to go to his/her room. -The resident entered his/her room and LPN G followed him/her into the room. -LPN F heard the resident say stop kicking me, and stop pulling my hair. -LPN F entered the resident's room with other staff and observed the resident sitting on the bed with LPN G standing over him/her. -LPN F asked what was going on and neither LPN G or the resident answered. -LPN F asked the resident for permission to administer the PRN injection and the resident was cooperative. The PRN medication was not effective. -The resident then threw a trash can at staff into the hallway and started kicking the wall, kicking the staff, and using racial slurs. -Staff entered the room to initiate a Code [NAME] (a facility wide alert that there is a situation involving a resident who was exhibiting violent or potentially dangerous behavior), and a CALM hold and LPN G stated, No, don't call it. I got this. I got him/her by myself. -LPN F then observed LPN G kick the resident. -LPN F intervened, separated the resident, made sure he/she was safe and asked LPN G to leave the unit. -LPN G did not leave the unit immediately. -LPN F then notified the administrator and Director of Nursing (DON) and was instructed to call the Police Department (PD). -The resident's range of motion and vital signs were at baseline and the resident denied pain or discomfort. -PD was notified twice before arriving at the facility. Review of the resident's hospital visit summary, dated 8/6/24, showed he/she was seen related to contusion (bruise) of his/her right hip and left knee pain related to a physical assault. Review of the resident's progress note, dated 8/6/24 at 10:05 A.M., showed: -Resident returned from the hospital and escorted by staff 1:1 to the social worker's office. -He/she had a pleasant attitude and stated he/she was feeling better. -When asked how he/she was feeling about the incident, he/she stated he/she was not affected unless the nurse (LPN G) returned. -He/She did not want that nurse on his/her unit. Administrator was notified. Review of the facility investigation, dated 8/6/24, showed: -The incident was alleged abuse. -There was one resident witness, Resident #32, the resident's roommate. -The incident involved Resident #9 and one other staff member. -The resident was unable to identify the staff person, just that it was a staff person with black hair. -Initially he/she stated the staff person slapped him/her and he/she fell to the bed; he/she then stated he/she was pushed and dragged by his/her arms out of the bed onto his/her knees. -Staff reported to the DON the resident had been kicked and hair pulled by LPN G. -Two employees reported they witnessed the resident being abused by kicking and hair pulling. -The DON instructed the staff to call Kansas City Police Department (KCPD). -An assessment of the resident was completed by the DON when he/she arrived at the facility. -A skin assessment was done by staff and no discoloration or injury was noted to face or knees. -The resident was sent to the hospital for evaluation due to increased behaviors, destruction of property, and increased physical aggression toward staff and peers. -LPN G was detained by KCPD and taken to jail. -LPN G was suspended pending investigation. -The resident stated he/she was kicked, hair pulled, and dragged over the floor by LPN G, but his/her story was convoluted. He/She remained on 1:1 observation. Review of the resident's Psychosocial Post-Incident Impact Questionnaire, dated 8/6/24, showed: -The resident said he/she was not trying to hurt him/herself or anyone; the nurse was trying to hurt him/her. -He/She was only biting him/herself so staff would not come near him/her and he/she only hit the nurse's hand. -Walking down the hallway, pacing back and forth, and walking around the dining area helps him/her to calm and it worked if the staff would leave him/her alone. -He/She did not feel like he/she could have done anything differently, because the nurse wouldn't listen to him/her or let him/her out of his/her room and made him/her cry really hard. -He/She felt safe and was ok as long as she (the nurse) was gone. -He/She wanted to press charges against the staff member who assaulted him/her. Review of the resident's skin evaluation, dated 8/6/24 at 10:49 A.M., showed: -The resident had a new skin issue located on his/her right lateral thigh, which was bruising. Review of the resident's undated written statement showed: -This bitch pulled him/her to the ground off his/her bed and put his/her foot on his/her back, even though he/she told him/her to get his/her foot off of him/her. -Then he/she (the staff person) said he/she would bitch-slap him/her and he/she would fuck me up. Review of Agency Certified Nursing Assistant (CNA) J's written witness statement, dated 8/6/24, showed: -He/She saw LPN G kicking, hitting, and being verbally abusive toward Resident #9. LPN G also pulled the resident's hair. -The resident started crying and was yelling to the staff to stop beating on him/her. -When Agency LPN F heard what was going on, he/she immediately told LPN G to leave the unit. -LPN G refused to leave the unit and made the statement, I love fucking with him/her. During an interview on 8/7/24 at 10:00 A.M., Agency CNA J said: -He/She had never worked with LPN G before. -When the incident took place, LPN G was not suppose to be working on that unit. -The resident was calling LPN G names. -The resident was having a behavior and getting agitated. He/She has the mentality of a five-year old. -The staff put on gloves in case they had to do a safety hold to give the resident a injection. -LPN G came over from another unit, but did not offer to help the staff with the resident, just started calling the resident names. -The resident was only combative with LPN G and tried to kick him/her. The resident was on a mattress on the floor. -LPN G was standing over the resident kicking him/her. He/She would walk up on the resident, kick him/her and back up, and kept doing it. -The staff were going to put the resident in a safety hold and LPN G said, No, I got it, get out! -As soon as the staff walked out, he/she heard the resident shouting at LPN G to stop hitting me and stop pulling my hair and start crying. He/She did not see LPN G pulling the resident's hair. All of the staff heard this. -Agency LPN F told the staff what to say about this incident so he/she would not get in trouble, but he/she was the resident's nurse and should have stood up to LPN G. He/She sat there and listened to LPN G abuse the resident and did nothing. -LPN G was going to do what he/she was going to do with the resident, even if the staff had stepped between them. -The corporate staffing agency did not offer any deescalation or CALM training. A lot of staff do not know how to work with mental health patients. -The staff could not touch LPN G to stop him/her or it would have been assault. All they could do was be the eyes and ears of the situation. Review of LPN G's written employee statement, dated 8/8/24, showed: -The resident was standing in the hallway talking and he/she told the resident to come on and go to his/her room. The resident then went to his/her room. -He/She told the resident he/she was going to sit with him/her for a little while to give everyone else a break because they had been dealing with him/her for a while. -The resident told him/her to get the fuck out and he/she said no, that he/she was going to be with him/her for a while. -The resident said, I'm getting out of here and you can't stop me and acted like he/she was going to go past him/her, but didn't and went to the wall where the head of the bed was. -The resident started slapping and kicking the wall. -He/She asked the resident to stop and the resident said no. -He/She asked him/her again to stop because everyone was going to sleep. -The resident said, Fuck you, bitch, no! -He/She said this was the last time he/she was going to ask and he/she was going to count to three and assist the resident to stop his/her actions. -The resident continued to kick the wall, which made a hole in the wall. -He/She went to the resident and put his/her hands on the resident's shoulders and pulled him/her from the wall. -The resident pulled away and flopped down on his/her mattress and said, Don't you push me again! -He/She said he/she didn't push him/her, that the resident broke from him/her. -The resident said, Get the fuck away, bitch, I'll kill you! He/She leaned back on the mattress and raised his/her legs and started kicking the wall where he/she had already been kicking it. -He/She put his/her hand on the resident's head and said to stop it and go to bed. -The resident laid down on his/her bed and grabbed the top of his/her head and said, You bitch, you pulled my hair. -He/She told the resident he/she did not pull his/her hair and the resident then said he/she didn't care and began kicking the wall again. -He/She asked the aides to come in the room and move the mattress and while waiting for them, the resident called him/her racial epithets. -The aides came in the room and helped him/her move the mattress. -The resident then began to kick him/her several times, as well as kick the night stand and the wall -He/She told the resident to quit kicking him/her and the resident continued to attempt to kick him/her. -He/She used his/her foot to block the kicks. -The resident continued to call him/her a bitch and yelled, You are abusing me! -He/She said, How am I abusing you? I am blocking you from kicking me! -The other staff were outside the room. The resident was still kicking at him/her. -The other nurse came in the room with a PRN injection and an oral medication. -The resident was given the injection and the resident was swatting at the staff and initially refused. Staff checked the resident's mouth to make sure he/she swallowed. -The resident flopped back down on the mattress and the staff left the room. -The resident continued to kick at the wall and yelled for him/her to give her the blankets. -He/She got the blanket for the resident and the resident threw it right back at him/her. -Nobody came into the room after that. He/She gave the resident the blanket back and turned off the light, at the resident's request. -He/She did not see anyone come in the room when the resident was yelling that he/she was being abused. -The resident also called him/her a pussy, and he/she replied, If I am a pussy, then you are a pussy. -He/She was in no way trying to hurt the resident, just trying to prevent him/her from hurting him/herself and prevent him/her from damaging property. During an interview on 8/7/24 at 10:30 A.M., LPN G said: -That night, the resident had just gotten back from being sent out to the hospital for behaviors. -When the resident was brought back, he/she walked him/her back to the unit. A skin assessment was not done on the resident at that time. -Two hours later, the resident was having a behavior and the staff were at their wits end from dealing with him/her. -He/She thought he/she would try to help out and give the other staff some relief, since the resident can wear out the 1:1 observation staff; the resident had a 1:1 at the time. -He/She said, 'I'll give you guys a break. -He/She was dealing with the resident and the resident was calling him/her names and racial names. The resident said, Fuck you, you stupid (racial slur), I'm going to fucking kill you. -He/She told the resident to go to his/her mattress and the resident said no. -The resident went to the wall and started hitting it with his/her hand and kicking it. -He/She told the resident to stop it, that it was too early in the morning and people were trying to sleep. -The resident said no and kept calling him/her names and saying, fuck you and calling him/her the N word. -He/She grabbed the resident's upper arms to turn him/her away from the wall so he/she could stop kicking and punching the wall. -When he/she turned the resident, the resident flopped down on the mattress and said, Don't you ever push me again. -He/She told the resident he/she didn't push him/her. -The resident continued kicking, so the staff moved the mattress. -Before they moved the mattress, he/she put his/her hand on the top of the resident's head and told him/her to stop again. -The resident then said, Don't you ever fucking pull my hair! That is when he/she had the staff help him/her move the mattress. -They didn't call a Code [NAME] because anyone who would have responded were already there. -The staff were in and out and moved the mattress to the center of the room, so the resident could not kick the walls anymore, so the resident started kicking at him/her. -The resident's kicking made contact with him/her and also with the nightstand. He/She used his/her feet to block the resident's kicks from him/her and the nightstand. He/She never made any contact with the resident's hip or thigh. -The resident kept saying, You're abusing me, and he/she said, How can I be abusing you when you are kicking me? -He/She moved the nightstand. -Nobody intervened to help him/her or stop the kicking. -Agency LPN F gave the resident a injection and an oral medication and the resident stood against the wall. -The resident stopped trying to kick him/her and asked for a cover, because he/she was going to go to bed, and asked for the light to be turned off. -He/She turned the light off and stayed for a few more minutes and then left. -He/She 100% thought the staff misconstrued what they saw. -At the end of the shift, the police came. He/She talked to the police officers and was then arrested for assault. -The police said they were going by what the others had said. Review of CNA F's written witness statement, dated 8/6/24, showed: -At about 2:15 A.M., the resident was having a behavior. -LPN G from 3 North came over to see what the problem was. -While he/she was charting, he/she then heard the resident say, Stop kicking me! -He/She got up to see what was going on. -Agency LPN F came up to handle the situation and give the resident medication. -He/She saw LPN G kick the resident once. During an interview on 8/9/24 at 11:40 A.M., CNA F said: -He/She was not the only one in the resident room. He/She was in the doorway. -He/She saw LPN G kick the resident after the resident kicked him/her. -It was possible LPN G was blocking the resident from kicking him/her with his/her foot. -He/She did not see LPN G pull the resident's hair. -He/She did hear LPN G call the resident a pussy. -Nobody stopped LPN G, but he/she felt he/she should have stepped between them. -The staff had CALM training. They were supposed to step between them. He/She knew that now. -LPN G should not have kicked back at the resident; that was abuse. -He/She assumed the charge nurse should have handled the situation and he/she also felt LPN G should have known how to handle the situation. -They were all nurses and should know what to do. Review of Agency CNA G's written witness statement, dated 8/6/24, showed: -On 8/5/24 at around 10:30 P.M., he/she was told to do 1:1 observation with the resident, which he/she had previously done in the past. -The resident was calm and they talked about correcting behaviors and forgiveness, and happy memories he/she had. -Around 12:30 A.M., he/she noticed a change in the resident's behavior, he/she starting pacing and getting agitated, and he/she notified the other CNA. -Around 1:00 A.M., he/she let the other CNA take over so he/she could help on 3 North. He/She told the nurse he/she was there to help and take a break from the resident, so he/she could be with a familiar face for a while. -He/She came back to 3 South at 2:00 A.M. and the resident was still pacing. -Around 3:00 A.M., LPN G came up and told Agency LPN F he/she had this. They discussed calling a Code [NAME] and LPN G said the resident did this all the time, he/she had this. -LPN G made the resident go in his/her room and he/she started hearing the resident screaming, You are pulling my hair! Stop kicking me! -He/She saw LPN G kick the resident. -He/She asked if this was protocol and LPN G said, He/She always does this. -They then had a kicking match. -The nurse came in and said he/she had the resident's medication. -He/She did not know whether to help hold the resident or not, because he/she was shocked. -After the resident got his/her injection, LPN G was cool and he/she left and asked what to do. -He/She was told when the resident woke up, ask him/her if he/she was ok. -The staff stated this situation was not ok and he/she needed to report what he/she had seen and heard. -He/She did not confront LPN G because he/she was scared. -He/She told the resident, when he/she awakened at 4:30 A.M. if he/she was not ok to let him/her know. -The resident said the nurse hurt him/her and he/she asked a staff person to call 911. During an interview on 8/9/24 at 11:30 A.M., Agency CNA G said: -He/She was not a regular employee at the facility and had only worked there 3 or 4 times previously. -He/She had done 1:1 observation of the resident when he/she worked. -He/She did not know the other staff's names. -He/She was in the room when the incident happened for some of the time. Other staff were in and out of the room. -The resident had been pacing around and was agitated and said the staff were going to beat him/her if he/she did not go to sleep. -He/She heard a lot of banging in the room. The resident was kicking the wall and the dresser and kicked LPN G in the knee. -The resident took off his/her shoes and threw one at the wall and one at LPN G, who threw the shoe back. -The resident was calling LPN G the N word. -LPN G called the resident a pussy. -He/She did not see LPN G pull the resident's hair. He/She saw the resident kick LPN G and LPN G kick the resident back. -Agency LPN F told LPN G he/she had it from there and LPN G refused to leave. -The resident had not been combative before or when he/she came back from the hospital. -Nobody stepped in between LPN G and the resident. Everyone was afraid. He/She was afraid he/she would get beat up. -When LPN G threw the shoe, he/she covered his/her eyes, but told him/her he/she was going to call the police. -When the incident happened, he/she was by the door of the room, about two feet away. -When he/she saw LPN G and the resident's physical aggression, he/she put his/her hand over his/her mouth and slid down the wall and asked, Is this protocol? One of the other staff said no, this wasn't supposed to be happening. LPN F also said no. -Agency LPN F coached everyone that they should write down what they witnessed and heard; if they felt like something was wrong, it was wrong. -Agency LPN F said he/she was not going to put his/her license on the line, because he/she told LPN G to stop and he/she didn't. -The police were called, and while they were waiting for the police to arrive, he/she told LPN G the police had been called, because the resident did not feel he/she had protected him/her. -LPN G said, Ain't nobody can protect him/her from me; not even his/her family wants him/her. -He/She felt the other staff knew protocol, so they should have stepped in, but did not because they were afraid of LPN G. Review of CNA I's written witness statement, dated 8/6/24, showed: -At about 2:15 A.M., the resident began to have a behavior. -They called the nurse to come to 3 South, and he/came, but did not have his/her medication key, so he/she called LPN G to come over with a medication. -While Agency LPN F was preparing the medication, LPN G told the resident to go to his/her room. -The resident did not want to go to his/her room, but he/she did. -Other staff came with Agency LPN F to go in the room. -He/She was standing outside the door. Agency LPN F wanted to call a Code Green, but LPN G said he/she had it. -He/She heard the resident say to stop kicking him/her and also to stop pulling his/her hair. -He/She went in to see what happened. LPN G was pushing the nightstand out of the room, so he/she took the nightstand, because the resident was kicking it. The resident was given his/her medication and the nurses left, and then the resident went to sleep. Review of CMT C's written witness statement, dated 8/6/24, showed: -He/She was called to bring medication to the unit. -The nurse on 3 South (Agency LPN F) needed needles for an injection. -The resident was having a behavior. -He/She asked the nurse on 3 North (LPN G) to unlock the cart and hand him/her a needle. -LPN G asked why he/she needed the needle and he/she replied that the resident was having a behavior. -LPN G stated he/she was going to go over there and be nosey, and left. -He/She was getting pain medications for other residents at the time. -He/She arrived on 3 South and the resident was in his/her room with LPN G. -He/She heard the resident saying to leave him/her alone and the nurse calling him/her a pussy and said, shut up, pussy bitch, kick me! -LPN G kept antagonizing the resident. -The resident kicked the LPN G by this time. -Other people started coming in the room. -Agency LPN F asked LPN G to leave the unit. -LPN G said, No, I got this. -He/She was in shock and tried to intervene, but LPN G grabbed the resident by his/her hair and kicked him/her several times. Every time the resident kicked him/her, LPN G kicked him/her back. -He/She was confused and had never experienced something like this before. During a interview on 8/12/24 at 10:00 A.M., CMT C said: -He/She got a call from Agency LPN F on 3 South that he/she needed a medication, but did not have any needles. -He/She asked LPN G if he/she had any needles on his/her cart. -LPN G asked who the injection was for, and he/she told him/her. -LPN G said he/she was about to go be nosy and started to head over to that unit. -By the time he/she got to the unit, LPN G was already in the room. -Agency LPN F was sitting down and he/she handed him/her the medication. -Only LPN G and the resident were in the resident's room. -Everyone else was standing around and looking around. -LPN G was not the nurse caring for the resident. -There was not a Code [NAME] called. He/She could not see what was going on, but heard the resident yelling at LPN G to leave him/her alone. -If the resident was having a behavior, he/she was known to tell staff to leave him/her alone. -LPN G called the resident a punk bitch, which was going to escalate the situation and make it worse. -When Agency LPN F was trying to give the resident his/her injection, the resident was saying to leave him/her alone. -The staff told the resident the medication was going to help him/her to try to calm down. -LPN G told the resident he/she was going to take the shot and the resident said he/she was going to call the administrator. LPN G told him/her nobody was going to save him/her. -Before he/she was given the injection, the resident had said to stop kicking him/her. The resident had also picked up the trash can and thrown it at staff, and was kicking his/her foot and saying he/she did not want the medication. -LPN G said, I dare you to kick me, and the resident kicked him/her and he/she kicked back, two to three times. These were actual kicks, not blocks. -He/She heard the resident said LPN G had pulled his/her hair, and he/she saw and it was definitely a pull. -He/She then let Agency LPN F know, because he/she had already left the room. -He/She did not know the procedure that he/she could touch a staff person to stop the situation. He/She did not want to start a fight in the room. During an interview on 8/7/24 at 11:35 A.M., the Social Worker said: -The resident had the mind of an 8-year-old and had trouble processing information. During an interview on 8/7/24 at 11:40 A.M., the resident said: -He/She kicked LPN G because he/she kicking him/her. -He/She told all the staff about it. He/She was unable state which staff he/she told. -He/She had scratches on his/her knee, because all of the staff pulled him/her on the ground. -He/She thought LPN G was very rude to him/her and nicer to other residents, which made him/her feel uncomfortable and sad. -LPN G pulled his/her hair and made him/her cry. -He/She didn't know why LPN G pulled his/her hair. -His/Her mattress was on the floor because he/she broke the footboard. -He/She called LPN G a bitch, bullshit and the N word and LPN cursed back at him/her. -LPN G called him/her names and said, Get your fat pussy up! -LPN G dragged him/her on the floor and pulled his/her arms. He/She did that all the time. -He/She tried to go tell someone and LPN G blocked him/her from going out the door. -There were some other staff members involved. He/She didn't know the names. -He/She said when he/she had a behavior, the staff were not supposed to stop it, they were supposed to call the social worker or the Administrator, but they never did. -He/She said he/she had two bruises from this incident and pointed at his/her hip. -He/She wanted to press charges on LPN G. He/She told the police he/she didn't know why LPN G would act that way. Observation of the resident on 8/7/24 at 11:40 A.M. showed the resident had a quarter-sized discolored green, yellow and purple area on his/her right hip that he/she said that it was from this incident with LPN G. The skin was not broken. Review of Resident #32's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 8/9/24 at 12:20 P.M., Resident #32 said: -He/She was the resident's current roommate. -He/She kept his/her privacy curtain open. -He/She heard someone call Resident #9 a pussy. During an interview on 8/29/24 at 11:00 A.M., Agency LPN F said: -The resident was having a behavior. -LPN G came over. He/She was not sure why LPN G came over. -LPN G told the resident to go in his/her room. The resident was already agitated. -He/She was the resident's nurse that shift. -He/She was waiting for CMT C, who was the night supervisor, to bring him/her intermuscular (IM) medication for the resident, since they did not have it on the unit. -He/She could hear the LPN G call the resident a pussy, so he/she went to look in the ro

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #23) was free from physical abuse from facility staff and other residents out of six sampled residents, when on 4/14/24 11:00 A.M. Housekeeper B used physical force to take the resident from his/her feet to the ground. While on his/her back, Resident #16 ran up the hall and kicked three times at Resident #23 with no staff intervention and then grabbed Resident #23's right arm. CNA D, Dietary Aide A, and Housekeeper B drug the resident across the hallway, flipped the resident over and had the resident's arms outstretched with Housekeeper B on the right arm, CNA A had the resident's left arm, Dietary Aide A had his/her knee on the resident's lower back buttocks area with the resident on his/her stomach. LPN A and CMT A watched the entire events and did not intervene. When the house manager showed up, CNA D, Dietary Aide A and Housekeeper B released the resident. Hall Monitor C used his/her foot to nudge the resident to get up. The resident stood up on his/her own, Hall Monitor C grabbed the resident by the collar of the resident's shirt and had another hand on the resident's arm, then walked the resident to his/her room. Hall Monitor C shoved the resident into his/her room by using his/her forearm pushing into the resident's neck. The employees remained on shift and at 12:20 P.M. Hall Monitor C walked toward Resident #23 and began punching the resident multiple times forcing the resident backwards. Hall Monitor C took the resident to the ground and continued to slap the resident. The resident's arms were flailing when Hall Monitor C grabbed the resident by the torso and arms and drug the resident into a resident room. LPN A, Dietary Aide A, Housekeeper B and CMT C were all present, having witnessed the entire event and did not intervene. No staff called the manager on duty to report the events. The resident reported fear of the facility staff. The events resulted in the bruising of resident left eye and chest soreness. The facility census was 109 residents. The Administrator was notified on 4/19/24 at 1:30 P.M. of an Immediate Jeopardy (IJ) which began on 4/14/24. The IJ was removed on 4/19/24, as confirmed by surveyor onsite verification. Review of the facility's policy titled Abuse and Neglect Policy dated 1/5/23 showed: -Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane way. -Physical abuse included handling a resident with anymore force than reasonable for a resident's proper control, treatment, or management. -Physical abuse also included, but was not limited to, hitting, slapping, punching, biting, and kicking. -Physical abuse also included corporal punishment, which meant physical punishment used to correct or control behavior. -Mistreatment, neglect, or abuse of residents was strictly prohibited by the facility. -The facility was committed to protecting the residents from abuse by anyone including, but not limited to, facility staff, other residents. 1. Review of Resident #23's face sheet showed he/she admitted to the facility with the following diagnoses: -Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Paranoid Schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly, delusions and hallucinations are the two symptoms that can involve paranoia). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident #23's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 2/8/24, showed he/she was cognitively intact. Review of Resident #23's care plan, dated 4/15/24, showed: -The resident had a history of PTSD which affected his/her behavioral symptoms and could flare-up without a known trigger with the following interventions: --Assess resident for suicidal or homicidal ideations to ensure safety of resident and others. --Encourage the resident to express his/her emotions in a secure setting. --Allow the resident the freedom to acknowledge his/her feelings and release any repressed emotions that may be exacerbating his/her distress. --Establish trust with the resident. --Provide a calming and reassuring environment. -The resident had a history of behavioral challenges that required protective oversight in a secure setting with the outcome that the resident would not receive any serious injuries due to his/her behaviors with the following interventions: --Use Crisis Assessment Linkage and Management (CALM) techniques as needed. --Use one-to-one (1:1- a term used by healthcare support workers whose role is to provide one to one nursing or observation care to an individual resident for a period of time) monitoring as needed. -On 4/14/24 the resident had been placed on a 1:1 for behavioral monitoring related to auditory hallucinations (sensory perceptions of hearing noises without external stimulus), in which he/she became physically aggressive with staff and peer and a Code [NAME] (a behavioral emergency and/or incident needing physical support and presence when an individual poses a threat to himself/herself or others) had been called. -On 4/15/24 the resident had been sent to the local hospital's emergency room for evaluation and treatment after being assaulted by peer/staff the day before. Review of Resident #16's face sheet showed he/she had admitted to the facility with the following diagnoses: -Schizoaffective Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). -Restlessness and Agitation. -Paranoid Schizophrenia. -Intermittent Explosive Disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts). -Attention-Deficit Hyperactivity Disorder (ADHD- a chronic condition including attention difficulty, hyperactivity, and impulsiveness). -Personal History of Traumatic Brain Injury (TBI- brain dysfunction caused by an outside source). Review of Resident #16's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #16's care plan, dated 4/15/24, showed: -The resident had a history of behavioral challenges that required protective oversight in a secure setting with the desired outcome that the resident would not harm self or others with the following interventions: --Provide physical and verbal cues to alleviate anxiety. --Give positive feedback. --Assist in verbalization of source of agitation. --When the resident became agitated the staff were to intervene before agitation escalated, guide the resident away from source of distress, engage calmly in conversation, if the response was aggressive then staff were to walk calmly away and approach the resident later. -The resident had a history of physical/verbal aggression towards others and self, attention seeking, and inappropriate behaviors with a history of Code Greens needing to be called. -The resident liked to insert himself/herself in situations when he/she did not need to be involved. -On 4/14/24 the resident was involved in physical aggression towards a peer after inserting himself/herself in matters not pertaining to him/her. Observation of the facility camera footage of the first incident, dated 4/15/24 at 11:24 A.M., showed: -The footage was a recording of the camera footage and not the actual recording. -No date or time could be seen in this video. -The recording was six minutes and 33 seconds long. -The footage took place in a hall on the unit close to the dining room. -At two minutes and 45 seconds: --LPN A was talking with Resident #23 in the hallway. --CMT A was standing at his/her medication cart. --Housekeeper B and CNA D were in the hallway. --Dietary Aide A was at the end of the hallway, sitting on a chair. --Resident #23 was attempting to leave the dining room and entered the hallway. --Resident #23 had attempted to push through CMT A and Housekeeper B to head into his/her room. -- Housekeeper B placed his/her left arm underneath Resident #23's left arm and placed his/her left forearm and hand on Resident #23's upper chest. --Resident #23 attempted to continue down the hall. --Housekeeper B then placed his/her right forearm and hand underneath Resident #23's right arm and onto Resident #23's upper chest. --Housekeeper B performed a one person take down of Resident #23, slamming Resident #23 on the ground. --LPN A, CMT A, and CNA D remained in the hallway and observed the take down. --Dietary Aide A remained at the end of the hall sitting in a chair. --Housekeeper B was attempting to keep Resident #23 on the floor. --Resident #23 was flailing and kicking his/her legs in attempt to get released from Housekeeper B's hold. --LPN A, CMT A, and CNA D continued to observe Resident #23 and Housekeeper B struggling without intervention. --LPN A and CMT A remained in the hallway observing the altercation. --Dietary Aide A remained at the end of the hall sitting in a chair. --Resident #16 started to run down the hallway towards the altercation. --Resident #16 started to kick Resident #23 while Resident #23 remained on the ground. No staff intervened. --Resident #23's left arm and leg become visible on the screen. --Housekeeper B remained to have his/her hands on Resident #23's body. --Resident #16 walked back towards the altercation. --Resident #23 remained on the floor and was kicking his/her legs toward Housekeeper B. --Resident #23 became blocked by residents again. --LPN A was calling out to Dietary Aide A and pointing down at the altercation. --Dietary Aide A got up from his/her chair and started to run down the hall. --Dietary Aide A continued to run down the hall towards the altercation. --Housekeeper B had a hold of some part of Resident #23's lower body and was beginning to drag Resident #23 towards the other side of the hallway. --CNA D had a hold of Resident #23's right arm, but did not look like he/she was pulling on Resident #23. --Resident #23 was positioned on his/her left side. --Housekeeper B remained to have a hold of Resident #23's lower body and dragged Resident #23 to the other side of the hall. --CNA D remained to have a hold of Resident #23's right arm. --Resident #16 had a hold of Resident #23's left arm. No staff intervened. --LPN A and CMT A remained in the hallway. --Dietary Aide A was still running down the hall. --Resident #16 let go of Resident #23's left arm. --Dietary Aide A reached the resident and bent down. --Housekeeper B continued to have a hold on Resident #23's lower body. --CNA D continued to have a hold on Resident #23's right arm. --Resident #23's body is mostly blocked and could not be seen on camera except for a part of his/her right arm and hand. --Resident #23's right arm was outstretched with his/her right-hand facing palm side down on the floor. --Housekeeper B and CNA D were still bent over Resident #23, but hand positions could not be seen. --Housekeeper B's right hand was holding Resident 23's right wrist. --CNA D was holding an unidentifiable part of Resident #23's body. --LPN A and CMT A remained in the hallway without touching Resident #23 and did not intervene --Resident #23's head and left arm became visible on camera. --CNA D was holding a part of Resident #23's left lower arm. --Dietary Aide A was crouched over Resident #23's body. --Resident #23 was lying on his/her stomach. --CNA D was holding Resident #23's left wrist and had his/her knee on top of Resident #23's elbow. --Dietary Aide A was crouching over the back part of Resident #23's body. --Housekeeper B was crouching over Resident #23's right side. --Resident #23 remained on his/her stomach. --Housekeeper B had a hold of Resident #23's right wrist/hand. --Dietary Aide A was still crouching over the back part of Resident #23's back side. --Resident #23 remained on his/her stomach with his/her right arm outstretched. --CNA D was crouched over Resident #23's left arm, but where he/she was holding Resident #23 was not visible on camera. --Dietary Aide A appeared to be holing a part of Resident #23's back side. --LPN A and CMT A were by the medication cart and appeared to be talking with each other. --Resident #23 remained on his/her stomach being held down by Housekeeper B, Dietary Aide A, and CNA D. --Housekeeper B had a hold of Resident #23's wrist/hand. --Dietary Aide A remained holding Resident #23's lower back/buttocks area. --CNA D had remained holding Resident #23's left lower arm. --LPN A and CMT A remained at the medication cart. --The Activities Director who was also the Manager on Duty at that time appeared at the top of the frame and started to walk down the hallway towards Resident #23 and the staff. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --CMT A was waving the Activities Director down the hall. --LPN A remained at the medication cart. --The Activities Director continued down the hall. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --LPN A bent down and appeared to be picking up something off the floor next to Resident #23. --The Activities Director continued to walk down the hall. --CMT A returned to the medication cart. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --LPN A and CMT A remained at the medication cart. --Hall Monitor C came into the frame at the top of the hall. --The Activities Director reached Resident #23 and the staff. --Resident #23 remained on the floor. --The Activities Director appeared to be discussing the incident with LPN A, CMT A, Housekeeper B, Dietary Aide A, and CNA D. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --Hall Monitor C continued down the hall. --Hall Monitor C reached Resident #23 and the staff. --CNA D released his/her hold of Resident #23's left arm and started to walk up the hall. --Housekeeper B released his/her hold of Resident #23's right wrist and started to walk up the hall. -- Dietary Aide A released Resident #23's lower back/buttocks area and started to walk up the hall. --Hall Monitor C nudged Resident #23's left side with his/her right foot. --Resident #23 got up from the floor. --Housekeeper B, Dietary Aide A, and CNA B continued up the hall. --The Activities Director and Hall Monitor C walk towards Resident #23. --Resident #23 started to walk towards his/her room. --The Activities Director went to the right side of Resident #23. --Hall Monitor C went to the left of Resident #23 and grabbed Resident #23's left wrist. --Resident #23 continued towards his/her room. --The Activities Director stayed to the right of Resident #23. --Hall Monitor C remained to the left of Resident #23, continued to have a hold of Resident #23's left wrist with his/her left hand, and grabbed the back of Resident #23's shirt with his/her right hand. --Resident #23 and Hall Monitor C continued towards Resident #23's room. --Hall Monitor C continued to hold Resident #23's left wrist and shirt. --The Activities Director walked behind Resident #23 and Hall Monitor C and was a few paces behind them. --Hall Monitor C shoved Resident #23 into his/her room. --The Activities Director continued to walk towards Resident #23's room. NOTE: Resident #23 stayed in his/her room for the remainder of the camera footage. --Hall Monitor C entered Resident #23's room. --The Activities Director continued towards Resident #23's room. --Resident #23's roommates exited the room and walked up the hall. --The Activities Director exited Resident #23's room. --LPN A and CMT A remained in the hallway. --The Activities Director waited outside of Resident #23's room facing away from the camera. --LPN A and CMT A remained in the hallway. --Hall Monitor C exited Resident #23's room. --The Activities Director started to walk up the hall. --Hall Monitor C remained outside of Resident #23's room and appeared to be talking to Resident #23. --LPN A and CMT A remained in the hall. --Hall Monitor C walked back towards Resident #23's door and stopped at the door frame and appeared to speak to Resident #23. --The Activities Director continued to walk up the hall. --LPN A and CMT A remained in the hall. --Hall Monitor C exited Resident #23's doorway and walked up the hall. --The Activities Director stopped at the medication cart, but only the lower half of his/her body was visible on camera. Observation of the facility camera footage of the second incident, dated 4/15/24, showed: -The footage was a recording of the camera footage and not the actual recording. -The recording was two minutes and 14 seconds long. -The footage took place on the unit hall near the elevator. -- Resident #23 entered the hall and into the frame of the footage with LPN A. -At 11:19:36 A.M. through 11:20:01 A.M.: --Resident #23 walked down the hall and LPN A walked down the hall in front of Resident #23 with about a three-door space between them. --LPN A exited the camera frame from the front of the hall. --Resident #23 continued to walk down the hall. --Hall Monitor C entered the frame at the bottom of the hall near the elevator. --Hall Monitor C made a punching/swinging motion towards Resident #23. --LPN A entered the frame at the bottom of the hall near the elevator. --Hall Monitor C and Resident #23 appeared to exchange some words with each other. --Hall Monitor C put his/her left and right arm up in a fighting stance, pulled his/her right arm back, and proceeded to punch Resident #23 in the jaw/neck area with his/her left fist. --Resident #23 brought his/her right arm up and put his/her right hand into a fist and attempted to block Hall Monitor C's punch, then made contact to Hall Monitor C's left shoulder with his/her right fist. --After Resident #23 made contact with Hall Monitor C's shoulder he/she punched Resident #23 again in the jaw. --Resident #23 continued to have his/her right arm up attempting to block the second punch. --LPN A remained by the elevator and appeared to observe the physical contact that was made between Hall Monitor C and Resident #23. No staff intervened. -At 11:20:13 A.M.: --Resident #23 swung at Hall Monitor C with his/her right arm and again made contact with Hall Monitor C's left upper arm/shoulder area. --Hall Monitor C punched Resident #23 again in the jaw causing Resident #23 to take a step back. --Resident #23 had hunched down in preparation to hit Hall Monitor C again, then raised his/her right arm, punched Hall Monitor C in his/her left shoulder and started to raise his/her right arm again in preparation to hit Hall Monitor C again. --Hall Monitor C appeared to make contact with Resident #23's chest/torso area once with his/her right hand and once with his/her left hand, then pushed Resident #23's head back with his/her right hand and made contact to Resident #23's upper body/neck area with his/her left hand. --LPN A began to walk towards the altercation. --Resident #23 attempted to hit Hall Monitor C again. --Hall Monitor C grabbed Resident #23's right and left wrists preventing Resident #23 from hitting him/her. --LPN A put his/her right hand up reaching out to Hall Monitor C's backside. --LPN A made contact with Hall Monitor C's back appearing to stabilize or push Hall Monitor C in the back towards Resident #23. --Hall Monitor C released his/her grip to Resident #23's wrists, kicked towards Resident #23, but contact could not be determined, while also bringing his/her left arm up and swinging towards Resident #23's face. --Resident #23 attempted to swing at Hall Monitor C with his/her left hand once he/she was released from the grip of Hall Monitor C and took a step back away from Hall Monitor C. --Resident #23 continued to step backwards away from Hall Monitor C. --Hall Monitor C lowered his/her hands, but walked toward Resident #23 when Resident #23 was stepping back. --LPN A continued to observe and walk towards the altercation, but was a few paces behind Resident #23 and Hall Monitor C. --Resident #23 continued to step away from Hall Monitor C. --Hall Monitor C raised his/her left arm and punched Resident #23 in the head. --LPN A continued to observe and walk towards the altercation, remaining a few paces behind Resident #23 and Hall Monitor C. --Resident #23 put his/her hands up attempting to cover his/her face and hunched over to avoid more hits by Hall Monitor C. --Hall Monitor C continued to walk toward Resident #23, it could not be determined if any contact with Resident #23 was made. --Housekeeper B and Resident #16 entered the frame at the bottom of the hall. --LPN A continued to observe and walk towards the altercation, remaining a few paces behind Resident #23 and Hall Monitor C. --Resident #23 remained hunched over and stepping back away from Hall Monitor C. --Hall Monitor C continued to walk towards Resident #23, raised his/her arms up reaching for the back of Resident #23's shirt. --LPN A, Housekeeper B, and Resident #16 continued to observe and walk towards the altercation. -Dietary Aide A entered the frame at the bottom of the hall. --CMT A appeared at the top of the frame and was exiting a resident's room. --Resident #23 was attempting to get away from Hall Monitor C and had his/her hands up attempting to protect himself/herself from more hits from Hall Monitor C. --Hall Monitor C continued to grab Resident #23's shirt preventing Resident #23 from leaving the altercation. --LPN A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe and walk towards the altercation. No staff intervened. --CMT A stood outside of the resident's room he/she had just exited and observed the altercation and did not intervene. --Hall Monitor C continued to hold Resident #23's back of shirt and started to push Resident #23 towards the floor. --Resident #23 had put his/her right arm and hand out to help brace for the impact as he/she was being pushed towards the floor. -- LPN A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe and walk towards the altercation. --CMT A remained in the hall and observed the altercation and did not intervene. --Resident #23 disappeared from the frame. --Hall Monitor C appeared to be hunched over Resident #23. --Resident #23 reappeared on camera and was on the floor and Hall Monitor C appeared to have some sort of hold on Resident #23. --Hall Monitor C was hunched over Resident #23 and was holding Resident #23's left arm. --LPN A, Housekeeper B, Dietary Aide A, and Resident #16 made a semi-circle around the altercation and remained to observe the altercation without intervention and did not intervene. --CMT A remained in the hall observing the altercation and had taken a couple steps forward towards the altercation and did not intervene. --Resident #23 remained on the floor, but had kicked his/her right leg up towards Hall Monitor C. --Hall Monitor C remained hunched over Resident #23 and had a hold on Resident #23. --When Resident #23 tried to kick Hall Monitor C, Hall Monitor C began to slap Resident #23 with his/her left hand. --LPN A, CMT A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe the altercation without intervention. --Resident #23 remained on the floor and had his/her legs up in the air bent at the knee. --Hall Monitor C remained over top Resident #23 with his/her legs straddled over Resident #23's left leg and continued to slap Resident #23. --LPN A, CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. -Resident #23 remained on the floor with his/her legs up in the air bent at the knee. --Hall Monitor C remained over top of Resident #23 with his/her legs straddled over Resident #23's left leg and was holding onto Resident #23. --Resident #23 remained on the ground and had lifted his/her right arm up and appeared to be reaching for Hall Monitor C. -- LPN A, CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. --Resident #23 remained on the ground in the same position as before. --Hall Monitor C continued to straddle Resident #23's left leg and had a hold of Resident #23's left arm. --Resident #23 remained on the ground and in the same position as before. --Hall Monitor C appeared to be reaching towards a resident's room while keeping the same hold on Resident #23. --CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. --Hall Monitor C began to drag Resident #23 into a resident room while keeping Resident #23 in the same position as before and exited the camera frame. --LPN A, CMT A, Housekeeper B, and Dietary Aide A began to walk towards the resident room where Hall Monitor C was dragging Resident #23 into. --Dietary Aide A and Housekeeper B turned around and began to walk down the hall. --LPN A and CMT A continued to walk towards the resident room where Hall Monitor C and Resident #23 were located. --Hall Monitor C and Resident #23 remained off camera. --CMT A entered the resident's room where Hall Monitor C and Resident #23 were located. --LPN A continued to walk towards the same room. --Hall Monitor C and Resident #23 remained off camera. --CMT A exited the resident's room and stayed by the door frame. --LPN A walked to the door frame and stayed next to CMT A. --Hall Monitor C and Resident #23 remained off camera. --LPN A and CMT A began to walk away from the resident's room and walk down the hall. --Hall Monitor C and Resident #23 reappeared into the camera frame. --Hall Monitor C had a hold of Resident #23's shirt and was walking Resident #23 out of the resident's room. --LPN A remained at the end of the hall by the elevator. --CMT A began to walk into a different resident's room. --Hall Monitor C and Resident #23 continued to walk up the hall in the same hold as before. --LPN A walked onto the elevator, did not intervene, and exited the camera frame. --Hall Monitor C and Resident #23 continued to walk up the hall in the same hold as before. --CMT A exited the other resident's room and did not intervene. During an interview on 4/18/24 at 11:28 A.M., the Administrator said: -The date that could be seen on the video footage of the second incident was 24 hours behind indicating the incident occurred on 4/14/24. -The time that could be seen on the video footage of the second video was an hour behind indicating the incident occurred between 12:19 P.M. through 12:21 P.M. NOTE: This was verified while on-site. Review of Resident #23's Skin Evaluation, dated 4/15/24 at 9:31 A.M., showed: -The resident had bruising to his/her right eye, left temporal area, and right knee. -The resident had redness to his/her right and left fingers. -The resident had a scratch to his/her right lower leg. Review of Resident #23's hospital discharge paperwork, dated 4/15/24 at 5:34 P.M., showed: -The resident was seen for assault, contusion to the chest wall, abrasions at multiple sites, and contusion of face. -A Computed Tomography (CT) Scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) of the resident's face, head, neck, and chest were completed and had not shown any abnormalities. -An X-ray was completed of the resident's left ankle which had not shown any acute fracture or bony abnormality. Review of and Admin/Registered Nurse (RN) Investigation, completed on 4/15/24 at 10:16 A.M., showed: -The date of the incident was 4/14/24. -Resident #23, Resident #16, and Housekeeper B were involved in the incident. -Investigative Narrative: --The nurse stated Resident #23 had been in the hall asking to be removed from 1:1 monitoring. --Resident #23 had been placed on 1:1 monitoring for protective oversight. --Resident #23 had stated sometimes hearing voices and since they were not telling him/her to self-harm he/she didn't need to be on a 1:1, he/she only needed a PRN. --The nurse had educated Resident #23 on the reasoning of the 1:1 monitoring. --Resident #23 had continued to plead with the nurse. --Housekeeper B then inserted himself/herself into the conversation and told Resident #23 to shut up and move on. --Resident #23 then began to curse and use racial slurs towards Housekeeper B. --The nurse tried to take control of the situation and had asked a CNA to take Resident #23 to his/her room. --Resident #23 then started to walk to his/her room and had flared out his/her arms as he/she walked past Housekeeper B, subsequently hitting Housekeeper B in the face with an open hand. --Housekeeper B then grabbed Resident #23 from behind, interlocking his/her arms with Resident #23's arms and slammed Resident #23 to the ground. --Resident #23 and Housekeeper B were entangled on the floor and had exchanged hits. --Resident #23 had kicked Housekeeper B in his/her face and chest several times. --Resident #16 observed the altercation and joined the altercation by kicking and punching Resident #23. --A Code [NAME] had been called and staff had responded appropriately. --The nurse was then able to successfully separate the involved parties. -In conclusion the incident was a result of abuse. Review of an Employee Statement, dated 4/15/24 at 10:56 A.M., from Hall Monitor C showed: -He/She had not hit Resident #23. -Resident #23 had tried to swing on the Activities Director, so he/she and the Activities Director put Resident #23 in a two-man hold. Review of an Admin/RN Investigation, completed on 4/15/24 at 11:32 A.M., showed: -The date of the incident was 4/14/24. -Resident #23, Hall Monitor C, LPN A, and CMT A were involved in the incident. -Resident #23 stated the following: --He/She had spoken with the Administrator related to a cigarette break. --He/She had gone down the hall to inform Hall Monitor C about the approved smoke break. --He/She had been told by Hall Monitor C that he/she wasn't getting nothing. --After making that comment Hall Monitor C began inflicting harm to him/her. --He/She was hit with a closed fist in his/her upper torso area. --He/She was repeatedly punched in his/her arms and slapped across the face. --He/She was then grabbed by Hall Monitor C to the nearest room. --He/She was then escorted to his/her room by Hall Monitor C and was told to stay in his/her room. --The altercation was witnessed by LPN A, CMT A, Housekeeper B, and the kitchen [NAME]. -When reviewing the camera footage, the altercat

Based on interview and record review, the facility failed to ensure the facility staff had the competencies and skills to assure resident safety for one sampled resident (Resident's #23), when on 4/14/24 at about 11:00 A.M., Housekeeper B failed to utilize non-physical crisis intervention and de-escalation techniques in accordance with facility policy, resulting in physical abuse and psychosocial harm to the resident. About 12:20 P.M., Hall Monitor C made derogatory statements to the resident, based on their behavioral health symptoms and engaged in a physical altercation with the resident against facility policies and training for a behavioral intervention resulting in abuse of the resident. Six residents were sampled for review. The facility census was 109 residents. Review of the facility policy titled, Behavioral Emergency, dated 1/5/24, showed: -To provide safe treatment and humane care to the Resident in a behavioral crisis, to outline steps to follow to correctly care for the Resident in a behavioral crisis, to ensure that the Resident is not being coerced, punished or disciplined for staff convenience. -The licensed nursing staff will assess the resident who is exhibiting behaviors, ensuring that safety of the resident and others is the first priority. -Behavioral emergency which is classified as a Code [NAME] is called when a resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations. -A one to one monitoring of Resident will be initiated immediately. Review of the facility policy titled, CALM (Crisis Alleviation Lessons and Methods) Certification, dated 2/26/21, showed: -To set guidelines for employees of the facility to become CALM certified. -To provide safe treatment and humane care to the resident in a behavioral crisis. -After time of hire, all employees working with behavioral residents will become CALM certified. Review of the facility undated CALM workbook showed: -A Crisis Response Team (CRT) should be made up of staff specifically trained in crisis response. -The team should consist of 6-8 people representing various disciplines and departments. -The CRT was to evaluate each specific crisis situation and develop a plan for behavior management including: assess the crisis event; attempt to verbally de-escalate the resident; assure the milieu was safe; look for turning point of the event when physical intervention was required; provide assistance to the leader. -The team leader may be the first person to the scene; the person with the relationship or rapport to the resident; the person with the most expertise in handling crisis situations. -The team leader should be changed if the resident was responding poorly to the leader or the leader was responding inappropriately. -Five Person Control Take Down: --The team leader was responsible for maintaining the safety of the resident's head during the takedown and provide direction for the takedown to the staff. --The first two people to respond after the team leader were responsible for controlling the resident arms. The resident should be held at the wrist and above the inside of the shoulder. --The staff were to kneel down behind the resident, place the staff outside hand above the resident knee, place the staff inside hand at the resident ankle, place the staff shoulder on the back of the resident thigh and when all staff members were in position the staff were responsible for the resident legs would drive the staff shoulders forward. --When holding the resident in the five person hold the resident should be monitored for discomfort, attention should be paid to the resident joints and any undue pressure to the resident joint. --The staff maintain upper body control of the resident by placing the staff's knee against the torso in the arm pit of the resident. One staff person should control the resident's thighs and another the resident's lower legs. --The five person carry: the resident's arms are crossed in front of the resident's head, the staff responsible for the resident's arms will need to switch the resident arm they are holding. The resident is lifted at the armpit area and cross the resident's arms underneath the resident body. --The staff responsible for the resident's head would direct the staff to look at them when the staff are ready to lift. The staff responsible for the resident's head should say one, two, three, lift. Rise to a squatting position and lift the resident's wrist and opposite elbow. The staff responsible for the resident's head are to support the resident's head not lift it. -Two Person Escort: -The two person escort is not a control position. It is used for cooperative residents. -The staff escorting puts their arm underneath the resident's armpit and holds the resident's arm at the wrist. Secures the hold with the other resident's arm and walks the resident to a safe location. Review of the Facility Assessment Tool, dated 3/27/23 showed: -CALM training upon hire, before working the behavioral unit. -The facility accepts residents with Psychiatric/Mood Disorders, including: --Psychosis, Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder, Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that needs interventions, Personality disorder, Schizoaffective Disorder, Explosive Disorder. -Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, schizoaffective disorders, schizophrenia, bipolar disorder, personality disorder, other psychiatric diagnoses, intellectual or development disabilities. 1. Review of Resident #23's Level II Pre-Admission Screening and Record Review (PASRR) dated 4/22/16 showed: -The resident had a major mental illness. -The resident had recurrent emergency room visits related to suicidal ideation. -The resident needed the following psychiatric support/services: --Medication therapy, administration, and monitoring. --In-patient psychiatric treatment. --Safety Precautions. --Group Therapy/Counseling. -The resident was forgetful at times and had poor judgement and insight. -The resident interacted with others well, but would self-isolate at times. -The resident also had impulsive behaviors and anger outbursts. -Long-Term Care services were recommended. -The resident needed to be on a secure unit. Review of Resident #23's face sheet showed he/she admitted to the facility with the following diagnoses: -Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Paranoid Schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly, delusions and hallucinations are the two symptoms that can involve paranoia). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident #23's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 2/8/24, showed: -The resident was cognitively intact. -The resident had not had any behavioral symptoms towards himself/herself or others within the seven days look back period of the assessment. Review of Resident #23's care plan, dated 4/15/24, showed: -The resident had a history of PTSD which affected his/her behavioral symptoms and could flare-up without a known trigger with the following interventions: --Assess resident for suicidal or homicidal ideation's to ensure safety of resident and others. --Encourage the resident to express his/her emotions in a secure setting. --Allow the resident the freedom to acknowledge his/her feelings and release any repressed emotions that may be exacerbating his/her distress. --Establish trust with the resident. --Provide a calming and reassuring environment. -The resident had a history of behavioral challenges that required protective oversight in a secure setting with the outcome that the resident would not receive any serious injuries due to his/her behaviors with the following interventions: --Use Crisis Assessment Linkage and Management (CALM) techniques as needed. --Use one-to-one (1:1- a term used by healthcare support workers whose role is to provide one to one nursing or observation care to an individual resident for a period of time) monitoring as needed. -On 4/14/24 the resident had been placed on a 1:1 for behavioral monitoring related to auditory hallucinations (sensory perceptions of hearing noises without external stimulus), in which he/she became physically aggressive with staff and peer and a Code [NAME] (a behavioral emergency and/or incident needing physical support and presence when an individual poses a threat to himself/herself or others) had been called. -On 4/15/24 the resident had been sent to the local hospital's emergency room for evaluation and treatment after being assaulted by peer/staff the day before. Review of Resident #16's Level II PASRR dated 4/3/18 showed: -The resident had a serious mental illness. -The resident had recurrent in-patient visits to local hospitals and psychiatric hospitals. -The resident needed to following psychiatric support/services: --Medication therapy, administration, and monitoring. --In-patient psychiatric treatment. --Group therapy/counseling. --Fall, suicidal, assault, elopement, and close observation precautions. -The resident was forgetful at times with poor concentration, judgement, and insight. -The resident was suspicious of others and disturbed other residents. -The resident liked to be in the middle of things when it came to conflict with peers. -The resident was verbally aggressive and sometimes physically aggressive towards other residents. -Long-Term Care services were recommended. Review of Resident #16's face sheet showed he/she had admitted to the facility with the following diagnoses: -Schizoaffective Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). -Restlessness and Agitation. -Paranoid Schizophrenia. -Intermittent Explosive Disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts). -Attention-Deficit Hyperactivity Disorder (ADHD- a chronic condition including attention difficulty, hyperactivity, and impulsiveness). -Personal History of Traumatic Brain Injury (TBI- brain dysfunction caused by an outside source). Review of Resident #16's Quarterly MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident had not had any behavioral symptoms towards himself/herself or others within the seven days look back period of the assessment. Review of Resident #16's care plan, dated 4/15/24, showed: -The resident had a history of behavioral challenges that required protective oversight in a secure setting with the desired outcome that the resident would not harm self or others with the following interventions: --Provide physical and verbal cues to alleviate anxiety. --Give positive feedback. --Assist in verbalization of source of agitation. --When the resident became agitated the staff were to intervene before agitation escalated, guide the resident away from source of distress, engage calmly in conversation, if the response was aggressive then staff were to walk calmly away and approach the resident later. -The resident had a history of physical/verbal aggression towards others and self, attention seeking, and inappropriate behaviors with a history of Code Greens needing to be called. -The resident liked to insert himself/herself in situations when he/she did not need to be involved. -On 4/14/24 the resident was involved in physical aggression towards a peer after inserting himself/herself in matters not pertaining to him/her. Observation of the facility camera footage of the first incident, dated 4/15/24 at 11:24 A.M., showed: -The footage was a recording of the camera footage and not the actual recording. -No date or time could be seen in this video. -The recording of the camera footage occurred on 4/15/24 at 11:24 A.M. -The recording was six minutes and 33 seconds long. -The footage took place in a hall on the unit close to the dining room. -At two minutes and 45 seconds: --LPN A was talking with Resident #23 in the hallway. --CMT A was standing at his/her medication cart. --Housekeeper B and CNA D were in the hallway. --Dietary Aide A was at the end of the hallway, sitting on a chair --Resident #23 was attempting to leave the dining room and entered the hallway. --Resident #23 had attempted to push through CMT A and Housekeeper B to head into his/her room. -- Housekeeper B placed his/her left arm underneath Resident #23's left arm and placed his/her left forearm and hand on Resident #23's upper chest. --Resident #23 attempted to continue down the hall. --Housekeeper B then placed his/her right forearm and hand underneath Resident #23's right arm and onto Resident #23's upper chest. --Housekeeper B performed a one person take down of Resident #23, slamming Resident #23 on the ground. (facility policy and training does not include a one person physical restraint.) --LPN A, CMT A, and CNA D remained in the hallway and observed the take down. --Dietary Aide A remained at the end of the hall sitting in a chair. --Housekeeper B was attempting to keep Resident #23 on the floor. --Resident #23 was flailing and kicking his/her legs in attempt to get released from Housekeeper B's hold. --LPN A, CMT A, and CNA D continued to observe Resident #23 and Housekeeper B struggling without intervention. --LPN A and CMT A remained in the hallway observing the altercation. --Dietary Aide A remained at the end of the hall sitting in a chair. --Resident #16 started to run down the hallway towards the altercation. --Resident #16 started to kick Resident #23 while Resident #23 remained on the ground --Resident #23 remained on the ground and his/her left arm and leg become visible on the screen. -Housekeeper B remained to have his/her hands on Resident #23's body. --Resident #16 walked back towards the altercation. --Resident #23 remained on the floor and was kicking his/her legs toward Housekeeper B. --Resident #23 became blocked by residents again. --LPN A was calling out to Dietary Aide A and pointing down at the altercation. --Dietary Aide A got up from his/her chair and started to run down the hall. --Dietary Aide A continued to run down the hall towards the altercation. --Housekeeper B had a hold of some part of Resident #23's lower body and was beginning to drag Resident #23 towards the other side of the hallway. --CNA D had a hold of Resident #23's right arm but did not look like he/she was pulling on Resident #23. --Resident #23 was positioned on his/her left side. --Housekeeper B remained to have a hold of Resident #23's lower body and dragged Resident #23 to the other side of the hall. --CNA D remained to have a hold of Resident #23's right arm. --Resident #16 had a hold of Resident #23's left arm and no staff intervened. --LPN A and CMT A remained in the hallway watched and did not to intervene. --Dietary Aide A was still running down the hall. --Resident #16 let go of Resident #23's left arm. --Dietary Aide A reached the resident and bent down. --Housekeeper B continued to have a hold on Resident #23's lower body. --CNA D continued to have a hold on Resident #23's right arm. --Resident #23's body is mostly blocked and could not be seen on camera except for a part of his/her right arm and hand. --Resident #23's right arm was outstretched with his/her right-hand facing palm side down on the floor. --Housekeeper B and CNA D were still bent over Resident #23, but hand positions could not be seen. --Housekeeper B's right hand was holding Resident 23's right wrist. --CNA D was holding an unidentifiable part of Resident #23's body. --LPN A and CMT A remained in the hallway without touching Resident #23 and did not intervene. --Resident #23's head and left arm became visible on camera. --CNA D was holding a part of Resident #23's left lower arm. --Dietary Aide A was crouched over Resident #23's body. --Resident #23 was lying on his/her stomach. --CNA D was holding Resident #23's left wrist and had his/her knee on top of Resident #23's elbow. --Dietary Aide A was crouching over the back part of Resident #23's body. --Housekeeper B was crouching over Resident #23's right side. --Resident #23 remained on his/her stomach. --Housekeeper B had a hold of Resident #23's right wrist/hand. --Dietary Aide A was still crouching over the back part of Resident #23's back side. --Resident #23 remained on his/her stomach with his/her right arm outstretched. --CNA D was crouched over Resident #23's left arm, but where he/she was holding Resident #23 was not visible on camera. --Dietary Aide A appeared to be holing a part of Resident #23's back side. --LPN A and CMT A were by the medication cart and appeared to be talking with each other. --Resident #23 remained on his/her stomach being held down by Housekeeper B, Dietary Aide A, and CNA D. --Housekeeper B had a hold of Resident #23's wrist/hand. --Dietary Aide A remained holding Resident #23's lower back/buttocks area. --CNA D had remained holding Resident #23's left lower arm. --LPN A and CMT A remained at the medication cart. --The Activities Director who was also the Manager on Duty at that time appeared at the top of the frame and started to walk down the hallway towards Resident #23 and the staff. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --CMT A was waving the Activities Director down the hall. --LPN A remained at the medication cart. --The Activities Director continued down the hall. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --LPN A bent down and appeared to be picking up something off the floor next to Resident #23. --The Activities Director continued to walk down the hall. --CMT A returned to the medication cart. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --LPN A and CMT A remained at the medication cart. --Hall Monitor C came into the frame at the top of the hall. --The Activities Director reached Resident #23 and the staff. --Resident #23 remained on the floor. --The Activities Director appeared to be discussing the incident with LPN A, CMT A, Housekeeper B, Dietary Aide A, and CNA D. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --Hall Monitor C continued down the hall. --Hall Monitor C reached Resident #23 and the staff. --CNA D released his/her hold of Resident #23's left arm and started to walk up the hall. --Housekeeper B released his/her hold of Resident #23's right wrist and started to walk up the hall. -- Dietary Aide A released Resident #23's lower back/buttocks area and started to walk up the hall. --Hall Monitor C nudged Resident #23's left side with his/her right foot. --Resident #23 got up from the floor. --Housekeeper B, Dietary Aide A, and CNA B continued up the hall. --The Activities Director and Hall Monitor C walk towards Resident #23. --Resident #23 started to walk towards his/her room. --The Activities Director went to the right side of Resident #23. --Hall Monitor C went to the left of Resident #23 and grabbed Resident #23's left wrist. --Resident #23 continued towards his/her room. --The Activities Director stayed to the right of Resident #23. --Hall Monitor C remained to the left of Resident #23, continued to have a hold of Resident #23's left wrist with his/her left hand, and grabbed the back of Resident #23's shirt with his/her right hand. --Resident #23 and Hall Monitor C continued towards Resident #23's room. --Hall Monitor C continued to hold Resident #23's left wrist and shirt. --The Activities Director walked behind Resident #23 and Hall Monitor C and was a few paces behind them. --Hall Monitor C shoved Resident #23 into his/her room. --The Activities Director continued to walk towards Resident #23's room. NOTE: Resident #23 stayed in his/her room for the remainder of the camera footage. --Hall Monitor C entered Resident #23's room. --The Activities Director continued towards and entered Resident #23's room. --Resident #23's roommates exited the room and walked up the hall. --The Activities Director exited Resident #23's room. --LPN A and CMT A remained in the hallway. --The Activities Director waited outside of Resident #23's room facing away from the camera. --LPN A and CMT A remained in the hallway. --Hall Monitor C exited Resident #23's room. --The Activities Director started to walk up the hall. --Hall Monitor C remained outside of Resident #23's room and appeared to be talking to Resident #23. --LPN A and CMT A remained in the hall. --Hall Monitor C walked back towards Resident #23's door and stopped at the door frame and appeared to speak to Resident #23. --The Activities Director continued to walk up the hall. --LPN A and CMT A remained in the hall. --Hall Monitor C exited Resident #23's doorway and walked up the hall. --The Activities Director stopped at the medication cart, but only the lower half of his/her body was visible on camera. Observation of the facility camera footage of the second incident, dated 4/15/24, showed: -The footage was a recording of the camera footage and not the actual recording. -The recording was two minutes and 14 seconds long. -The footage took place on the unit hall near the elevator. -- Resident #23 entered the hall and into the frame of the footage with LPN A. -At 11:19:36 A.M. through 11:20:01 A.M.: --Resident #23 walked down the hall and LPN A walked down the hall in front of Resident #23 with about a three-door space between them. --LPN A exited the camera frame from the front of the hall. --Resident #23 continued to walk down the hall. --Hall Monitor C entered the frame at the bottom of the hall near the elevator. --Hall Monitor C made a punching/swinging motion towards Resident #23. --LPN A entered the frame at the bottom of the hall near the elevator. --Hall Monitor C and Resident #23 appeared to exchange some words with each other. --Hall Monitor C put his/her left and right arm up in a fighting stance, pulled his/her right arm back, and proceeded to punch Resident #23 in the jaw/neck area with his/her left fist. --Resident #23 brought his/her right arm up and put his/her right hand into a fist and attempted to block Hall Monitor C's punch, then made contact to Hall Monitor C's left shoulder with his/her right fist. --After Resident #23 made contact with Hall Monitor C's shoulder he/she punched Resident #23 again in the jaw. --Resident #23 continued to have his/her right arm up attempting to block the second punch. --LPN A remained by the elevator and appeared to observe the physical contact that was made between Hall Monitor C and Resident #23 and did not intervene. -At 11:20:13 A.M.: --Resident #23 swung at Hall Monitor C with his/her right arm and again made contact with Hall Monitor C's left upper arm/shoulder area. --Hall Monitor C punched Resident #23 again in the jaw causing Resident #23 to take a step back. --Resident #23 had hunched down in preparation to hit Hall Monitor C again, then raised his/her right arm, punched Hall Monitor C in his/her left shoulder and started to raise his/her right arm again in preparation to hit Hall Monitor C again. --Hall Monitor C appeared to make contact with Resident #23's chest/torso area once with his/her right hand and once with his/her left hand, then pushed Resident #23's head back with his/her right hand and made contact to Resident #23's upper body/neck area with his/her left hand. --LPN A began to walk towards the altercation. --Resident #23 attempted to hit Hall Monitor C again. --Hall Monitor C grabbed Resident #23's right and left wrists preventing Resident #23 from hitting him/her. --LPN A put his/her right hand up reaching out to Hall Monitor C's backside. --LPN A made contact with Hall Monitor C's back appearing to stabilize or push Hall Monitor C in the back towards Resident #23. --Hall Monitor C released his/her grip to Resident #23's wrists, kicked towards Resident #23, but contact could not be determined, while also bringing his/her left arm up and swinging towards Resident #23's face. --Resident #23 attempted to swing at Hall Monitor C with his/her left hand once he/she was released from the grip of Hall Monitor C and took a step back away from Hall Monitor C. --Resident #23 continued to step backwards away from Hall Monitor C. --Hall Monitor C lowered his/her hands, but walked toward Resident #23 when Resident #23 was stepping back. --LPN A continued to observe and walk towards the altercation, but was a few paces behind Resident #23 and Hall Monitor C. --Resident #23 continued to step away from Hall Monitor C. --Hall Monitor C raised his/her left arm and punched Resident #23 in the head. --LPN A continued to observe and walk towards the altercation, remaining a few paces behind Resident #23 and Hall Monitor C. --Resident #23 put his/her hands up attempting to cover his/her face and hunched over to avoid more hits by Hall Monitor C. --Hall Monitor C continued to walk toward Resident #23, it could not be determined if any contact with Resident #23 was made. --Housekeeper B and Resident #16 entered the frame at the bottom of the hall. --LPN A continued to observe and walk towards the altercation, remaining a few paces behind Resident #23 and Hall Monitor C. --Resident #23 remained hunched over and stepping back away from Hall Monitor C. --Hall Monitor C continued to walk towards Resident #23, raised his/her arms up reaching for the back of Resident #23's shirt. --LPN A, Housekeeper B, and Resident #16 continued to observe and walk towards the altercation. -Dietary Aide A entered the frame at the bottom of the hall. --CMT A appeared at the top of the frame and was exiting a resident's room. --Resident #23 was attempting to get away from Hall Monitor C and had his/her hands up attempting to protect himself/herself from more hits from Hall Monitor C. --Hall Monitor C continued to grab Resident #23's shirt preventing Resident #23 from leaving the altercation. --LPN A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe and walk towards the altercation and did not intervene. --CMT A stood outside of the resident's room he/she had just exited and observed the altercation. --Hall Monitor C continued his/her hold of Resident #23's back of shirt and started to push Resident #23 towards the floor. --Resident #23 had put his/her right arm and hand out to help brace for the impact as he/she was being pushed towards the floor. -- LPN A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe and walk towards the altercation. --CMT A remained in the hall and observed the altercation. --Resident #23 disappeared from the frame. --Hall Monitor C appeared to be hunched over Resident #23. --Resident #23 reappeared on camera and was on the floor and Hall Monitor C appeared to have some sort of hold on Resident #23. --Hall Monitor C was hunched over Resident #23 and was holding Resident #23's left arm. --LPN A, Housekeeper B, Dietary Aide A, and Resident #16 made a semi-circle around the altercation and remained to observe the altercation without intervention. --CMT A remained in the hall observing the altercation and had taken a couple steps forward towards the altercation. --Resident #23 remained on the floor, but had kicked his/her right leg up towards Hall Monitor C. --Hall Monitor C remained hunched over Resident #23 and had a hold on Resident #23. --When Resident #23 tried to kick Hall Monitor C, Hall Monitor C began to slap Resident #23 with his/her left hand. --LPN A, CMT A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe the altercation without intervention. --Resident #23 remained on the floor and has his/her legs up in the air bent at the knee. --Hall Monitor C remained over top Resident #23 with his/her legs straddled over Resident #23's left leg and continued to slap Resident #23. --LPN A, CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. -Resident #23 remained on the floor with his/her legs up in the air bent at the knee. --Hall Monitor C remained over top of Resident #23 with his/her legs straddled over Resident #23's left leg and was holding onto Resident #23. --Resident #23 remained on the ground and had lifted his/her right arm up and appeared to be reaching for Hall Monitor C. -- LPN A, CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. --Resident #23 remained on the ground in the same position as before. --Hall Monitor C continued to straddle Resident #23's left leg and had a hold of Resident #23's left arm. --Resident #23 remained on the ground and in the same position as before. --Hall Monitor C appeared to be reaching towards a resident's room while keeping the same hold on Resident #23. --CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. --Hall Monitor C began to drag Resident #23 into a resident room while keeping Resident #23 in the same position as before and exited the camera frame. --LPN A, CMT A, Housekeeper B, and Dietary Aide A began to walk towards the resident room where Hall Monitor C was dragging Resident #23 into. --Dietary Aide A and Housekeeper B turned around and began to walk down the hall. --LPN A and CMT A continued to walk towards the resident room where Hall Monitor C and Resident #23 were located. --Hall Monitor C and Resident #23 remained off camera. --CMT A entered the resident's room where Hall Monitor C and Resident #23 were located. --LPN A continued to walk towards the same room. --Hall Monitor C and Resident #23 remained off camera. --CMT A exited the resident's room and stayed by the door frame. --LPN A walked to the door frame and stayed next to CMT A. --Hall Monitor C and Resident #23 remained off camera. --LPN A and CMT A began to walk away from the resident's room and walk down the hall. --Hall Monitor C and Resident #23 remained off camera. --Hall Monitor C and Resident #23 reappeared into the camera frame. --Hall Monitor C had a hold of Resident #23's shirt and was walking Resident #23 out o

Based on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #1, #17 and #22) were free from abuse, out of 26 sampled residents. On 2/24/24, Resident #2 pushed staff aside and pulled Resident #1 from his/her chair to the floor. Resident #2 struck Resident #1 in the face and on the head multiple times. Resident #2 then stomped on Resident #1's head. Resident #1 sustained a bump and discolored area on his/her forehead. Resident #2's physical and aggressive behavior resulted in six sampled residents (Resident #3, #6, #9, #13, #4, and #15) verbalization of fear for their safety from Resident #2. Additionally, on 2/27/24, Resident #19 struck Resident #17 in his/her face resulting in Resident #17 having a bloody nose and mouth. On 4/3/24, Resident #18 wrapped his/her hand around Resident #22's neck and squeezed until staff intervention. The facility census was 112 residents. The Administrator was notified on 4/1/24 at 2:00 P.M. of an Immediate Jeopardy (IJ) which began on 2/24/24. The IJ was removed on 4/4/24, as confirmed by surveyor onsite verification. Review of the facility policy titled, Abuse and Neglect, dated 1/5/23 showed: -The facility was committed to protecting residents from abuse by anyone. -Physical Abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or humane manner. -Verbal Abuse was using profanity or speaking in a demeaning or non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples included: mocking, insulting, ridiculing, yelling in an intimidating manner, and threatening. -Mental Abuse was using verbal or non-verbal conduct which would cause or potentially cause a resident to experience intimidation, humiliation, fear, shame, agitation or degradation. This included hovering over a resident with intent to intimidate and threaten. -The facility was committed to protect residents from abuse by anyone, including staff, other residents, consultants, volunteers, agency staff, family members, guardians, friends or any other individuals. 1. Review of Resident #1's facility face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Schizoaffective disorder, (a mental health condition characterized by symptoms such as delusions, hallucinations, and mood disorders that can impact daily functioning). -Impulse disorder, (a mental health condition that is characterized by inability to resist impulses, urges and temptations that may harm oneself or others). -Major depressive disorder, recurrent, (persistent low mood, loss of interest or pleasure, fatigue, feelings of worthlessness and difficulty concentrating, that have severe impact on daily functioning and quality of life). Review of Resident #1's Care Plan, dated 6/7/23, showed: -He/she had the potential for physical or verbal behaviors toward self and others. -Interventions included: education on coping skills; analyzing triggers for aggression and staff intervention to allow time to calm down; administration of medications as ordered; anticipation of resident's needs; separation of parties involved; 1:1 observation. Review of Resident #1's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 12/18/23 showed: -The resident was cognitively intact. -No behaviors were observed during the assessment period. Review of Resident #2's PASRR (Preadmission Screening and Resident Review - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility; the screening assures appropriate placement of persons known or suspected of having a mental impairment(s) and also that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment), dated 7/29/22, showed the following information: -He/she had poor insight and required structure and consistently displayed poor/unsafe decision making. -He/she had a history of disorganized behaviors, depression, mania, impulsive behaviors, psychosis, depression, was suspicious and paranoid, abnormal thought processes, verbal and physical aggression, suicide attempts and self harm, -He/she was violent toward medical staff and actions were dangerous to the public. -He/she had a history of becoming violent in public places and threatening to shoot others. -He/she had hit his/her fiance with a crowbar and thought he/she was dead. -He/she had a guardian appointed. Review of Resident #2's facility face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Schizoaffective disorder, bipolar type, (a mental health condition that combines features of schizophrenia, (a severe mental disorder that affects how a person thinks, feels and behaves), and bipolar disorder, (a mental health condition characterized by extreme mood swings), where the individual experiences mood disturbances along with psychotic (a mental state where the individual experiences a break with reality). -Post-traumatic stress disorder, chronic, (long-term, persistent mental health condition that can develop after experiencing or witnessing a traumatic event). -Reactive attachment disorder of childhood, (a rare, but serious condition that can develop in children who have experienced significant neglect, abuse or disruption in early caregiving relationships). -Major depressive disorder, recurrent. Review of Resident #2's Care Plan, dated 9/1/23, showed: -He/she had a long history of mental illness and frequent psychiatric hospital admissions. --Interventions included: use of CALM technique, (Crisis Alleviation Lessons and Methods - to provide safe treatment and humane care to residents in a behavioral crisis), if needed, long term psychiatric management and counseling, if needed; pharmaceutical interventions, if needed and 1:1 observation, if needed. -He/she had a history of behavioral challenges that required protective oversight in a secure setting and had a previous act of physical aggression toward a peer on 1/27/24. --Interventions included: using CALM technique if needed, long term psychiatric management and counseling, if needed; pharmaceutical interventions, if needed, 1:1 observation, if needed, referrals sent out for transfer. Review of Resident #2's MDS, dated [DATE], showed he/she was cognitively intact. Review of a video, dated 2/24/24, showed: -Resident #1 was sitting at a table with Resident #5 getting his/her hair fixed by Certified Medication Technician (CMT) A. -Resident #2 became visible in a chair across the room, taking off his/her shoes and socks. -Resident #2 stood up and the two Hall Monitors (HM A and HM B) stood up and stepped between the residents and it appeared a verbal exchange was taking place between the two residents. -CMT A was still fixing Resident #1's hair. -Resident #2 flipped his/her middle finger at Resident #1. -Resident #2 stood behind Resident #5 and was speaking. -Resident #2 used his/her body to push the two HMs out of the way and started slapping Resident #1, pulled his/her hair and drug him/her to the ground. -CMT A was standing behind Resident #1 using his/her body as a shield. -When Resident #2 pushed the staff out of the way, he/she also slapped at CMT A three times. -Resident #2 gave Resident #1 at least ten slaps on the head and then was on top of him/her. -CMT A stepped aside to call a Code Green. -The three staff were able to get Resident #2 off Resident #1 and put him/her in a hold. -Resident #2 kicked at staff. -CMT A pulled Resident #1 away. -Resident #2 was able to stand up, staff pulled him/her away and let him/her go. -Resident #2 stepped forward and started stomping on Resident #1's head 4 times. -Another staff arrived and removed Resident #2 from the area. Review of the facility's investigation, dated 2/24/24 at 7:49 A.M., showed: -Both residents lived on a locked behavioral unit. -The residents had a verbal altercation earlier in the day. Floor staff intervened and separated the residents so no physical alteration ensued. -The staff thought it was over and did not inform the nurse of the event. -After dinner, the staff were helping Resident #1 with his/her hair. Resident #1 was upset because Resident #2 did not assist the staff with his/her hair. -The two residents started a verbal exchange and the resulting altercation could have been avoided if the staff had separated the residents during their verbal argument. -Resident #2 had the approved CALM hold used to separate him/her from Resident #1. -Resident #1 sustained a hematoma to his/her forehead and some abrasions. He/she was sent to the hospital for evaluation. -Resident #2 received an ordered as needed (PRN) medication and was placed on 1:1 observation. -Resident #2 had previously been in one physical altercation at the facility. Review of Resident #2's Progress Notes, dated 2/24/24 at 6:30 P.M., showed: -Staff responded to a Code [NAME] (used to alert staff to the need for assistance in deescalating a potentially volatile situation), when nurse arrived, staff reported he/she attacked a peer. -When the nurse asked the resident what happened, he/she stated he/she was angry at Resident #1, because Resident #1 was calling him/her names and he/she became mad. He/she said his/her intention was not to hurt the other resident, but to shut him/her up. -He/she was placed on 1:1 observation. Police, guardian, primary care physician, Director of Nursing (DON) and Administrator were notified. During an interview on 2/28/24 at 10:50 A.M., Resident #2 said: -He/she did not want to do Resident #1's hair and told Resident #1 he/she needed to wash and brush his/her own hair. -Resident #1 called him/her multiple names. -He/she had several verbally aggressive encounters with Resident #1 before, but no physical aggression. -He/she should have gone to his/her room and ignored Resident #1 as he/she had done many times before. -He/she approached Resident #1, reached around staff, grabbed Resident #1's hair and pulled him/her to the ground. -Someone called a Code Green. -There were two other staff present. -He/she hit Resident #1 on top of the head, but not on his/her face. -He/she was on top of Resident #1 and staff tried to get him/her off. -When he/she got up, he/she stomped on Resident #1. -He/she was trying to injure Resident #1. -The male staff grabbed him/her and got him/her away from Resident #1 and made him/her sit in a chair. -He/she was in a rage. -He/she asked for a PRN medication and got it. -He/she was asked several times if he/she wanted to go to the hospital and he/she said no. -It took a lot to make him/her mad. -Things that would trigger him/her were talking about his/her kids, being around slow people 24/7 and being told he/she can't do things. -He/she was stuck in a small area with these people. Observation and interview with Resident #1 on 2/28/24 at 11:20 A.M., showed: -He/she had a purple, green, and yellow fading discolored area about two inches in diameter on his/her left forehead at the hairline. -He/she said a staff person was fixing his/her hair when he/she was cussing Resident #2 out and calling him/her a bitch. -He/she had been trying to stop him/herself from calling names, but called Resident #2 all kinds of names. -Resident #2 was at the next table. -The staff told the two of them to stop arguing, but they did not listen. -Resident #2 started the fight, pulled him/her out of his/her chair, pulled his/her hair, punched him/her, and stomped on his/her head. -Staff tried to stop Resident #2 and called a Code Green. -It took a lot of staff to get them apart because Resident #2 was really strong. -He/she stayed in the dining room in a chair and Resident #2 went to a different area. -He/she was moving to a different unit, where he/she thinks he/she would be safe. -He/she didn't know what made Resident #2 so mad. -Resident #2 was bullying people in the dining room during the past weekend. -He/she was afraid of Resident #2. Review of Resident #6's MDS, dated [DATE], showed he/she was cognitively intact. Review of a statement written by Resident #6 on 2/24/24 at 6:35 A.M. showed: -He/she was in the dining room right before Resident #1 was attacked by Resident #2. -The two residents were having a verbal exchange. -Resident #2 told Resident #1 he/she hoped he/she slept with one eye open, because he/she was going to put socks in his/her mouth and pillows over his/her head. -Resident #2 took off his/her socks and shoes, then went over near Resident #1 and Resident #5. -Resident #2 told Resident #5 to stick his/her middle finger at Resident #1 and said, Fuck you, bitch. -Resident #2 attacked Resident #1 and had him/her on the floor, punching him/her in the head and face. During an interview on 2/29/24 at 11:55 A.M., Resident #6 said: -He/she was present when Resident #2 attacked Resident #1. -Resident #2 told Resident #1 he/she would have to sleep with one eye open because he/she was going to stuff some socks in his/her mouth and put a pillow over his/her head. -Resident #2 started taking off his/her shoes and socks, because he/she was going to fight Resident #1. -Resident #1 was getting his/her hair done. -Resident #5 flipped Resident #1 off and called him/her a fucking bitch, because Resident #2 told him/her to. -Staff were between Resident #1 and Resident #2 the whole time. -Resident #2 reached around the staff and pulled Resident #1 down and started beating him/her. -The staff tried to intervene, but Resident #2 was too strong. -Two of the staff tried to help and one got on the walkie-talkie to call a Code Green. A total of three staff were there. -Then another staff member came in and pulled Resident #2 away. -He/she was afraid of Resident #2 and the other residents were afraid of him/her. -When Resident #2 had a behavior, the staff would try to calm him/her, but it didn't always work. -Resident #2 tells him/her to do things, and since he/she is afraid of him/her, he/she does them. -Resident #2 threw water twice and ripped the wig off of one of the nurses. Review of a statement written by Certified Medication Technician (CMT) A on 2/24/24 at approximately 6:25 A.M., showed: -He/she was detangling Resident #1's hair. -The involved residents were in the dining room. -Residents #2, #5 and #6 were in the dining room. -Resident #1 and Resident #2 were having words and calling each other names. -He/she and the other staff asked Resident #2 to please leave Resident #1 alone. -Resident #2 told Resident #5 to call Resident #1 a lot of names and told him/her to put his/her finger up at him/her. -All of a sudden, Resident #2 attacked Resident #1 and stomped his/her head on the floor a couple times. During an interview on 2/29/24 at 12:05 P.M., CMT A said: -Resident #1 and Resident #2 were making remarks to one another. -He/she and the two other staff put their bodies around Resident #1 and stepped between the two residents. -He/she and the other staff thought Resident #2 was just coming over to talk to Resident #5 who was sitting at the table. -Resident #2 reached around the two other staff and started beating Resident #1. -When Resident #2 started hitting, he/she stepped to the side of the room and called a Code Green. During an interview on 2/29/24 at 12:35 P.M., Nurse Practitioner (NP) A said: -He/she was aware of the fight. -Resident #2 had always been in trouble, attention seeking and fighting at his/her previous facility. Review of Resident #9's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 2/29/24 at 1:24 P.M., Resident #9 said: -He/she was present in the room during the fight. -He/she saw the two residents arguing because of things Resident #1 said. -The staff were trying to stop the whole thing from happening. -Resident #2 pushed the staff out of the way. -Resident #2 pulled Resident #1 out of his/her chair. -He/she saw Resident #2 hitting Resident #1 on his/her head. -He/she was yelling, No, no, stop! and started crying. -He/she went to his/her room at that point. -He/she is scared of Resident #2. During an interview on 2/29/24 at 2:13 P.M., Hall Monitor (HM) A said: -CMT A was working on Resident #1's hair. -Resident #2 was saying Resident #1 needed to learn to do things for him/herself, and was antagonizing him/her. -Resident #1 was telling Resident #2 to leave him/her alone. -Resident #2 said if Resident #1 said anything else, he/she was going to go over there and started taking his/her shoes and socks off. -They were telling Resident #2 it was not worth it and to leave Resident #1 alone. -At that point, they stood behind Resident #1 to keep the two residents apart. They were trying to keep the residents separated. -Resident #2 got up and walked over to them. -When he/she and the other staff were standing between Residents #1 and #2, Resident #2 used his/her body to push them out of the way. -Resident #2 was very strong. -CMT A went to call a Code Green. -Resident #1 was shouting and Resident #2 started stomping. -The nurse came and took Resident #2 away. He/she told Resident #1 not to get up. -Resident #2 wanted to go to the smoke room and said he/she was not going to apologize until Resident #1 apologized first. -Resident #1 did not fight back. -Resident #1 went to the hospital. -Police came later and documented the event. Review of Resident #3's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 2/29/24 at 10:25 A.M., Resident #3 said: -He/she was in the smoke room and heard Resident #2 state he/she had given Resident #1 what he/she deserved. -He/she was afraid of Resident #2. During an interview on 3/6/24 at 10:04 A.M., the Director of Nursing (DON) said: -Resident #2 hitting Resident #1 was abuse. -He/she did not know if this incident could have been predicted or prevented, but if a Code [NAME] were called sooner, the severity might have been diminished. During an interview on 3/6/24 at 10:15 A.M., the Administrator said: -Resident #2 beat up another resident at his/her previous facility. -The facility did not receive his/her history and behavior notes from the previous facility until after he/she arrived at the current facility. -He/she did not know if this incident could have been predicted or prevented. -Resident #2 was not intimidated by staff and did not fight fairly. -If a Code [NAME] was called sooner, the injury might have been less. -The police came to the facility that day and took a statement. -Resident #1 pressed charges and Resident #2 had a court date assigned. Review of Resident #15's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 3/7/24 at 12:50 P.M., Resident #15 said: -Resident #2 had never attacked him/her. -He/she was afraid of Resident #2 and would stay away from him/her. -Resident #2 was unreliable; one minute friendly and the next angry. -Resident #2's whole demeanor and the way he/she walked and talked was intimidating. -The previous night, he/she saw Resident #2 rip a nurse's wig off, throw a laptop on the floor and knock medications off the cart. -Resident #2 previously beat up another agency nurse. Review of a written statement by Resident #15 dated 3/12/24 showed: -He/she was not comfortable, nor did he/she feel safe with Resident #2 on the unit. -Resident #2 had beaten 6 people up, 2 of which were agency nurses. -Resident #2 was a menace and unpredictable. -The facility was his/her home and he/she should feel safe and at peace. During an interview on 3/7/24 at 1:05 P.M., Resident #3 said: -The residents were all afraid of Resident #2. -Resident #2 threatened him/her and put a sign on his/her door calling him/her a fat [NAME]. Resident #2 also threatened to rip his/her earring out. -Resident #2 would instigate other residents to do things. -He/she did not see the incident with the agency nurse, but Resident #2 bragged about it and said the nurse was incompetent and a dumb bitch. -Resident #2 was unpredictable, and one would never know when he/she was going to get aggressive. -Resident #2 showed no remorse for his/her actions. Review of Resident #13's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 3/12/24 at 9:50 A.M., Resident #13 said: -Resident #2 was threatening staff. -Resident #2 previously threatened to kill him/her but did not say why. -Resident did not show any signs when he/she was going to get aggressive, he/she would just do it. -People could not tell when Resident #2 was going to do something. -The residents did not want Resident #2 to come back to the facility. -Since Resident #2 had been gone, the unit was more peaceful and there was less drama. Review of Resident #14's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 3/12/24 at 10:00 A.M., Resident #14 said: -Resident #2 had previously never hit him/her, but had threatened him/her. -He/she was afraid of Resident #2 because he/she had threatened to hit him/her with his/her walker in the past. -Resident #2 got violent this last time, because he/she thought someone stole his/her things, but nobody had done so. -Resident #2 was yelling and threw some drink pitchers and a chair, and threw the linen cart. -There were staff present; some of them were afraid of the resident. -Resident #2 threatened to hurt the staff and the residents. -When Resident #2 was being taken out of the room, he/she was making threats to get you and kill you to the staff. -He/she was terrified Resident #2 would come back and hurt all of them. -Resident #2 had threatened to stab them and kill them, and had already hurt two agency nurses. During an interview on 3/12/24 at 10:47 A.M., Licensed Practical Nurse (LPN) A said: -Anything could trigger Resident #2. He/she could go off without warning. -Some staff were afraid of the resident, as he/she had made threats toward them. -All of the residents were afraid of this resident. His/her roommate would buy him/her treats to stay on his/her good side. During an interview on 3/12/24 at 11:00 A.M., Certified Nursing Assistant (CNA) B said: -He/she did not think Resident #2 had any real triggers, but would just go off. -Resident #2 did not show any agitation or other signs before he/she would get violent. -Resident #2 just wanted to do what he/she wanted to do, when he/she wanted to do it. Positive reinforcement didn't work with him/her. -Code Greens and CALM techniques had no effect on the resident. He/she would continue to threaten the other residents and staff. -The other residents were terrified Resident #2 was going to return to the facility. During an interview on 3/7/24 at 2:05 P.M., the DON said: -One moment Resident #2 could be really talkative and the next moment, hateful. He/she didn't give a build-up, but it was random and you didn't know what would set him/her off. -Resident #2 was unpredictable and changeable. During an interview on 3/12/24 at 11:30 A.M., Guardian A said: -The resident was a master manipulator. The residents did not want Resident #2 to come back to the facility. -Since the resident had a guardian, the prosecuting attorney would not press charges. During an interview on 3/12/24 at 12:00 P.M., Resident #1 said he/she was afraid of Resident #2. 37841 2. Review of Resident #17's PASSR, dated 11/29/23, showed: -Assistance needed to complete activities of daily living (ADL's - eating, dressing, grooming, bathing, incontinence care). -Assistance needed for transfers, ambulation, fall prevention. -Medical treatment and/or monitoring for chronic conditions. -Behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management. -Lack of community/family supports to maintain functioning at home. -Self injurious behaviors of hitting him/herself in the head. -Physical and verbal aggression toward men. -History of abuse. -Inappropriate sexual comments to staff. -Poor insight and judgement. Review of Resident #17's facesheet showed he/she admitted to the facility 2/16/24 with diagnoses that included: -Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe). -Schizophrenia. -Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that is strong enough to interfere with ones daily activities). -Major Depressive Disorder. -Intermittent Explosive Disorder (repeated sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts; with reactions that are too extreme for the situation). -Traumatic Brain Injury (brain dysfunction caused by an outside force, usually a violent blow to the head). Review of Resident #17's admission MDS, dated [DATE], showed the facility was not able to assess cognitive status related to the resident not understanding questions, with severely impaired cognition. Review of Resident #17's care plan, dated 2/26/24, showed: -Resident has an ADL performance deficit related to paraplegia. -- Encourage the resident to participate to the fullest extent possible with each interaction. --Praise all efforts at self care. -Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others; these behaviors include buying, selling, borrowing and trading behaviors with peers. --Administer medication as needed when non pharmacological interventions are ineffective. --Give positive feedback for good behavior. --Notify guardian/physician as needed. Review of Resident #19's PASSR, dated 12/17/14, showed: -Victim of a gang shooting in 1993 which left him/her paraplegic. -Long standing depressive issues, suicidal ideation, and suicide attempts. -Poor concentration and judgement. -Delusions, auditory hallucinations. -Assistance needed with ADL's - toileting, bathing, and dressing. Review of Resident #19's face sheet showed he/she admitted to the facility 1/18/24 with diagnoses that included: -Major Depression. -Schizophrenia. -Anxiety Disorder. -Encephalopathy (a broad term for any brain disease that alters brain function or structure). Review Resident #19's admission MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #19's care plan, dated 2/26/24, showed: -The resident has an ADL self care performance deficit related to paraplegia. --Encourage the resident to participate the fullest extent possible with each interaction. --Praise all efforts at self care. -Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others; these include yelling at staff, buying, selling, borrowing and trading behaviors with peers. --Administer medication as needed when non-pharmacological interventions are ineffective. --Give positive feedback for good behavior. --Notify guardian/physician as needed. Review of the facility investigation, dated 3/1/24, showed: -The incident happened on 2/27/24. -CNA C notified the DON he/she witnessed Resident #19 hit another resident in the face. -When asked Resident #19 said he/she hit Resident #17 because Resident #17 had not paid him/her for five cigarettes. -When asked Resident #19 said he/she did not hit Resident #17. -Resident #19 denied giving/selling Resident #17 cigarettes. -Resident #17 had a bloody nose and mouth. During an interview on 4/1/24 at 2:30 P.M., Resident #17 said: -He/she did not remember getting in an argument with anyone or being hit in the nose. During an interview on 4/1/24 at 2:40 P.M., Resident #19 said: -He/she remembered hitting Resident #17 in the face. -CNA C saw it. -Resident #17 owed him/her cigarettes. During an interview on 4/1/24 at 2:52 P.M., CNA C said: -He/she was coming through the glass doors to the hall where the residents go out to smoke. -He/she saw Resident #19 hit Resident #17 with a closed fist in the face. -Both of the residents were in their wheelchairs. During an interview on 4/1/24 at 3:00 P.M., the DON said: -During the investigation, Resident #19 denied hitting Resident #17. -Resident #17 did have a bloody nose and mouth, so it looked like the resident was hit. -Resident #19 also denied selling or giving cigarettes to Resident #17. -He/she did have a staff witness the incident, so it was assumed Resident #19 did hit Resident #17. -Education was given again to Resident #19 on not selling or giving items such as cigarettes to other residents. -Education was given again to Resident #17 on not asking for items such as cigarettes, from other residents. During an interview with the Administrator on 4/1/24 at 3:15 P.M., he/she said: -The staff reported to him/her that Resident #19 hit Resident #17 in the mouth or nose. -This reportedly happened right outside the smoking area in the hallway. -The residents have been re-educated on not selling or giving each other items such as cigarettes. -Resident #19 denied hitting Resident #17. -He/she feels as though this was more of a behavior than abuse. 3. Review of Resident #18's PASSR, dated 12/10/20, showed: -Major neurocognive disorder secondary to surgical ablation (removal) related to seizures (Right frontal lobe ablation - right frontal lobe is responsible for higher cognitive functions such as memory, emotions, impulse control, problem solving, social interaction and motor function). -Schizoaffective Disorder. -Major Depression. -Schizophrenia. -Mild Cognitive impairment. -Mood Disorder (Marked disruptions in emotions). -Psychotic disorder with delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally in reference to a mental disorder). -Severe physical aggression. -Required outpatient psychiatric follow-up/consultation. -Required secured/behavioral unit. -Required assessment and implementation of behavioral support plan, monitoring of behavioral symptoms and provision of behavioral supports. Review of Resident #18's facility face sheet showed: -Resident admitted to the facility on [DATE], with diagnoses that included: --Epileptic seizures (happens as a result of abnormal electrical brain activity, also known as a seizure). --Violent behavior. --Mood disorder. --Schizoaffective disorder. --Anxiety disorder. --Bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs). --Unspecified Psychosis. Review of Resident #18's quarterly MDS, dated [DATE], showed he/she had moderately impaired cognition. Review of Resident #18's care plan, dated 4/3/24, showed: -The resident had manifestations of behaviors related to his/her mental illness and brain surgery in 2015 that may create disturbances that affect others. -These behaviors include verbal/physical aggression, poor impulse control, false allegations toward peers, low cognitive ability. --Assisted resident in addressing root cause of change in behavior or mood as needed. --Give positive feedback for good behavior. -

Based on observation, interview and record review, the facility failed to ensure six sampled residents (Resident #2, #3, #4, #5, #7 and #9) were free from abuse. On 10/6/22, Resident #1 struck Resident #2 resulting in bruising and swelling to the left eye and left cheek and an orbital floor fracture (a break in one of the bones surrounding the eyeball). On 10/16/22, Resident #8 swung at Resident #9 resulting in bruising to Resident #9's left cheek and nose. On 10/14/22, Resident #3, Resident #4, Resident #5 and Resident #7 struck one another out of 12 sampled residents. The facility census was 112 residents. Record review of the facility's Abuse and Neglect Policy, dated 9/17/21, showed: -Physical abuse includes, but is not limited to, hitting, slapping, punching, biting and kicking. -It was the policy of the facility that every resident has the right to be free from physical. -Abuse of residents was prohibited by the facility, including physical abuse. -The facility was committed to protecting residents from abuse by anyone including other residents. Record review of the facility's Resident's Rights policy, dated 4/29/21, showed a resident has the right to be free from verbal, mental and physical abuse, corporal punishment and involuntary seclusion. Record review of the facility's Behavioral Emergency Policy, dated 2/26/21, showed: -It was a policy of the facility to provide a safe environment and humane care to all residents. -Behavioral emergency was defined a code green. 1. Record review of the Resident #1's Preadmission Screening and Resident Review (PASRR) Level II Evaluation, dated 12/25/2020, showed: -Mental health diagnosis include: --Paranoid schizophrenia (delusions and hallucinations, debilitating symptoms blur the line between what is real and what isn't, making it difficult for the person to lead a typical life). --Psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions, people lose touch with reality). --Panic disorder with agoraphobia (have a hard time feeling safe in any public place, especially where crowds gather). --Narcissistic personality disorder (an excessive need for admiration, disregard for others' feelings, an inability to handle any criticism, and a sense of entitlement). -He/she had history of aggressive, assaultive or violent behavior. -He/she had not made good decisions. -He/she had impaired judgement. Record review of the resident's Quarterly Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents), dated 5/20/22, showed he/she was cognitively intact. Record review of Resident #1's undated Care Plan showed: -He/she had a behavior problem including episodes of agitation, anger, and behaviors resulted in code green (facility response to behavioral emergency). -He/she would remain free from harm to self and others. -Facility staff should intervene as necessary to protect the rights and safety of others. -Facility staff should approach and speak to him/her in a calm manner, divert attention his/her attention and remove him/her from the situation and take to alternate locations as needed. Record review of Resident #2's PASRR Level II, dated 9/16/2014, showed: -He/she had a history of irritability, agitation, and impulsive anger issues. -He/she had poor insight and judgement. -He/she had a history of incarceration for aggressive behavior. -He/she had periods of anger outburst. Record review of Resident #2's admission record showed readmitted on [DATE] with the following diagnosis: -Schizoaffective disorder. -Impulse disorder. -Anxiety disorder (feelings of nervousness, panic and fear). Record review of Resident #2's Admission MDS, dated [DATE], showed he/she was cognitively intact. Record review of Resident #2's undated Care Plan showed: -On 10/6/22 the resident was involved in physical aggression with another peer. -He/she made accusatory statement towards Resident #1 in relation to noise level of music, demanding he/she turn the music off. -He/she displayed aggression and Resident #1 responded resulting in Resident #2 had injury to his/her left eye. Record review of Resident #2's hospital records, dated 10/6/22, showed: -His/her chief complaint was assault, head pain and facial pain. -He/she had bruising and swelling to the left eye and left cheek. -He/she was found to a have orbital floor fracture. -Consultation with the plastic physician whom recommended follow-up in the office next week. Record review of the Facility Investigation, dated 10/6/22, showed: -Resident #1 and Resident #2 engaged in physical altercation which resulted injuries to both residents. -Resident #2 was sent to the hospital for evaluation and treatment for injury to his/her left eye due to the assault. -First aid was administered to Resident #1 related to scratches on his/her right face. Observation and interview on 10/18/22 at 12:17 P.M., Resident #1 said: -The scratch marks on his/her face were from an altercation with Resident #2. -The fight was over Resident #2 having the radio on all of the time. -Resident #2 had a history of violence and that was why Resident #2 was moved to the unit. -The resident was observed with scratch marks to the right side of his/her face. During an interview on 10/19/22 at 11:59 A.M., Resident #1 said: -Resident #2 had been standing at his/her bedside in a verbal confrontation about the radio. -When he/she went to the bathroom, Resident #2 followed behind him/her and kicked the door open. -An argument ensued and Resident #2 initiated physical contact. -He/she said there were no witnesses. -He/she reported the incident to staff. During an interview on 10/19/22 at 1:04 P.M., Resident #2 said: -He/she got in a fight with Resident #1. -Law Enforcement Officers had come and took him/her to the hospital. -He/she had an ice pack for the swelling to his/her left eye. During an interview on 10/19/22 at 2:30 P.M., the Administrator and the Director of Nursing (DON) said: -Residents #1 and Resident #2 had conflict over the radio. -Resident #2 was injured and had a follow up with the physician to make sure everything was okay. -He/she would call people in to assist for one on one supervision for residents when needed. -Resident #2 has had no physical aggression since becoming a resident at the facility. -Resident #2 was sent to the hospital for medication adjustment and monitored closely. -Clergy had done rounds twice per week for the residents. -He/she was always available for the staff and residents. 2. Record review of Resident #8's PASRR Level II, dated 5/11/06, showed he/she: -Was verbally and physically aggressive. -Had threatening fist fights. -Went from being happy and calm to extremely angry and hard to control. -Had not been making good decisions. Record review of Resident #8's Admission Record showed he/she admitted on [DATE] with the following diagnosis: -Paranoid schizophrenia. -Antisocial personality disorder (manipulative, deceitful and reckless, and will not care for other people's feelings). Record review of the residents Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Record review of Resident #8's undated Care Plan showed: -He/she had the potential to be verbally aggressive related to mental and emotional illness. -He/she had episodes of agitation, anger, behavior resulting in need for code green to be called. -When he/she was agitated staff should intervene before agitation escalated, guide him/her away from source of distress and engage him/her calmly in conversation. -If his/her response was aggressive, staff were to walk away and approach later. -The resident had the potential to be physically aggressive related to anger. Record review of Resident #9's PASRR Level II, dated 7/6/14, showed: -He/she had the following diagnosis: --Schizophrenia. --Mood disorder. --Psychotic disorder. --Schizoaffective disorder. -Oppositional defiant disorder (uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures, more troubling to others than they are to themselves). -Poor judgement and insight. -Disturbing other residents. -Physically threatening. -Striked other provoked. -Inappropriate responses and interactions: verbal and physical aggression blamed on others. -Tends to have inflammatory verbal and physical reactions when things don't go his/her way. -Required careful monitoring and structured, secured environment to control substance abuse and redirect physical and verbal aggression. -Crisis intervention as needed, careful with roommate placement due to acting-out behavior. Record review of the residents Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Record review of Resident #9's undated Care Plan showed: -The resident had the potential to be physically aggressive related to diagnosis of restlessness and agitation and other psychoactive substance abuse. -The resident would not harm self or others. -Staff were to analyze times of day, places, circumstances, triggers and what de-escalated behavior and document for the resident. -Staff were to provide physical and verbal cues to alleviate anxiety, assist verbalization of source of agitation and encourage seeking out staff member when he/she was agitated. -Staff were to monitor, document, and report as needed any signs and symptoms of resident posing a danger to self and others, -The resident had a mood problem related to diagnosis insomnia, schizophrenia and anxiety. -The resident would have improved mood state through the review date. -On 10/16/22 he/she was involved in physical aggression with another peer regarding a chair that belonged to a different resident. -Arguing ensued and this resident in frustration attempted to strike resident but missed and was slapped in the face. Record review of the Facility Investigation, dated 10/16/22, showed: -On 10/16/22 Resident #8 and Resident #9 were engaged in a physical altercation. -Resident #9 was given Haldol (antipsychotic medicine that is used to treat schizophrenia) for his/her behavior. Observation and interview on 10/18/22 at 12:11 P.M., Resident #9 said: -He/she was attacked by Resident #8 two or three days ago. -He/she avoided Resident #9 now. -The resident had bruising to the left cheek and nose areas, purple in color. During an interview on 10/19/22 at 12:18 P.M., Certified Medication Technician (CMT) A said: -He/she entered the resident's room to give Resident #8 his/her medication and found Resident #8 and Resident #9 arguing. -He/she was holding Resident #8's medications in one hand and a cup of water in the other when he/she entered the resident room and saw Resident #8 swing at Resident #9. -He/she left the room to get help and called a code green. -The incident escalated so fast he/she had no time to intervene. During an observation and interview on 10/18/22 at 1:00 P.M., Resident #8 said: -Resident #9 had rushed (made a physical motion toward) him/her. -He/she swung over Resident #9, because he/she thought the resident was going to hit him/her. -Resident #9 was pulling his/her hair and he/she was trying to get free. -The cuts on his/her right hand were from the fight. -Observation showed cuts to the resident's knuckles on the right hand. Observation and interview on 10/18/22 at 1:11 P.M., Resident #9 said: -Resident #8 had hit him/her a long time ago. -He/she denied any pain or discomfort. -Observation showed swelling and bruising to his/her left eye. During an interview on 10/20/22 at 12:38 P.M. Licensed Practical Nurse (LPN) B said: -When residents become escalated, you try an verbally de-escalate. -If the escalation continued, the staff should call code green. -The charge nurse directed what roles everyone was responsible for during a code green. -Charge nurse was responsible for incident report, notifying the DON, enters progress notes, room changes, talk to residents, give workbooks, and exercise with the residents. -His/her expectation was for staff to do rounds. -The incidents were not preventable. 42984 3. Record review of Resident #3's PASRR, dated 7/8/22, showed: -He/she showed signs or symptoms of a major mental illness. -He/she had serious difficulty in adapting to typical changes in circumstances associated with work, school, family or social interactions. -He/she had difficulty making decisions in new situation and occasionally required supervision in decision making. -He/she had a history of being verbally and physically aggressive, withdrawn, depressed and expressing suicidal/homicidal ideation, including yelling, screaming, hitting, threats to burn down the house, tripping or pushing staff and property destruction. Record review of Resident #3's Admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Post-traumatic Stress Disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). -Unspecified Mood Disorder (any group of conditions of mental and behavioral health where a disturbance in the person's mood is the main underlying feature). -Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). -Mild Intellectual Disability (slowness in all areas of conceptual development and social and daily living skills). -Borderline Personality Disorder (a mood disorder characterized by unstable moods, behavior and relationships). -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #3's Care Plan, dated 10/16/22, showed: -He/she had behavioral issues where he/she initiated conflict with peers, then attempted to be the peacemaker and deny responsibility. -On 10/14/22, the resident was involved in verbal aggression with another peer over borrowing/selling/trading. The resident was removed from the situation, provided education on boundaries, reviewed facility policy on borrowing/selling/trading and provided therapeutic education. -The resident's needs were to be anticipated and met. -Medications should be administered to him/her as ordered, and monitored for side effects and effectiveness. -Caregivers were to provide opportunity for positive interaction and attention. -Staff were to assist him/her to develop more appropriate methods of coping and interacting with peers. -He/she was to be encouraged to express feelings appropriately. -The resident, family and caregivers were to be educated on successful coping and interaction strategies such as boundaries and relationship formation Record review of Resident #7's Admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Borderline personality disorder. -Restlessness and agitation (a sense of inner tension or discomfort that prevents a person from relaxing). -Major depressive disorder. Record review of Resident #7's Care Plan, dated 7/1/21, showed: -He/she had manifestations of behaviors related to his/her mental illness that might create disturbances that affected others. -He/she had episodes of agitation/anger/behavior resulting in the need for a Code Green to be called. -He/she had a past history of displaying socially inappropriate/disruptive behaviors. -CALM, (a comprehensive program designed to provide staff a practical skill set they can exercise when dealing with open, empty-handed force encounters, skills that encompass proper communication strategies, sound decision-making and lifesaving medical considerations), technique would be used as needed. -He/she would be educated on voicing concerns and feelings to assist in decreasing episodes of disturbing others. -On 10/14/22, the resident was involved in a verbal and physical altercation with his/her roommate regarding borrowing/selling/trading. The residents were immediately separated by staff. -The resident was educated on boundaries, no borrowing/selling/trading, and therapeutic communication. -He/she had a history of harming him/herself and suicidal thoughts. -He/she was to be monitored/documented/reported as needed for any risk for harm to self, suicidal plan, past attempts at suicide, risky actions, intentionally harming or trying to harm him/herself, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. -He/she was to be administered PRN, (as needed), medications as needed/ordered when non-pharmacological interventions were not effective. Record review of Resident #7's MDS, dated [DATE], showed he/she was cognitively intact. Record review of Resident #5's MDS, dated [DATE], showed he/she was cognitively intact. Record review of Resident #5's Admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Borderline personality disorder. -Bipolar disorder. -Generalized anxiety disorder, (persistent excessive worrying about everyday events or situations). Record review of Resident #5's Care Plan, dated 10/16/22, showed: -The resident had a potential to be physically aggressive toward staff and peers related to anger and poor impulse control. -He/she was to be monitored for any signs or symptoms of posing a danger to him/herself or others. -He/she was to receive medications as ordered. Record review of Resident #5's Progress Notes, dated 10/14/22 at 9:00 P.M., showed: -He/she was in a room visiting when Resident #7 and Resident #3 got into a misunderstanding. -He/she was told by staff to leave the room. -He/she stated he/she was part of the incident and refused to leave the room. -The administrator was called, and he/she asked the resident to leave the room. -The resident left the room and stood in the doorway. -He/she went back in the room when the other two residents got into an altercation, and then left again. -Staff asked the resident to stay out of the room. -He/she then went back to the doorway and exchanged verbal arguments with Resident #3. -Resident #4 told him/her to shut up. -He/she told Resident #4 to make her shut up. -Resident #4 ran toward this resident and became physically aggressive. -The Code Green team was already on the unit and separated the residents. -Both residents were assessed and no injuries were found. -The administrator was on the unit. Record review of Resident #5's Progress Notes, dated 10/15/22 at 11:00 A.M., showed the Administrator discussed with him/her triggers and coping skills, as well as talking with staff when he/she was feeling physically or verbally aggressive. Record review of Resident #4's PASRR Level II Evaluation, dated 4/1/20, showed: -His/her first hospitalization for mental health issues was at age 10. -He/she saw angels that would talk to him/her, flight of ideas, nightmares, acting out with arguments or emotional experiences, threatening to harm him/herself with a knife, throwing things, temper fits, breaking things, agitation, paranoia of people watching or following him/her, hallucinations, depression, crying, liability of moods. -He/she could refuse to talk or cooperate with treatments. -He/she had multiple hospitalization s for thoughts of self-harm, suicidal ideation, aggressive outbursts, and frequent contacts with law enforcement due to increased behaviors, property destruction and rapid mood cycling. -He/she had multiple incidents of self-harming behaviors resulting in superficial cutting. -He/she had behaviors including frequent/continuous yelling, impatient demanding, destroying property, verbally threatening, disturbing other residents, self injury, suspicion of others, talks of suicidal ideation, and suicide threats. Record review of Resident #4's Admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate). -Bipolar disorder. -Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). -Anxiety disorder. -Major depressive disorder. Record review of Resident #4's MDS, dated [DATE], showed he/she was cognitively intact and had behaviors. Record review of the Resident #4's Care Plan, dated 10/16/22, showed: -The resident had manifestations of behaviors related to his/her mental illness that could create disturbances that affect others, including verbal and physical aggression. -If he/she was disturbing others, encourage him/her to go to a more private area to voice concerns or feelings to assist in decreasing episodes of disturbing others. -Non-pharmacological interventions included listening to music and talking with his/her parents on the phone. -Staff should administer medications as needed/ordered when non-pharmacological interventions were non-effective. -Staff should give positive feedback for good behavior. -The resident had a psychosocial well-being problem related to anxiety, Aspberger's and recent admission to the facility. -When conflict arose, residents should be remove to a calm, safe environment and allowed to vent and share feelings. -The resident needed encouragement to identify triggers/stressors and positive coping skills. -On 10/14/22 the resident was involved in a verbal and alleged physical altercation with a peer and stated he/she reacted to commotion on the unit. The residents were separated by staff. He/she was placed on 1:1 observation until he/she went to sleep, and educated on boundaries, allowing staff to handle concerns, not inserting him/herself in other peers' situations, and therapeutic communication. Record review of the facility Investigation, dated 10/14/22, showed: -Resident #3, Resident #4, Resident #5 and Resident #7 were involved in the incident. -There was one witness which was Certified Nursing Assistant (CNA) B. -On 10/14/22 at approximately 8:30 A.M., Resident #3 was verbally aggressive and upset that his/her roommate, Resident #7, had thrown a banana at him/her. -The charge nurse was instructed to remove Resident #3 from the room. -The administrator received a call from the charge nurse that Resident #3 refused to change rooms. -When the administrator arrived at the facility, Resident #3 was in the dining room. -The administrator explained to Resident #3 that he/she had to change rooms, and he/she agreed to the change. -CNA A and Resident #3 returned to the room to retrieve his/her belongings from the closet and found Resident #7 pulling Resident #3's pictures from the wall. -The two residents began cursing at each other. -Resident #7 approached Resident # 3 and hit him/her, and Resident #3 hit back. -Staff immediately intervened and called a Code Green. -Resident #3 remained verbally and physically aggressive. -CALM technique was utilized. -During the Code Green, Resident #4 became upset at Resident #5, who was present. -Resident #4 struck Resident #5 on the top of the head and pulled his/her hair. -Staff immediately intervened and separated the residents. -Resident #4 walked away and pushed a med cart and attempted to throw a chair. -CALM was utilized to provide resident safety and protective oversight. -Resident #3 was placed on 1:1 observation for resident safety and protective oversight. -The provider for Long Term Psychiatric Medicine, (LTPS), was notified and orders received to give Resident #3 Thorazine 50 mg IM/PO PRN for agitation, which was administered by the charge nurse. -No injuries were noted. -Resident #4 was administered PRN Hydroxizine for agitation and placed on 1:1 observation until he/she went to sleep. -Guardians, physicians and the Kansas City Police Department were notified. -The staff used CALM hold techniques appropriately. -The behavior emergency required use of physical and chemical interventions. -Physical and chemical interventions were not used for staff convenience or as punishments. -After the event, discussion was held with all residents regarding what their triggers were and what coping skills could be used to avoid future events. -The conclusion of this investigation stated it was reasonable to believe this incident was not caused by abuse or neglect, was not preventable, and was not a previous ongoing problem that the facility could have foreseen due to prior history. Record review of Resident #7's Progress Notes, dated 10/14/22 at 9:00 P.M., showed: -Resident #3 reported to the charge nurse that this resident threw a banana at him/her. -When the charge nurse arrived at the room, there was a banana peel on the floor. -The resident denied throwing a banana on Resident #3. -The administrator was notified and determined the residents would have to have a room change. -Resident #3 followed the charge nurse back to the residents' room and the residents became verbally aggressive to one another. -Neither resident wanted to change rooms. -The administrator was notified again, and he/she spoke to both residents. -Resident #3 agreed to move, and in the process of collecting his/her belongings, Resident #7 mumbled something that upset Resident #3. -The two residents got into a physical altercation. -Staff attempted to separate staff. -A Code Green was called, and the code team responded promptly. -The residents were separated and assessments were done on both residents. -Neither resident had any injuries. Record review of Resident #4's Progress Notes, dated 10/14/22 at 9:15 P.M., showed: -He/she got upset by a peer's (Resident #5) verbal aggressiveness toward another peer (Resident #3). -He/she asked the peer to shut up, and the peer told him/her to make me to. -He/she then ran towards Resident #5 and became physically aggressive. -Staff was able to intervene and separated both residents. -He/she then walked toward the dining room and pushed the nurse's cart and threw a chair on the floor. -The Code Green team was present on the unit and intervened using the CALM technique. -The administrator was present on the unit, and redirected the resident. -No injuries were noted. -PRN medication was administered as ordered. -He/she was monitored for behaviors until he/she fell asleep. Record review of Resident #7's Progress Notes, dated 10/15/22 at 9:00 A.M., showed: -The administrator discussed triggers and coping skills with him/her, as well we the importance of speaking with staff when he/she had concerns. Record review of Resident #3's Progress Notes, dated 10/14/22, showed: -The resident stated to the charge nurse that his/her roommate, Resident #7, had thrown a banana at him/her. -He/she asked to speak to the administrator. -The administrator spoke to him/her and redirected him/her. -Per the administrator, there would be a room change for the residents. -Neither resident wanted a room change. -The residents got in an argument, staff intervened and the administrator was called again. -The administrator talked to both residents and the residents were separated. -He/she ran back in the room and attempted to be physically aggressive toward Resident #5, who had entered the room. -Staff stopped Resident #3 and called a Code Green (behavioral emergency). -The code team intervened promptly. -He/she was placed on 1:1 observation, but continued to be verbally aggressive. -The administrator arrived on the unit and talked to the resident, who agreed to change rooms. During an interview on 10/18/22 at 12:00 P.M., Resident #3 said: -He/she ordered Chinese food for Resident #7 and Resident #5 in his/her room. -He/she and Resident #7 were previously roommates. -He/she went to the dining room to get a banana and went back to his/her room. -He/she peeled the banana and found that it was bruised, so he/she asked Resident #7 if he/she wanted it. -Resident #7 did not answer, so he/she asked Resident #5 if he/she wanted the banana. -Resident #7 said, You always do that! and got angry and threw the banana, and it hit his/her leg. Resident #7 said he/she threw it on the floor. -He/she came out of the room to tell the staff. -He/she got really upset and started yelling and screaming. -The staff called the administrator. -The administrator said the residents had to make a room change. -He/she went to the old room to get his/her belongings and Resident #7 started tearing down his/her pictures, calling him/her names and cursing and shouting at him/her. -He/she was trying to get to Resident #7, so staff restrained him/her. -Resident #7 kicked him/her in the head and arm. -After that, he/she went to his/her new room. -He/she was placed on 1:1 observation. -He/she had previously had small arguments with Resident #7, but never had a fight with him/her. -CNA B, LPN A and LPN D were present. During an interview on 10/18/22 at 12:50 P.M., Resident #7 said: -He/she had a fight with Resident #3, who was his/her roommate. -He/she was best friends with Resident #5, who was in his/her room visiting him/her. -Resident #3 started saying rude things and shouting. -Resident #3 gave him/her a banana, which he/she threw on the floor. -Resident #3 got angry because he/she thought he/she was throwing the banana at him/her, but he/she was not. -Resident #3 charged at him/her and tried to hit him/her. -He/she lifted his/her leg and pushed Resident #3 away with his/her foot, to defend him/herself. -Resident #3 jumped toward him/her and hit him/her on the side of the leg. -Resident #5 and a CNA pulled Resident #3 away. -He/she hit Resident #3 one time on the head. -They got Resident #3 calmed down and took him/her out of the room. -The residents had never had any issues previously. -He/she had never previously tried to hit anyone. He/she was only defending him/herself. -He/she was not hurt and was getting along fine with his/her new roommate. During an interview on 10/18/22 at 1:12 P.M., Resident #4 said: -On 10/14/22 night, there was an argument between Resident #3 and Resident #5. -He/she shouted at them and told them to stop. -Resident #5 told him/her to stay out of it. -He/she went to the room and then was triggered when he/she saw Resident #5 hit at Resident #3's head. -The staff were dealing with Resident #3 and Resident #7. -He/she wanted to help and attacked Resident #5. -The staff were there when he/she attacked Resident #5 and separated them. -He/she got angry and threw a chair and the staff had to take him/her down because he/she hit a staff member. During an interview on 10/18/22 at 2:30 P.M., Resident #5 said: -He/she was in Resident #7's room visiting. -Resident #3 asked if anyone wanted a banana, and Resident #7 said he/she did. -Resident #3 then asked if he/she wanted it. -Resident #7 asked Resident #3 why he/she always does that. -Resident #3 shouted in Resident #7's face that he/she did not always do that, and slammed the banana down on the table. -Resident #7 picked up the banana and threw it on the floor. -Resident #3 thought the banana was thrown at him/her. -The staff came in the room and called the administrator, who told him/her to leave the room. -Resident #3 attacked Resident #7 on his/her bed. -Resident #7 had a bad leg and would not have attacked. -CNA B and other staff got in the middle of the residents to separate them. -He/sh

Based on interview and record review, the facility failed to prevent staff to resident abuse for three sampled residents who resided on a locked unit (Resident #1, #2, and #3) out of nine sampled residents, when the residents alleged facility staff were providing them with marijuana and/or crack cocaine, resulting in all three residents being transferred to the hospital for evaluation and testing positive for crack cocaine. The facility census was 114 residents. The Administrator was notified on 9/10/21 at 1:30 P.M. of an Immediate Jeopardy (IJ) which began on 8/16/21. The IJ was removed on 9/13/21 as confirmed by surveyor onsite verification. Review of the facility policy titled Abuse and Neglect, dated 8/26/21, showed: -Failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any resident when that failure presents either imminent danger to the health, safety, or welfare of a resident, or a substantial probability that death or physical injury would result. -Abuse includes deprivation of goods or services by staff that are necessary to attain or maintain physical, mental, and psychosocial well-being. -In these cases, staff has the knowledge and ability to provide care and services, but chose not to do it. -The facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Review of the facility policy titled Drug and Alcohol Testing for Employees, dated 8/27/21, showed: -The use, consumption, possession, transportation, sale or distribution of unlawful or unauthorized drugs, inhalants, alcohol, or abuse of prescribed drugs or alcohol by anyone while on company property, on company time or in connection with company business, will be cause for immediate discharge. -Illegal or controlled substances (other than a valid prescription) will be confiscated and the appropriate law enforcement agency notified. Review of Medscape Drug Interaction Checker showed the following adverse interactions with medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Cocaine (a tropane alkaloid and stimulant drug obtained primarily from the leaves of two coca species and is most commonly used as a recreational drug and euphoriant) and Sertaline (an antidepressant) will increase serotonin levels (a key hormone that stabilizes mood). Recommended to monitor therapy closely. -Cocaine and [MEDICATION(S)] (a cardiac medication to treat high blood pressure) will increase the risk of [CONDITION(S)] (chest pain caused by reduced blood flow to the heart). [MEDICATION(S)] will increase the effect of the cocaine. -Cocaine and [MEDICATION(S)] (an antidepressant) will increase serotonin levels. Recommended to monitor therapy closely. -Marijuana (THC - Tetrahydrocannabinol is the main psychoactive compound in cannabis that produces the high sensation) and [MEDICATION(S)] (an antidepressant) will increase sedation. -Marijuana and [MEDICATION(S)] will increase the level or effect of [MEDICATION(S)]. -Marijuana and [MEDICATION(S)] (an antipsychotic) will increase sedation. -Marijuana and [MEDICATION(S)] (an antipsychotic) will increase sedation. Marijuana will increase the level or effect of [MEDICATION(S)]. -Marijuana and [MEDICATION(S)] (a sedative used to treat panic disorders and anxiety) will increase sedation. -Marijuana and [MEDICATION(S)] (an antihistamine) will increase sedation. 1. Review of Resident #1's Level One Nursing Facility Pre-Admission Screening for Mental Illness/Mental [CONDITION(S)] or Related Conditions form (PASSAR), dated 12/10/20, showed he/she: -Had signs or symptoms of major mental disorder. -Had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's facility face sheet showed he/she admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] --[CONDITION(S)] (delusions and hallucinations that blur the line between what is real and what is not making it difficult for the person to lead a typical life). --Chronic Paranoia (the irrational and persistent feeling that the person is the subject of persistent, intrusive attention by others). --Poly Substance Abuse (the consumption of one or more illicit substances over a defined period or simultaneously). --Depression (a constant feeling of sadness and loss of interest which stops a person from doing normal activities). --Hypertension (high blood pressure). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for assessment and care planning), dated 12/17/20, showed: -Brief Interview of Mental Status (BIMS ) score of 14, resident was cognitively intact. -Resident required no support from staff for Activities of Daily Living (ADL's - bathing, grooming, dressing, transfers, walking, eating, toileting). -No behavioral symptoms recorded during this assessment period. Review of the resident's care plan, dated 6/2/21, showed he/she: -Had episodes of agitation/anger/behavior. -Was to ensure protective oversight of the resident through review date. Review of the resident's physician orders, dated 8/15/21, showed: -[MEDICATION(S)] 50 mg (milligrams) tablet, take one daily by mouth (for major depressive disorder). -[MEDICATION(S)] 25 mg tablet take one half tablet by mouth twice daily (for hypertension). -[MEDICATION(S)] 20 mg tablet take one tablet by mouth at bedtime (for paranoid [CONDITION(S)]). -[MEDICATION(S)] 100 mg/milliliter(ml) inject two ml intramuscularly once monthly (for paranoid [CONDITION(S)]). Review of the resident's Hospital Medical Records, dated 8/16/21, showed: -He/she was admitted to the hospital on 8/16/21 to inpatient psychiatry for ongoing medication stabilization and management. -Patient presented to the Emergency Department (ED) from the facility health care center with a staff member for evaluation of possible cocaine ingestion. -Patient admitted to THC use. -Patient stated he/she did smoke THC and did not feel right and was told that the THC was laced with cocaine. -Patient stated that he/she was suicidal. -Chief complaint: [CONDITION(S)] disorder and suicidal ideation. -The patient was despondent (in low spirits from loss of hope or courage) and flat. -The patient had anhedonia (inability to feel pleasure). -Lacks motivation and had apathy. -Motor activity was psychomotor retarded (a central feature of depression which includes motor and cognitive impairments). -Ongoing suicidal ideation's without any intent or plan. -Patient reported that group home was an unsafe environment. -Patient listed several things including that staff members had been providing residents with marijuana and cocaine. -By day of discharge patient was no longer endorsing any suicidal homicidal ideation's and reported no suicidal ideation's in the last several days. -Facility administered Urine Cocaine screen was positive on 8/15/21. -Facility administered Urine Marijuana screen was positive on 8/15/21. -Discharge from the hospital to the facility on [DATE]. During an interview on 8/16/21 at 11:02 A.M., the hospital Registered Nurse (RN) said: -The resident was brought to the ED when the facility found the resident with a substance thought to be illicit drugs. -The resident tested positive for THC and Cocaine. -The resident resided on a locked unit at the facility and did not have access to leave the facility in order to obtain illegal drugs on his/her own. -The resident would remain in the ED waiting on bed for admission to in-patient psychiatric for thoughts of harming himself/herself. During an interview on 8/16/21 at 11:06 A.M., the resident said: -He/she was given a joint called a [NAME] marijuana laced with crack (a derivative of cocaine) on Friday or Saturday night when the facility staff let him/her smoke it with them. -Resident #1, #2, #3 and #4 participated. -Resident #2 bought the crack/cocaine directly from Staff A. -Staff B and Staff C had brought the marijuana and sold it to the residents. -He/she received the money from his/her resident banking to pay for the drugs. -He/she reported that he/she does not feel safe living there. During an interview on 8/19/21 at 10:30 A.M., the resident's Guardian A said: -He/she was aware that the resident had received illicit drugs, per a phone call from the facility. -He/she expected the resident to be free of illicit drugs and live in a safe and secure environment. -The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -The facility certainly should have known this resident information from the care plan meetings that the guardian had attended regarding the resident. During an interview on 8/25/21 at 11:45 A.M., the resident said: -He/she was able to get crack cocaine and pot from the staff. -He/she usually got his/her drugs from Resident #3. -Resident #3 gets it from Staff A, B and C. -He/she saw Staff A dealing the drugs to Resident #3. -They all sell drugs to the residents. -It was not regular pot (marijuana) it was laced with cocaine and it was known as [NAME]. -It made him/her sweat, dizzy, and nauseated. -They kept him/her in the hospital, because he/she told them he/she was suicidal. 2. Review of Resident 2's PASSAR, dated 02/11/14, showed: -He/she had signs or symptoms of major mental disorder. -[CONDITION(S)] Disorder (a combination of symptoms of [CONDITION(S)] and mood disorder, such as depression or [CONDITION(S)] disorder). -Polysubstance abuse. -[CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). -Disorganized [CONDITION(S)] (one of five sub types of [CONDITION(S)]). Review of the resident's facility face sheet showed he/she admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] --[CONDITION(S)]. --Personality Disorder (maladaptive patterns of thought, behavior, cognition and inner experience). --Inhalant Abuse (broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication). Review of the resident's annual MDS assessment, dated 7/23/21, showed: -BIMS score of 15, resident is cognitively intact. -Resident required no support from staff for ADL's. -No behavioral symptoms recorded during this assessment period. Review of the resident's care plan, dated 7/23/21, showed: -Adjustment related to change in environment, [CONDITION(S)] disorder, alcohol abuse, and substance abuse. -Provide positive feedback for making decisions and participating in self care. -Episode of agitation/anger/behavior related to [CONDITION(S)] disorder and anxiety. -Ensure protective oversight for the resident. Review of resident's physician orders, dated 8/2/21, showed: -[MEDICATION(S)] ER 6 mg tablet, take one tablet by mouth every morning (for [CONDITION(S)]). -[MEDICATION(S)] one mg tablet by mouth three times a day (Anxiety disorder). During an interview with on 8/16/21 at 2:37 P.M., the resident said: -He/she got pretty messed up and does not remember much. -It was the three of us, Resident #1, #3 and him/her. -He/she talked about an Angel bringing them the antidote. -It made him/her feel like him/herself again. During an interview on 8/20/21 at 9:45 A.M., the resident's Guardian B said: -He/she was aware of the resident receiving illicit drugs when the facility called to notify him/her. -The resident was drug seeking before admission to the facility and the facility was aware of this. -This was the resident's thing, illicit drugs. -The only visitors allowed to see the resident were his/her parents. -The only time the resident was allowed out of the facility on visits, was to his/her parents. -There can't be any other way the resident received illicit drugs except by the facility staff providing to the resident. During an interview on 8/25/21 at 12:00 P.M., the resident said: -If a resident wanted something they were going to get it. -He/she got the drugs from another resident. -He/she would not say who, as he/she was not a rat. -It was more a spiritual type thing. He/she takes drugs for his/her mortal experience, and cocaine is more of a godly entity. 3. Review of Resident 3's PASSAR, dated 9/17/18, showed: -Psychiatric Assessment showed [CONDITION(S)] disorder - [CONDITION(S)] type. -Had met the federal definition of serious mental illness, but does not require specialized services. Review of the resident's facility face sheet showed he/she admitted to the facility 6/14/19 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] --[CONDITION(S)] Disorder. --Chronic Airway Disease (a group of lung diseases that block airflow and make it difficult to breathe). --Hypertension. --Anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that is strong enough to interfere with one's daily activities). --[CONDITION(S)] Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's care plan, dated 5/25/21, showed: -Impulse control disorder and history of illegal substance, but denied when asked. -Will exhibit acceptable behavior as evidenced by no use of alcohol through review date. -Discuss with resident/guardian any issues which may lead to substance abuse/misuse as needed. -Explore alternative methods of coping. Review of the resident's annual MDS assessment, dated 5/28/21, showed: -BIMS score of 15, resident is cognitively intact. -Resident required no support from staff for ADL's. -No behavioral symptoms occurred during the assessment period. Record review of the resident's physician orders, dated 8/2/21, showed: -[MEDICATION(S)] 5 mg tablet take one by mouth every morning. -[MEDICATION(S)] 225 mg take one tablet by mouth once daily (anxiety disorder). -[MEDICATION(S)] 300 mg tablet take one tablet by mouth twice daily before meals ([CONDITION(S)] disorder). During an interview on 8/16/21 at 2:22 P.M., the resident said: -He/she received crack cocaine and smoked it on Saturday, he/she liked it and wanted some more from Staff A. -It had cost twenty dollars ($20.00). -The drugs made him/her feel amped up/good. -Staff C had brought weed every so often, if he/she asked, Staff C would bring it the next day, a twenty dollar bag, which is enough to get three joints (marijuana cigarettes). -Staff C last brought the weed on Thursday. -On Sunday, Staff A had another resident come and get the resident and he/she came to Staff A and Staff A handed him/her the drugs in the hallway about 4:00 or 4:30 P.M. During an interview on 8/20/21 at 11:30 A.M., the resident's Guardian C said: -He/she was aware that the resident had received illicit drugs, per a phone call from the facility. -Had to have received the drugs from staff, as not a lot of outside folks, if any, visit the resident. -Knows that it is hard, but facility had to make sure that staff are not giving the resident illicit drugs. During an interview on 8/25/21 at 12:20 P.M., the resident said: -He/she had gotten crack and pot from two staff members. -The staff told him/her crack would give him/her heart trouble. -He/she had gotten crack from Staff A and Staff C, and marijuana from Staff B. 4. Review of Resident 4's PASSAR, dated 1/10/06, showed: -[CONDITION(S)] Disorder. -Depression. -[CONDITION(S)]. Review of the resident's facility face sheet showed he/she admitted to the facility 9/8/16 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] --History of sexually aggressive behavior. --Hypertension. --[CONDITION(S)] Disorder. --[CONDITION(S)] Disorder. --Anxiety Disorder. --Major Depression (a mental disorder characterized by a persistently depressed mood and long term loss of pleasure or interest in life). Review of the resident's care plan, dated 10/26/20, showed: -Had behavioral problems that started at age [AGE] years. -History of suicidal ideation's. -History of auditory and visual hallucinations and voices telling him/her to harm self. -Non compliant with medications and cares. -Observe and report any pertinent changes noted with mood/behavior and intervene as deemed necessary. Review of the resident's annual MDS assessment, dated 7/19/21, showed: -BIMS score of 15, resident is cognitively intact. -Resident required no support from staff for ADL's. -No behavioral symptoms occurred during the assessment period. During an interview on 8/16/21 at 3:00 P.M., the resident said: -Two to three residents here were smoking crack. -Staff B brought us weed, three to four days ago. -He/she didn't smoke it, others did, they tried to give it to me. During an interview on 8/20/21 at 12:02 P.M., the resident's Guardian D said: -The resident did not really have a history of drug seeking behavior. -The biggest problem with the resident was that he/she was a follower. -He/she would expect the facility to provide oversight in preventing illicit drugs from entering the facility. During an interview on 8/25/21 at 12:30 P.M., the resident said: -He/she only smoked pot. -It was tempting, it helped calm his/her nerves. 5. Record review of the facility investigation titled RN Investigation Report, dated 8/15/21 showed: -Persons involved in the Incident: --Resident #1, #2, #3 and Staff A, B and C. -Witnesses to the incident included Resident #4. -Statements were received from witnesses. -Statements were received from affected persons. -Suspension of Staff A, B and C. -On 8/15/21 during evening medication pass, Certified Medication Technician (CMT) entered resident room with the intention of administering Resident #3's medication, instead observed the resident with white rock like substance and plastic card attempting to break substance into smaller pieces. -Residents #1 and #2 were also present in the room and attempted to warn Resident #3 of the CMT's presence. -CMT immediately confiscated the substance and brought it to the attention of the DON. -Administrator was notified and made aware, immediate investigation initiated. -Residents #1 and #2 both concur that drugs were provided to them by Staff A (the hall monitor) and shared that Staff B and C had recently and in the past supplied them with marijuana. -Neither resident could provide specific dates/times. -Facility drug test administered with positive results for THC and Cocaine present for Residents #1, #2 and #3. -Residents were placed on immediate one to one for oversight. -Guardians notified and made aware. -Physician notified and order received to send residents out to emergency room for evaluation and treatment. -All suspected staff placed on suspension pending investigation outcomes. -Resident #3 was escorted to the DON office and assessed by a charge nurse with the following findings: --Alert and Oriented. --Remained calm and cooperative with staff. --Stated he/she received the crack from Staff A, the hall monitor. --Was sent to the hospital for evaluation and treatment as indicated. --Reviewed with the resident facility rules and drug usage policy. --Resident verbalized understanding. --Resident returned from the ED with positive confirmation of illegal drug use, no new orders. --Resident remained in room remainder of shift. --Placed on continuous observation for oversight. -Resident #2 was escorted to the DON office and assessed by a charge nurse with the following findings: --Alert and oriented. --Resident #2 denied any first hand knowledge of anything, stated he/she was just in the room watching television. --Resident #2 was sent to the ED for evaluation and treatment if indicated. --Resident returned to the facility with a positive confirmation of illegal drug use, no new orders. --Placed on continuous observation for protective oversight. --Reviewed facility rules and drug usage policy. --Resident verbalized understanding. --Remained in room remainder of shift. -Resident #1 was escorted to DON office and assessed by charge nurse with the following findings: --Alert and oriented. --Resident admitted to smoking illegal substances and that he/she believed the drugs came from Staff A (the hall monitor). --Resident was sent to the ED for evaluation and treatment if indicated. --He/she was admitted to the the Psychiatric unit of the hospital for suicidal ideation's. ---Resident #1 Serology Screen, dated 8/24/21, from the hospital showed: ----Positive for Cocaine and Positive for Marijuana. ---Resident #2 Serology Screen, dated 8/15/21, from the hospital showed: ----Positive for Cocaine and Positive for Marijuana. ---Resident #3 Serology Screen, dated 8/15/21, from the hospital showed: ----Positive for Cocaine and Positive for Marijuana. -Staff A, B and C were immediately removed from resident areas and suspended pending investigation outcomes. Record review of the local Police Department report, dated 8/15/21 at 7:28 P.M., showed: -Unit was dispatched to the facility for a suspicious drug activity call. -Upon arrival police contacted the Administrator of the facility. -Administrator stated that staff observed Resident #3 cutting up a white rock like substance on the table in his/her room. -Staff confiscated the white rock like substance and placed it in a container. -Staff asked Resident #3 what the substance was and he/she told staff it was Crack. -Staff had asked Resident #3 where he/she got it and Resident #3 told staff he/she got it from Staff A. -Administrator stated that Resident #3 was taken the ED for evaluation and treatment. -Administrator stated Resident #3 had tested positive for cocaine in his/her system. -Administrator stated the facility contacted the police to recover the substance. -Staff A, B and C were no longer at the location, so police were unable to get statements. -Investigation revealed the above statements. -Observed a white rock like substance in the plastic cup staff had put it in. -On 8/15/21 at 10:25 P.M., a presumptive test on the recovered substance showed the presence of cocaine. -The cocaine weighed in at 0.21 grams. During an interview on 8/19/21 at 7:00 P.M., Physician A said: -He/she was the physician for Resident #3 and Resident #4 and partnered with the physician for Resident #1 and Resident #2. -He/she was on call the weekend of the incident and was only notified of the illicit drug use for Resident #3. -The facility did not notify him/her of the illicit drug use with Resident #1, #2 and #3. -Medications interacting with cocaine, he/she guessed that if a resident had a cardiac condition, this would be a concern, as it would raise the heart rate. During an interview on 8/24/21 at 1:20 P.M., RN D said: -It had been a rumor from the residents that the staff were bringing in drugs to the residents, however, it was just a rumor and no names had been named. -Also, families and friends bring in items to the residents, such as carry out food and groceries. -We try and search all items coming into the facility, but it is of course difficult with the food drop offs, we don't like digging through the food. -We are being more diligent now however, with the searches of these items. -He/she had no knowledge of any staff member providing the residents with illicit drugs. During an interview on 8/24/21 at 2:00 P.M., Staff E said: -He/she was aware that one of the residents said that a staff member brought him/her illicit drugs a few Sundays ago. -The resident didn't say a name. -He/she had no idea who might have done that, but if he/she heard, he/she would report it to the Administrator. During an interview on 8/24/21 at 2:10 P.M., the Nurse Practitioner B, with the facility Psychiatric group said: -Certainly any resident who had depression and who took an antidepressant, could be affected by THC as this was a depressant. -The drug could interfere with efficacy of an antidepressant. -Cocaine used concurrent with antipyretics, could potentate side effects with [CONDITION(S)]. -Also anyone who was taking cardiac medications and cocaine, was at risk as cocaine was a stimulant. -He/she would expect the facility to provide protective oversight regarding the residents receiving any illicit drugs. -Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Cocaine and any cardiac medications would place the resident at risk related to cocaine being a stimulant, increased heart rate. -Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Sertaline being an antidepressant, could have decreased efficacy in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #3 does have a physicians order for Acetaminophen as need for fever/pain. Acetaminophen is an antipyretic, which could interact with cocaine and potentate side effects. During an interview on 8/25/21 at 11:10 A.M., the Administrator said: -The investigation was completed. -Staff A, B and C would not answer his/her phone calls. -Staff A, B and C have been terminated. During an interview on 8/25/21 at 11:30 A.M., the DON said: -According to the residents, this was the first time they were able to get cocaine from Staff A. -Resident interviews revealed Staff A would speak of his/her personal life which gave them a clue he/she could get cocaine. -All employees have a drug test upon hire. -Staff A had been here about one and a half months and tested negative for drugs upon hire. -He/she agreed the residents should not be receiving drugs from the staff or anyone. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 540 & MO 551

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from sexual abuse when Licensed Practical Nurse (LPN) A came onto the resident's unit and engaged in a sexual act with the resident. The facility failed to further protect Resident #1 when LPN A was allowed to continue his/her shift after the abuse allegation was made. Additionally, the facility failed to protect Resident #1 when, during the investigative process, the staff department heads were interviewing Resident #1 and placed him/her in a two-man hold (restraining the resident) when he/she wanted to leave the room and not watch the video any longer resulting in bruising on the resident's wrists and arms. The facility census was 114 residents. The Administrator was notified on 5/21/20 at 3:24 P.M., of the Immediate Jeopardy (IJ) which began on 5/16/20. The IJ was removed on 5/21/20, as confirmed by surveyor onsite verification. Record review of the facility Abuse, Neglect, Grievance Policy and Procedure, dated 11/28/16 and revised on 8/28/18, showed: -It is the policy of the facility that every resident has the right to be free from any physical or chemical restraints. -Mistreatment, neglect or abuse of residents is prohibited by the facility. -This facility will not employ individuals who have been convicted of abusing, neglecting or mistreating individuals. -The facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents, consultants or any other individuals. -Sexual Abuse - Causing a resident to touch an employee for sexual purposes. -Mental Abuse includes either verbal or nonverbal conduct which causes, or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. -During orientation of new employees the facility teaches sensitivity to resident rights, resident's needs and what constitutes physical, sexual, verbal and mental abuse. -On a periodic basis, staff will receive a review of the above topics. -Employees are required to immediately report any occurrences of potential neglect, abuse, sexual assault, misappropriation of property and injury of unknown source to a supervisor or the administrator. -The abuse, neglect, exploitation or sexual assault are reported immediately, but no later than two hours after the allegation is made to other officials including State Survey Agency in accordance with State law through established procedures. -The facility shall immediately call 911 to involve the police department when there is abuse. -Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by the administrator. -Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Record review of the facility Behavioral Emergency Policy, dated 4/6/17, showed: -Provide safe treatment and humane care of the residents in a behavioral crisis. -Ensure that the resident is not being coerced, punished or disciplined for staff convenience. -There are only two reasons that staff will utilize approved Crisis and Aggression, Limitation and Management (CALM- best practice principles in de-escalation and physical intervention. Physical intervention or physical restraint can only be used where all other intervention strategies have been ineffective and there is immediate danger of physical harm to individuals and there is no danger, where doing so, of placing that staff member in immediate danger of physical harm). -Approved CALM hold techniques are never utilized for punitive reasons, discipline or for staff convenience. -Each resident who has an increased potential for aggressive behavior toward self or others, or shows a history of harm to self or others will have an assessment completed upon admission or prior to the use of approved supportive CALM take down techniques. -A resident who displays or is assessed as having physical/medical limitations and is assessed to be clinically inappropriate to use approved CALM supportive take down techniques will be placed on the Behavior Management/Care List with the acronym STOP (Supportive Techniques Oversight Protection). -Other supportive methods to control behaviors will be outlined in the plan of care individually for those residents in a behavior emergency crisis. -After every utilized CALM hold technique, the director of nursing (DON)/designee will complete a Registered Nurse Investigation of the occurrences regarding the resident's behavior and staff responses. -The physician and legal guardian must be notified and this should be a part of the individualized plan of care. -The licensed nurse will document the behavioral emergency (define behavior, interventions, reaction/response, plan and evaluation) in the resident's medical record. -Any resident who requires approved CALM hold techniques must have a complete skin assessment with vital signs monitored for 72 hours. -The physician and legal guardian will be notified of assessment findings and other concerns regarding the resident's behavior emergency crisis. 1. Record review of Resident #1's Face Sheet, dated 5/11/19, showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Major [MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Anxiety Disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). -Impulse Disorder (a person has trouble controlling emotions or behaviors). -Post-Traumatic Stress Disorder ([MEDICAL CONDITION] - a disorder in which a person has difficulty recovering after experiencing or witnessing a shocking, scary, or dangerous event). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 12/23/19, showed: -The resident had a Brief Interview for Mental Status (BIMS - is used to assess cognitive status in residents) score of 15 out of 15 (indicating the resident was cognitively intact). Record review of the resident's Care Plan, dated 12/23/19, showed: -Behavior: Risk for episodes of agitation/anger/behavior resulting in the need for Code Green (used to help get more staff on the unit to help with behaviors) to be called and CALM techniques will be used as needed. -Ascertain if the resident is on the STOP Program. -Remove from public area when behavior is disruptive and unacceptable as needed. -Administer medication as prescribed and monitor effectiveness. -Allow the resident to verbalize and ventilate feelings. -Provide 1 to 1 attention to resident as needed. -Redirect as able/needed to encourage positive behavior choices. -Identify causes for the behavior and reduce factors that may provoke the resident. -Discuss options for appropriate channeling of anger. -Assist in selection of appropriate coping mechanisms. -Provide reality orientation, remaining calm, encouraging, and non-judgmental. -If current interaction is not de-escalating the situation or the resident is becoming more upset, allow staff member with best rapport with the resident to intervene and attempt to resolve and calm the resident. -If experiencing hallucinations, allow the resident to express his/her thoughts/fears while maintaining eye contact and removing unnecessary external stimuli. -Attempt to ascertain what the resident would need/accept to calm down and provide if able. -If resident smokes, allow him/her to smoke with supervision to assist with de-escalation. -After situation resolves, place on 1 to 1 for protective oversight. -Notify physician, administrator, DON, family/guardian of need for CALM hold and results. -Send out to the hospital for evaluation/medication adjustment if ordered. Record review of the resident's Physician order [REDACTED]. -May have Psychiatrist and Psychologist consult as needed. -May have Behavioral Therapist consult as needed. 2. Record review of Resident #2's Face Sheet, dated 2/21/20, showed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] Disorder. -Attention-Deficit [MEDICAL CONDITION] Disorder (ADHD, a developmental disorder typically characterized by a persistent pattern of inattention and/or [MEDICAL CONDITION] - a physical state in which a person is abnormally and easily excitable or exuberant, as well as forgetfulness, loss of control or impulsiveness, and distractibility). -[MEDICAL CONDITION] (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Mood (affective) Disorder (are illnesses that affect the way you think and feel and can be dramatic or extreme changes of mood). Record review of the resident's annual MDS, dated [DATE], showed: -The resident had a BIMS score of 15 out of 15 (indicating the resident was cognitively intact). 3. Record review of Resident #6's Face Sheet dated 12/25/19, showed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -Major [MEDICAL CONDITION]. -Obsessive-Compulsive Disorder (OCD - is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions). -Anxiety Disorder. -Auditory hallucinations (false perceptions of sound). Record review of the resident's quarterly MDS, dated [DATE], showed: -The resident had a BIMS score of 15 out of 15 (indicating the resident was cognitively intact). Record review of Resident #1's Nurse's Note, dated 5/16/20 7:00 P.M. to 7:00 A.M., showed: -At approximately 10:50 P.M., Resident #1 came to the Nurse's station and told LPN B to get his/her phone and go to Resident #1's room. -Resident made sexual allegations toward LPN A. -Resident #1 stated that they had oral sex and had been witnessed by another resident. -No bruising, bleeding or pain noted at this time. -Administrator notified. Record review of Resident #1's Nurse's Note, dated 5/17/20 at 7:00 A.M., showed: -Resident #1 was monitored by LPN B, all through the shift. -Resident #1 rested well, no concerns voiced during the rest of the shift. -No bruising, pain or genitalia bleeding noted. -Resident #1 went to bed at approximately 12:45 A.M. -Resident #1's safety made priority with frequent safety checks. Record review of Resident #1's Nurse's Note, dated 5/17/20 7:00 A.M. to 7:00 P.M., showed: -Reported to this charge nurse, LPN C, allegations continue from last night. -Direct supervisor and police were notified of the incident. -Police report was filed and Resident #1 was sent to the hospital for evaluation and treatment at 4:30 P.M. -Guardian notified as well as all responsible parties. -Resident remains in the hospital for further testing while results pending. Record review of the Registered Nurse (RN) Investigation Report, dated 5/16/20 at 11:05 P.M., showed: -Resident #1 reported to charge nurse, LPN B, that he/she was allegedly sexually assaulted by LPN A in his/her room. -Resident #1 was helping LPN A with his/her personal laptop when LPN A reached out and slid his/her hand under Resident #1's night clothes and caressed his/her body. -Resident #1 smacked LPN A's hand away and told him/her no. -Resident #1 continued to work on LPN A's laptop when Resident #2 entered Resident #1's room and asked LPN A to go to the store for him/her. -LPN A left Resident #1's room and went to the store for Resident #2. -LPN A returned from the store and entered Resident #1's room and watched Resident #1 work on the laptop. -LPN A was standing on the left side with his/her back to the door obstructing his/her view of the hallway. -Resident #1 states LPN A unzipped his/her pants and produced his/her genitalia and instructed Resident #1 to give me head (oral sex). -Resident #1 stated he/she told LPN A no, but LPN A then put the resident's head down and forcefully opened his/her jaw. -He/She opened his/her mouth, because he/she did not want any bruising, that is when LPN A put his/her genitalia in Resident #1's mouth. -LPN A started to ejaculate in the resident's mouth then LPN A said Oh[***]and went to the bathroom to finish in the toilet. -He/She still had seminal fluid in his/her mouth and swallowed it. -LPN A then left Resident #1's room and the unit. -Resident #1 stated he/she felt sick to his/her stomach, but did not puke. -Resident #1 went to LPN B and asked him/her to come to his/her room, because LPN A was just in there and put his/her thing in my mouth and that is his/her sperm in the toilet. -Resident #2 witnessed it and told CNA A about what he/she had just seen. -Resident #1 stated that LPN A has been fingering him/her when he/she is awake and asleep. -He/She has not told anyone due to [MEDICAL CONDITION]. -He/She does not know what gave him/her the courage to report the behavior now. -LPN B assessed Resident #1 for bruising, none was found on the face or body and no bleeding from the genitalia area. -The investigation began. -The administrator, Assistant Director of Nursing (ADON), the regional office, and guardian were notified of the alleged sexual abuse. -The police were notified on 5/17/20 at 9:00 A.M. -Police were on site 5/17/20 at 4:30 P.M. -Resident #1 was sent to the hospital on [DATE] at 4:30 P.M. -Call received from the hospital at 9:00 P.M., stating Resident #1 had evidence of sexual abuse. -Resident #1 returned back to the facility on [DATE] at 1:00 A.M. Record review of Resident #1's Police Report, dated 5/17/20 at 3:13 P.M., showed: -The police were called to the facility in regard to a sexual assault. -Upon arrival LPN C was contacted by the police officer. -LPN C was informed by LPN B that Resident #1 was sexually assaulted by LPN A. -LPN C advised he/she was told by Resident #1 that LPN A had fingered him/her and forced him/her to perform oral sex on him/her on 5/16/20. -The officer contacted Resident #1 who stated the following: --On 5/16/20 around 10:30 P.M. or 11:00 P.M., LPN A brought a laptop to his/her room for him/her to download MP3 music off of. --LPN A stated he/she wanted Resident #1 to download an anti-virus software on his/her laptop in exchange for the music, in which Resident #1 agreed to. --LPN A was sitting down at a desk while Resident #1 stood next to LPN A slightly leaning over LPN A to download the software. --While Resident #1 was leaning over, LPN A reached behind Resident #1 and up through the bottom of his/her clothing, placing his/her fingers inside his/her genitalia. --Resident #1 told LPN A to stop, in which he/she did. --LPN A then stood up and stated he/she was going to the store to get something for another resident. --LPN A returned approximately five minutes later to Resident #1's room. --LPN A then stood in front of Resident #1, who was sitting at his/her desk, and unzipped his/her pants. --At this time, LPN A told Resident #1 to give him/her a hand job in which he/she stated no. --LPN A then grabbed Resident #1 by the head with both of his/her hands and pushed his/her head onto his/her genitalia forcing him/her to perform oral sex on him/her for approximately 30 seconds. --During this time, Resident #1 stated LPN A ejaculated in his/her mouth, which he/she then swallowed. --Resident #1 stated LPN A then went to the restroom. --Before leaving the room, LPN A stated to Resident #1 to be quiet and stay out of the hallway because it will make him/her look guilty, and to not tell anyone. --LPN A then pushed Resident #1 onto the bed and exited the room. --Resident #1 advised this has been going on for approximately three weeks, but has been too scared to say anything. --Resident #1 stated there has been nights where he/she has woke up during the night with LPN A over him/her and his/her legs spread apart. --LPN C advised LPN A is not currently working at the facility while the facility conducts their own investigation of the incident. --Resident #1 advised that Resident #2 may have witnessed the incident. --Resident #1 and his/her guardian agreed to get a Sexual Assault Nurse Examiner (SANE - a forensic nurse conducts assault evidentiary exams for sexual assault, rape and abuse) exam completed. --The facility agreed to save the camera footage of the hallways for the date and time of the incident. Record review of Resident #1's Hospital Report, dated 5/17/20, showed: -The resident was admitted to the emergency room at 5:38 P.M. -The resident presents to the emergency department for a SANE exam. -The resident has had a staff member that has been forcing him/her to perform oral sex and stated the staff member had been sticking his/her fingers in his/her genitalia. -He/She is not his/her own guardian. -The resident will be discharged back to the facility. Record review of Resident #1's Nurse's Note, dated 5/17/20 7:00 P.M. to 7:00 A.M., showed: -At approximately 9:00 P.M., the hospital notified the facility that Resident #1 was not coming back to the facility. -Resident #1 wanted to get placement in a sister facility. -The hospital nurse notified LPN B that there was evidence of sexual abuse and it was not safe for Resident #1 to return to the facility. -The hospital nurse was referred to the administrator. -At 11:15 P.M., hospital nurse called LPN B and stated that Resident #1 was able to come back to the facility if the alleged nurse, LPN A, was not working. -Resident #1 was safe to come back to the facility, administrator was notified. Record review of Resident #1's Nurse's Note, dated 5/18/20 at 1:00 A.M., showed: -The resident returned back to the facility by ambulance. -Resident in pleasant mood. -New order per hospital physician standard STD (an infection transmitted through sexual contact, caused by bacteria, viruses, or parasites) cultures within two weeks. -Follow up with facility physician. -Administrator and DON notified of the resident's return to the facility. -At 6:30 A.M., resident rested well during night, no acute distress noted, and no concerns voiced during shift. -No time given, resident demonstrated brief violent outburst upon returning from unit meeting with administrative staff. -Resident easily redirected and medication compliant without any further behaviors or concerns. -Resident noted to be tearful while lying in bed and did not come out of his/her room throughout the evening. -Resident able to validate feelings and advises this charge nurse, he/she needs to make a phone call to gain permission to smoke on 1 to 1 supervision. -He/She was tearful because of being back at the facility and the sexual abuse. He/She did not feel safe staying at the facility. -Request was denied. Will continue on 1 to 1 monitoring. Record review of Resident #1's Resident Statement, dated 5/16/20, showed: -To whom it may concern LPN A had been fingering him/her when he/she is asleep. LPN A had also been making him/her give LPN A oral sex for everything that LPN A buys him/her. Record review of LPN A's Employee Written Statement, dated 5/19/20, showed: -On Friday 5/15/20, Resident #1 asked him/her to help get an ear piece to a resident on two south and to ask that resident if Resident #1 could get the computer so Resident #1 could download some music. -The computer was not usable because the computer had [MEDICAL CONDITION]. -LPN A promised Resident #1 to help him/her with one of his/her computers from home the next day. -On Saturday 5/16/20, LPN A brought the computer and notified LPN B that he/she would be in Resident #1's room to work on the computer. -LPN A was in Resident #1's room for about three minutes, while Resident #1 was in and out of his/her room constantly. -When this was done, LPN A went to the store for some energy drinks for Resident #2. -LPN A came back from the store and gave Resident #2 the energy drinks that he/she asked LPN A to go and buy for him/her and then took an ice cream bar for Resident #1. -By then Resident #1 was working on the computer, LPN A stepped in to see if Resident #1 was downloading on the computer. -While LPN A was standing with his/her back to the door, Resident #2 walked into Resident #1's room with some candy and stood for a while looking as Resident #1's head was down. -Resident #1 lifted his/her head and asked what to Resident #2. -Resident #2 left Resident #1's room. -LPN A stayed for a little while and walked out of Resident#1's room, spoke with LPN B and went to the kitchen and filled his/her water bottle. -LPN A left the women's unit and returned later with the midnight census, left for three north and returned on three south unit with some medications. -LPN A saw Resident # 1 on the hallway standing and LPN A asked Resident #1 to step into his/her room, which he/she did. -LPN A left the unit and did not return the rest of the night until the early hours between 3:30 A.M. and 4:30 A.M. That is when the nurse notified him/her of Resident #1's complaint. -At this time LPN A was getting ready for his/her morning routine and end of shift at 7:00 A.M. -He/She was called by the administrator while at home and suspended pending investigation. Record review of Resident #2's Written Statement, dated 5/18/20, showed: -He/She does not know what time it was on Saturday night 5/16/20, when he/she had asked LPN A to go to the store for him/her to get an energy drink. -He/She had asked LPN A to go to the store for him/her. -LPN A said he/she would think about it. -About 10 minutes later LPN A went to the store. -LPN A brought Resident #2's drink to his/her room and left. -Resident #2 went to Resident #1's room about 15 to 20 minutes later. -Resident #2 walked into Resident #1's room and saw LPN A standing with his/her back to Resident #2. -Resident #2 saw Resident#1's head at LPN A's crotch. -Resident #2 called Resident #1's name and Resident #1 looked around LPN A and wiped his/her mouth and said what. -Resident #2 then went and told CNA A. -Resident #2 and CNA A went to Resident #1's room and LPN A was in Resident #1's bathroom. -Resident #1 wiped his/her face and was smiling. Record review of CNA A's Employee Statement, dated 5/17/20, showed: -Resident #2 asked him/her if he/she could take some money back to Resident #1. -When Resident #2 came back to the room, he/she was shocked because of what he/she had just witnessed. -Resident #1 was sitting in a chair and LPN A was standing very close to Resident #1 and Resident #2 heard sounds and motions of Resident #1 giving LPN A oral sex. -CNA A asked how did he/she know if that is what he/she was really doing and Resident #2 said Resident #1 looked up wiping his/her mouth. -While CNA A talked to Resident #2 and tried to calm him/her down, Resident #1 had went to LPN B before CNA A and Resident #1 told on his/herself. Record review of LPN C's Employee Statement, dated 5/17/20, showed: -Upon arriving at the facility for his/her shift, Resident #1 asked if he/she could come to his/her office. -Resident #1 came into his/her office and started telling him/her about an incident that occurred last night with him/her and a staff member (LPN A). -Resident #1 stated that he/she had asked LPN A to use his/her old computer to download music on. -LPN A brought up the computer. As he/she was setting up the computer LPN A spread his/her legs apart and attempted to finger him/her. -Resident #1 stated he/she slapped LPN A's hand away and told LPN A, he/she can handle it from here. -LPN A left the room and the resident's unit. -LPN A returned to Resident #1's room. As he/she was sitting in a chair, LPN A unzipped his/her zipper and told him/her to give LPN A a hand job. -When Resident #1 told LPN A no, LPN A held Resident #1's face and head and told him/her to open his/her mouth and LPN A put his/her genitalia in Resident #1's mouth. -All the lights were on and the door was open. -Resident #1 was assessed for any bruising or pain, which Resident #1 denies. -No bruising noted. Record review of Resident #6's Written Statement, dated 5/18/20, showed: -Starting approximately 2 weeks ago and continuing each night that LPN A would go into Resident #1's room at night and LPN A worked until Saturday 5/16/20. -Resident #6 stated, I stand in my doorway a lot and about 2 weeks ago I witnessed LPN A come onto the unit on Thursday, Friday, Saturday and Sunday. -Resident #1 calls LPN A into his/her room, at first Resident #6 thought that they were just talking. -Resident #1 had been showing up with money. -On two occasions with a $10 and a $20 dollar bill after seeing LPN A go into Resident #1's room. -Resident #6 asked Resident #1 where he/she got that money. -Resident #1 would say, My little secret, my little secret. -It is always right after LPN A left Resident #1's room. -Sometimes when LPN A went into Resident #1's room, the door was open and sometimes the door was shut. -He/She never saw Resident #1 and LPN A. They were always behind the wall out of eyesight. -It was always quiet when the door was open, never any talking when the door was open. -When the door was shut, LPN A was usually in Resident #1's room for about 10 minutes. -On Sunday, 5/17/20, Resident #1 came to Resident #6 and told him/her that oral sex was forced. -Resident #1 told Resident #6 that LPN A pushed his/her head down and gave LPN A oral sex. Record review of the ADON's Employee Written Statement, dated 5/20/20, showed: -He/She interviewed Resident #1 on 5/18/20 at 9:30 A.M., regarding alleged rape on 5/16/20. -Resident #1 stated he/she had asked LPN A if he/she could use LPN A's laptop to download music. -LPN A came to Resident #1's room and while assisting with computer setup LPN A made inappropriate sexual advances. -Resident #1 stated LPN A entered his/her room while he/she was bent over in her closet, LPN A came over and lifted his/her night clothes and inserted three of his/her fingers into Resident #1's genitalia and wiggled then around for about 10 - 15 seconds. -LPN A then left Resident #1's room and went to the store for another resident. -LPN A came back into Resident #1's room stood next to Resident #1 while he/she was typing and LPN A unzipped his/her pants pulled out his/her genitalia and told Resident #1 to suck his/her genitalia. -Resident #1 refused, LPN A forcefully placed Resident #1's (face) near his/her genitals, used his/her hand to open Resident #1's mouth and inserted his/her genitalia. -LPN A moved his/her hips in a back-and-forth motion until he/she ejaculated a little in Resident #1's mouth and the rest in trash can. -LPN A then left the room and Resident #1 notified LPN B immediately. -When he/she asked Resident #1 why he/she did not notify staff of the first incident, Resident #1 said he/she was having a [MEDICAL CONDITION] flashback of previous rape in the past that caused him/her to be scared. During an interview on 5/18/20 at 4:10 P.M., Resident #1 said: -Between 10:00 P.M. and 11:00 P.M., Resident #1 was in his/her room when LPN A entered Resident #1's room with his/her laptop. -Resident #1 had told LPN A that he/she could download an anti-virus program on LPN A's laptop since it was an older computer. -LPN A left Resident #1's room and went to the gas station down the road for another resident. -When LPN A returned, he/she sat down in Resident #1's chair and asked Resident #1 if he/she would show him/her how to download the anti-virus program for the future. -Resident #1 was dressed in his/her night clothes. -Resident #1 was leaning over to show LPN A how to download the program. -Resident #1 asked LPN A to please move out of his/her chair. -Before LPN A moved out of the chair, LPN A reached up Resident #1's night clothes and was rubbing his/her body. -Resident #1 asked LPN A what he/she was doing and LPN A removed his/her hand from under the night clothes. -LPN A got up out of the chair and the resident sat down in the chair. -Then LPN A unzipped his/her pants. -The resident asked LPN A what he/she was doing and LPN A told the resident he/she was going to give him/her oral sex and LPN A pulled out his/her genitalia -Resident #1 said he/she told LPN A no and would not open his/her mouth. -The resident said LPN A took both of his/her hands and pushed on the resident's jaw just hard enough to get the resident to open his/her mouth, but not hard enough to cause bruising. -LPN A put his/her genitalia into the resident's mouth and started moving the lower part of his/her body back and forth while holding the back of the resident's head. -That is when Resident #2 came into Resident #1's room to return six cents Resident #2 owed Resident #1. -Resident #2 saw Resident #1 pull his/her head up from LPN A's crotch. -LPN A went into Resident #1's bathroom and finished what he/she was doing and left the room. -Resident #1 went down to the nurse's station upset and told LPN B to get his/her phone and to come to his/her room with him/her. -Resident #1 told LPN B that LPN A had forced him/her to have oral sex and showed LPN B a mucus like substance in the toilet and said it was LPN A's mucus like substance. -Resident #1 wanted LPN B to take a picture of the substance in the toilet. -Resident #1 told LPN B to get the administrator on the phone because he/she want to talk to him/her about the incident. -He/She never got to talk to the administrator. -LPN B tried to get Resident #1 out to the vending area so LPN A could talk to him/her, but he/she was too scared to go out and talk to LPN A. -Resident #1 said he/she was shaking and crying because LPN A was still in the facility and he/she was scared of LPN A. -He/She does not feel safe living at the facility. -Everywhere he/she looks, he/she sees LPN A's face. -He/She cannot sleep or eat and has no one to talk to about the incident. -He/She just wants to go somewhere he/she is safe. -The police came to the facility finally on Sunday, 5/17/20 and that is when the facility sent him/her to the hospital for a rape exam. -He/She has signs of sexual trauma and was bleeding in his/her genitalia. -He/She said that while sitting in the chair that same day LPN A spread his/her legs open and stuck 3 fingers in his/her genitalia area, that is how he/she got scratched and why he/she was bleeding. Observation on 5/18/20 at 4:10 P.M., showed: -Resident #1 was very emotional and crying during the interview. -He/She had no visible bruises at that time on his/her face, arms, or body. During an interview on 5/19/20 at 10:08 A.M., LPN A said: -He/She brought in his/her old laptop for Resident #1 to download anti-virus on. -Resident #1 then would use the laptop to download music on his/her MP3 player. -Resident #2 had begged him/her to go to the store for him/her to get an energy drink for him/her. -He/She bou

Based on observation, interview and record review, the facility failed to ensure the resident environment was free from accident hazards when one sampled resident (Resident #4) accessed the locked men's unit medication room and obtained an unspecified type and amount of medications. The resident ingested the medications resulting in hospitalization in the Intensive Care Unit (ICU). The facility census was 114 residents. Record review of the facility's Medical Destruction policy dated (MONTH) 6, (YEAR), showed: - Any medication that was to be destroyed was to be locked in a separate cabinet and labeled to be destroyed. No other items, medications or treatments were allowed to be stored in the to be destroyed cabinet. - All medications must be destroyed in the presence of two licensed nurses. - All medications will be destroyed in accordance with the Federal Guidelines for proper pharmaceutical disposal. -- Medications that cannot be returned to the pharmacy are to be destroyed by the facility. -- If the medication were in pill form, the designated nurses will gather all medications and liquefy them by adding water. The liquefied medication will then be added to a kitty litter mixture, then placed in a trash bag and discarded. -- If the medication is in liquid form, the designated nurses will pour the liquid directly into the kitty litter and discard the litter in a trash bag. Liquid medication also qualifies as injectable solutions or liquid inhalants. - Whoever witnessed the destruction/disposal of medication must sign and date the medication destruction record. - The medication destruction record will provide the following information: -- Resident name; -- Date medication destroyed; -- The name and strength of the medication; -- Prescription number (if any); -- Name of dispensing pharmacy -- The quantity destroyed; -- Method of destruction; -- Reason for destruction; and -- Signature of witnesses. - Completed medication destruction records will be withheld by the facility for a minimum of two years. - Before discarding any medication cards or prescription bottles with labels, ensure that all resident information is removed or scratched out. 1. Record review of Resident #4's face sheet showed he/she was originally admitted to the facility on [DATE] and had readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. - Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety); - Personal history of [MEDICAL CONDITION] (disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury); and - Paranoid [MEDICAL CONDITION] (a form of [MEDICAL CONDITION] (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others) characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations). Record review of the resident's care plan dated 5/18/17, showed the resident had impaired thought processes related to mental illness. He/she had a history of [REDACTED]. The facility staff were instructed to: - Ensure the resident had access to a clock or watch at all times. - Place a calendar where the resident had access to it. - Provide consistent caregivers on all shifts. - Approach the resident warmly and positively and in a calm manner. - Always address the resident by his/her name. - Calmly talk with the resident and offer reassurance prior to initiating cares. - Provide instruction to the resident using a clear voice and simple sentences. - Keep the resident's environment free of clutter and safety hazards. - Ensure the call light is within his/her reach at all times in his/her room and the bathroom. Instruct the resident on the use of the call light and reinforce the need to use of the call light with each contact. - Monitor and document the resident's behavior and a status as needed. Report any change in the resident's cognitive status to the resident's physician. - On 1/1/19, a handwritten note was added: the resident was verbally aggressive towards staff. The resident was redirected using a non-invasive approach and the resident was placed on 1:1 staff supervision. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandatory assessment tool completed by the facility staff for care planning) dated 11/30/18, showed the resident: - Had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact; - Had a [DIAGNOSES REDACTED]. - The resident did not display any behaviors. Record review of the resident's nurse's notes showed he/she had a history of [REDACTED]. Record review of the resident's nurse's note dated 2/20/19 at 2:30 P.M., showed: - The resident was reported by roommate to be unconscious. - Upon assessment, a code was called. - The resident was alert and oriented x 2 after a sternum rub (the application of a painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) was performed. - The resident appeared pale in color while diaphoretic (heavy sweating). - The resident's blood pressure was 90/56 (normal blood pressure is 120/80), pulse was 65 beats per minute (normal pulse rate is 60 - 100 beats per minute), and his/her respiration rate was 16 breaths per minute (normal respiration rate is 12 - 20 breaths per minute). - The facility staff initiated neurological checks and Emergency Medical Services (EMS - a system that provides emergency medical care) was notified. - The resident was asked if he/she had ingested anything aside from food and the resident responded with slurred speech that was not understandable. - The resident stated I wanted a buzz after being asked a second time what he/she consumed. - Upon departure from the facility, the resident's blood pressure was 87/60, pulse rate was 60 beats per minute and respiration rate was 14 breaths per minute. - The resident was transported by EMS to the emergency department of a local hospital. Record review of the resident's Neurological (level of consciousness, pupil response, motor functions-hand grasps/extremities, pain response, and vital signs) Check Sheet dated 2/20/19 at 2:30 P.M., showed the resident's: - Blood pressure was 90/56; - Pulse was 65 beats per minute; - Respirations were 16 breaths per minute; - The resident was oriented x 2 with stimuli; - Not able to assess the resident's hand grips due to lethargy (lack of energy); - The resident speech was slurred. Record review of the resident's Neurological Check Sheet dated 2/20/19 at 2:40 P.M., showed the resident's: - Blood pressure was 87/60; - Pulse was 60 beats per minute; - Respirations were 14 breaths per minute; - No additional information was documented on this neurological check at 2:40 P.M. Record review of the resident's physician's orders [REDACTED]. - [MEDICATION NAME] (a water pill that prevents your body from absorbing too much salt, allowing the salt to instead be passed in the urine) 40 milligrams (mg) to the resident on a daily basis - the reason for administration was not listed; - [MEDICATION NAME] 40 mg to the resident daily for treatment of [REDACTED]. - [MEDICATION NAME] (a medication used to treat depression, panic attacks, [MEDICAL CONDITION], post-traumatic stress disorder, social anxiety disorder) 100 mg to the resident on a daily basis for treatment of [REDACTED].>- [MEDICATION NAME] (anti-[MEDICAL CONDITION] agent which is also used to help control extrapyramidal disorder, which are side effects that may result from taking anti-psychotic medications) 2 mg to the resident twice a day for treatment of [REDACTED].>- [MEDICATION NAME] (a medication used in the treatment of [REDACTED].>- [MEDICATION NAME] acid (a medication used to treat certain types of [MEDICAL CONDITION]) 250 mg two capsules (total of 500 mg) to the resident twice a day for treatment of [REDACTED].>- Xarelto (a medication used to treat blood clots and to prevent blood clots from forming) 20 mg to the resident daily at bedtime for treatment of [REDACTED]. - [MEDICATION NAME] (a medication used to help relax certain muscles in the body) 10 mg to the resident every eight hours as needed for treatment of [REDACTED].>- [MEDICATION NAME] (a medication used to treat certain mental/mood disorders such as [MEDICAL CONDITION] and/or [MEDICAL CONDITION] disorder) 234 mg intramuscularly (the injection of a substance directly into the muscle) to the resident every 30 days - the reason for administration was not listed. Record review of the facility's investigation showed a handwritten statement dated 2/20/19 by Licensed Practical Nurse (LPN) A showed: - At approximately 2:34 P.M., LPN A was notified by Resident #5 who expressed concern for Resident #4. - Resident #5 verbalized to LPN A, Resident #4 had obtained medication from getting into the medication room. - Resident #5 informed LPN A Resident #4 had taken a lot of pills. - LPN A immediately went to assess Resident #4, who was found initially to be lethargic. - Initial vital signs showed Resident #4's blood pressure was 90/56, pulse was 87 beats per minute, respirations were 16 breaths per minute and oxygen saturation was 95% on room air. - Resident #4 stated he/she put empty pill packages in the trash which were found. - Resident #4 stated the reason he/she took the pills was to get high. - LPN A immediately notified the Director of Nursing (DON) and the Administrator followed by EMS notification who transported Resident #4 to the local hospital. - Resident #4's physician and guardian were notified. - The empty pill packages were sent with Resident #4 to the hospital. Record review of the facility's investigation showed a handwritten statement dated 2/20/19 from Resident #5 showed: - Resident #4 woke Resident #5 up out of a dead sleep and said I broke into the medication closet and got all of these pills while asking which pills Resident #4 should take. - Resident #5 informed Resident #4 not to take any of the pills, because they sounded like blood pressure and heart pills. - Resident #5 further informed Resident #4 to put the pills back and not to involve him/her in this situation. - Approximately 45 - 60 minutes later, Resident #5 awoke to find Resident #4 passed out in a chair. - Resident #4 was responsive after being shaken to wake up. - Resident #5 yelled what the f-k are you doing and reported to the charge nurse. - The staff then assessed Resident #4 and called a code. Record review of the facility's investigation showed a handwritten statement dated 2/20/19 from LPN B showed: - The keys to the second floor locked unit were placed in his/her possession while on a different unit to enable LPN A to go on lunch. - At 1:05 P.M., a call was placed to LPN A as he/she was late returning and LPN B had a meeting that was beginning. - During the time LPN A was gone to lunch, LPN B did not go on the unit nor did he/she open any medication cart. - LPN B opened the medication cart at approximately 7:20 [NAME]M. - 7:30 [NAME]M., to look for an injection that the nurse stated he/she drew up for a resident and LPN B was going to assist. Record review of the facility's investigation showed a handwritten statement dated 2/20/19 from Resident #6 showed as Resident #6 came out of his/her room, Resident #4 had medications in his/her hand and he/she took the medications. Record review of an EMS report dated 2/20/19 showed: - A call from the facility was received at 2:34:58 P.M. - EMS was dispatched at 2:37:25 P.M. - EMS was in route to the facility at 2:39:45 P.M. - EMS arrived at the facility at 3:07:36 P.M. - EMS arrived at the resident's location at 3:07:38 P.M. - At 3:07 P.M., the resident's blood pressure was 95/70 and 112/64, pulse was 62 and 56 beats per minutes, respirations were 24 and 19 breaths per minutes and blood oxygen level was 97%; - The resident was unresponsive; - The resident's skin was pale; - The resident's pupils were constricted (pupils get smaller); - The narrative is as follows: -- Psychiatric patient broke into the medicine compartment of the facility and took a bunch of medications that didn't belong to him/her, including beta blockers that affected his/her vital signs. Upon leaving the facility, EMS was able to get to the patient without any problems, but leaving the facility the elevators shut down, so there was an extended time leaving the nursing home. While waiting for a plan to leave, the paramedic did as much on the scene to be able to provide the best care despite the unfavorable conditions. Vital signs were taken in route to the emergency department where the hospital staff will provide further evaluation and treatment. - EMS departed the facility at 3:07:38 P.M. - EMS arrived at the hospital with the resident at 3:12:35 P.M. Record review of the resident's hospital history and physical dated 2/20/19, showed: - He/she presented after an overdose. The patient was at a nursing home, had broken into the drug room and taken numerous doses of medications, for other patients, many psychiatric medications, significant doses of [MEDICATION NAME] as well. - EMS noted low blood pressure and low heart rate. Observation of the second floor locked unit medication door and lock on 2/21/19 at 12:40 P.M., showed: - The door opened from the right to the left into the medication room. - A lever type door knob with a lock was noted to be on the medication room door. - No damage was noted to the door knob, the door or the door jamb. - A metal plate was attached to the outside door jamb, located at the door knob level to prevent the lock from being opened without a key. During an interview on 2/21/19 at 12:46 P.M., the Administrator said: - They do not have cameras at the facility. - The lock on the doors to the medication rooms were changed on 2/21/19. - A metal plate was placed on the door jamb of the second floor locked unit medication room on 2/21/19. During an interview on 2/21/19 at 12:50 P.M., the Maintenance employee said: - He/she has a good rapport with Resident #6. - He/she went to talk with Resident #6 and found out Resident #6 had received some pills from Resident #4. - Resident #6 said he/she did not take any of the pills. - Resident #6 took three pills in separate packages from his/her drawer and handed the pills to the employee. During an interview on 2/21/19 at 12:53 P.M., Resident #6 said: - He/she was offered some pills from Resident #4. - He/she accepted some pills from Resident #4 and placed them in his/her drawer. - He/she did not know what the pills were. - Resident #4 had a hand full of pill packets. - Resident #4 said he got the pills from the medication room. - He/she did not know how Resident #4 got into the medication room. - Resident #4 gave him/her the pills about an hour before a Code Green was called on the unit. During an interview on 2/21/19 at 12:57 P.M., Resident #5 said: - Resident #4 woke him/her up out of a deep sleep and said man I just broke into the med room and got all these pills. Do you know what they are? - Resident #5 said the pills looked like blood pressure medication and heart medication. - Resident #5 said he/she told Resident #4 not to take the medications and he/she needed to put the medications back where he/she got them and did not want to be involved in any of it. - Resident #5 then went back to sleep. - Resident #5 awoke when a Code Green was taking place in the hallway outside of his/her room. - Resident #5 saw Resident #4 in the chair with his/her eyes closed. - Resident #5 called Resident #4's name and he/she did not respond. - Resident #5 approached Resident #4 and shook him/her, but Resident #4 did not respond. - Resident #5 then rubbed really hard on Resident #4's chest and got a small response. - Resident #5 left the room and told the charge nurse Resident #4 was unconscious after taking some pills he/she stole. - The staff then came into the room where Resident #4 was and started providing care. During an interview on 2/21/19 at 1:10 P.M., Certified Medication Technician (CMT) A said: - He/she had a key to the medication room. - He/she did not go into or access the medication room. - He/she was passing medications in the dining room right inside the door to the dining room. - Resident #4 had eaten his/her noon meal in the dining room. - He/she did not see or hear anything unusual. - He/she did not see any resident or staff lingering near the nurse's station. - At approximately 1:30 P.M., he/she relocated the medication cart to the hallway near the nurse's station and left the locked unit on the second floor. - When he/she returned to the unit, a lot was going on as a Code Green had been called and staff had responded to the Code (which was across the hall from Resident #4's room). During an interview on 2/21/19 at 2:20 P.M., the DON said: - He/she did not know what medications Resident #4 consumed. - The empty pill packets were sent with the EMTs to the hospital. - He/she did not take photocopies of the empty packets. - He/she did not know which resident(s) the medications were issued to. - He/she does not have any documentation of what medications were in the medication room that had been discontinued or to be sent back to the pharmacy for credit. - He/she expected Federal guidelines to be followed for documentation of medications to be destroyed or returned to the pharmacy. During an interview on 2/21/19 at 1:20 P.M., LPN A said: - As the Code Green was ending, Resident #5 came out of his/her room and said I feel like I'm narcing on a friend, but Resident #4 took a bunch of pills and is unconscious. - He/she was able to wake Resident #4 up enough to ask him/her why he/she took the pills and Resident #4 said he/she just wanted to get a buzz. - When Resident #4 said he/she threw the pill packets away in the trash in a sock. - 911 was called. - He/she found a sock stuffed full of empty pill packets. - He/she does not know who the medications belonged to, the names of the medications or the dosages of the medications. - EMS arrived and took over care of Resident #4. - All of the medication packets were sent with the EMTs when they left the facility. - He/she did not know how Resident #4 gained access to the medication room. - The pad lock to the medications to be destroyed cabinet was missing and had to be replaced after this incident occurred. - The lock on the door was replaced after the Administrator was able to open the lock and door with a credit card. - A metal plate was also placed on the medication door to prevent the door being opened with a credit card. During an interview on 2/21/19 at 1:10 P.M., LPN B said: - LPN A turned the keys over to him/her while LPN A took a lunch break around 1:00 P.M. - LPN B did not go to the locked unit at that time. - He/she had to call LPN A, as LPN A was late getting back from lunch. - LPN B believes he/she saw Resident #4 during lunch. - He/she did not notice anything when he/she was on the unit earlier. During an interview on 2/21/19 at 1:20 P.M., Certified Nurses Aide (CNA) A said: - Resident #4 was in the dining room for lunch. - He/she took the residents out for their smoke break around 1:30 P.M. - He/she did not notice anything different about Resident #4, other than he/she was more quiet than usual. - He/she did not notice anything unusual on the unit. Record review of the resident's hospital discharge summary dated 2/25/19, showed: - The resident was reportedly an in-patient on a locked psychiatric unit when he/she obtained access to a medication room and began ingesting as many pills as he/she could in a suicide attempt. - Judging from the individual pill packets that were sent with him/her ripped up, he/she likely ingested [MEDICATION NAME] (a medication used to treat depression) 100 mg, [MEDICATION NAME] (a medication used to treat depression), [MEDICATION NAME] (a medication used to treat high blood pressure), [MEDICATION NAME] (a medication used to treat certain mental conditions such as [MEDICAL CONDITION]), [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] disorders and [MEDICAL CONDITION] disorder) 1200 mg and [MEDICATION NAME] (a medication used to treat certain mental disorders such as [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 140 mg. - His/her toxin screen was otherwise negative and [MEDICATION NAME] (Aspirin) and [MEDICATION NAME] (Tylenol) levels were within normal limits. - Poison control center was notified. - He/she was hypotensive (low blood pressure) and bradycardic (slow heart rate) in the emergency room and was given some intravenous (into the vein) [MEDICATION NAME] (raises blood sugar levels), [MEDICATION NAME] (medication to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate) and calcium (enables blood to clot). - He/she continued to be hypotensive and a central line (a type of tube that is placed in a large vein that allows multiple IV fluids to be given and blood to be drawn) was placed with initiation of an [MEDICATION NAME] drip (used for low blood pressure). - In addition, he/she was obtunded (a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) and was intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway) for airway protection. During an interview on 2/21/19 at approximately 11:10 [NAME]M., the Administrator and DON said: - They are currently conducting their investigation. - He/she did not know how Resident #4 gained access to the medication room at this time. During an interview on 3/1/19 at 11:25 [NAME]M., Resident #4 said: - He/she was walking down the hall from his/her room, past the nurse's station, kitchenette and janitor's closet when he/she noticed the medication room door open a crack (the resident held his/her hand up to demonstrate the door was open approximately 2-3 inches). - He/she said he/she thought to himself/herself, he/she had an to opportunity to get high. - He/she did not see any staff down the hall or in the nurse's station, so he/she went into the medication room, closed the door a little bit to the same spot it was when he/she saw it open. - He/she said there was a black milk crate with pills, so he/she grabbed a bunch, put them in his/her waist band, then opened the door, peeked out, saw there were no staff visible, so he/she left the medication room, closing the door to the same spot he/she saw it when he/she entered (meaning kept it open a crack about 2-3 inches). - He/she then went to his/her room and asked his/her roommate, Resident #5, if he/she wanted to get high and threw some pills at him/her. - Resident #5 said he/she didn't know what the meds were, so he/she was not interested. - Resident #4 said he/she thought they were [MEDICATION NAME] (a narcotic pain medication) and [MEDICATION NAME] (a medication used to treat anxiety), but Resident #5 said he/she still was not interested, so Resident #4 took the pills back. - He/she then went to another resident's room, Resident #6, and asked him/her if he/she wanted to get high. - Resident #6 said yes, so he/she gave Resident #6 some pills. - Resident #6 asked how he/she got them, so he/she told him about the door being open and how he/she took them from the milk crate. - Resident #4 then popped about 10 white pills and 10-15 blue round pills and put them in his/her mouth and swallowed them with water. - Resident #6 also took some pills, he/she thought about 7 or 8 pills, at that same time. - Resident #4 then went to the dining room for lunch, ate his/her lunch, then went back to his/her room to drink some instant coffee he/she kept in his/her room. - The next thing he/she knew, he woke up in the hospital with his/her parent and step-parent near his/her bed. - Resident #4 said his/her intention was to get high, he/she was not intending to hurt or kill himself/herself. - He/she was trying to get high and feel happy. - He/she said he/she had not seen the door open before, so that is why he/she felt it was an opportunity to get high. - The events were then repeated back to Resident #4 and Resident #4 agreed with the above events. - Resident #4 repeated that the door was cracked open about 2-3 inches, staff were not in the hall or the nurse's station. - He/she thought staff may have been in the dining room preparing for lunch. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level [NAME] Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began immediately training the staff on identifying, assessing, reporting and putting interventions in place to frequently monitor the medication rooms and protect the residents. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation. MO 083

Based on observation, interview and record review, facility staff failed to provide protective oversight and implement interventions to ensure one resident was protected after reporting allegations of resident to resident sexual abuse for one of five sampled residents (Resident #1). Additionally, facility staff failed to follow-up on a resident's (Resident #1) statements of wanting to cause self-harm, failed to contact the resident's physician and guardian after the resident attempted to harm himself/herself, and failed to develop and implement interventions for the resident's self-harming behaviors. The facility census was 92 residents. 1. Record review of Resident #1's face sheet showed he/she: -admitted to the facility on [DATE]; -Had [DIAGNOSES REDACTED].e., abnormally high energy levels), post-traumatic stress disorder (PTSD, an emotional illness classified as an anxiety disorder, and usually develops as a result of terribly frightening, life-threatening, or otherwise highly unsafe experiences) and depression. Record review of the resident's quarterly Minimum Data Set (MDS; a federally mandated assessment tool required to be completed by facility staff) assessment, dated 8/19/15, showed staff assessed him/her as: -Alert and oriented with no cognitive impairment; -Understood others and others able to understand him/her; -[DIAGNOSES REDACTED]. -Independent with Activities of Daily Living (ADL's) and ambulation; -Had delusional behaviors, felt bad about himself/herself two to six days, and had trouble concentrating. Review of the resident's care plan, dated 11/10/15, showed staff assessed the resident as: -Independent with all ADL's and mobility; -Had a [DIAGNOSES REDACTED]. --Assist him/her to identify situations that trigger traumatic feelings; --Encourage him/her to verbalize feelings and fears; --Provide a safe, quiet, low-stimuli environment; -Had [DIAGNOSES REDACTED]. --Assess if the resident's behavioral symptoms present a danger to the resident and/or others, and intervene as needed; --Assess/record effectiveness of drug treatment; --Follow-up with facility psychiatrist as needed; --Monitor his/her behaviors and response to medication; --Quantitatively and objectively document the resident's behavior. Record review of Resident #2's face sheet showed he/she: -admitted to the facility on [DATE]; -Had [DIAGNOSES REDACTED]. Record review of Resident #2's MDS assessment, dated 10/9/15, showed staff assessed him/her as: -Alert and oriented with no cognitive impairment; -Understood others and others able to understand him/her; -[DIAGNOSES REDACTED]. -Independent with and ADL's and ambulation. Review of the Resident #2's care plan dated 10/15/15, showed staff assessed the resident: -Independent with all ADL's and mobility; -had a history of [REDACTED]. -Received psychoactive medication related to [DIAGNOSES REDACTED]. --Assess if the resident's behavioral symptoms present a danger to the resident and/or others, intervene as needed; --Assess/record effectiveness of drug treatment; --Medications as ordered by the physician; --Monitor the resident's behavior and response to medications; --Follow-up with facility psychiatrist as needed. Record review of Resident #1's Medication Administration Record (MAR), Nurses' Notes (NN), Social Service Notes (SSN), and Shift 24 hour report (SR) showed: -On 12/12/15 at 8:00 P.M. (NN), he/she complained of hearing voices, and the nurse administered Geodon 10 milligrams (mg) injection, and noted will monitor; -On 12/12/15 the MAR showed 10 mg Geodon injection administered and no documentation to show the reason for the administration and effectiveness of the medication; -On 12/13/15 at 7:00 A.M. (SR), the night nurse had no reports regarding resident; -On 12/13/15, no documentation of NN; -On 12/14/15 at 7:00 A.M. (SR), the night nurse reported the resident attempted to cut himself/herself with a plastic cap, no injury noted; -On 12/14/15, no documentation of NN; -On 12/14/15 no time (SSN), it was reported the resident cut himself/herself, it was unclear why the resident self-harmed, staff will continue to closely monitor for overall health and mental wellness; -On 12/14/15 at 7:00 P.M. (SR), the day nurse had no reports regarding the resident; - On 12/15/15 at 4:00 P.M. (NN), he/she complained of feeling agitated and anxious about being able to visit family over the holidays, the nurse administered Geodon 10 mg injection, and noted tolerated well; he/she told staff he/she had a desire to bite himself/herself, resident on 15 minute checks; -On 12/15/15 at 4:45 P.M. (SSN), he/she notified social services about biting himself/herself earlier today, was given Geodon by the nurse, he/she did not think the medication kicked in and believes he/she may do it again; the social service director spoke with the nurse regarding this issue, nurse reports baseline and perhaps resident seeking attention; -On 12/16/15 at 12:30 P.M. (SSN), he/she notified social services that last night he/she told the night Certified Nurse Assistant (CNA) that someone touched him/her a sexual manner (would not identify who), social services spoke to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) and noted may be self-seeking behavior, however the resident's guardian will be notified, and social services asked the nurse to contact the resident's physician and guardian; -On 12/16/15 at 7:00 A.M. (SR), the night nurse reported the resident received a Geodon injection at 10:45 P.M., and he/she continued to say he/she wanted to harm himself/herself and that nobody cared about him/her; -On 12/16/15 no time noted (SSN), staff contacted the resident's guardian, and the guardian asked if staff hotlined the sexual assault. Social services spoke to the resident, and he/she changed his/her story to it happened this past Saturday and again last night at the end of the hall, he/she stated the name of alleged perpetrator to social services, social services instructed the resident to stay away from the alleged perpetrator and that the incident would be checked out, social services consulted with the Administrator, the DON and ADON, investigation in process, social services made the call to the Hotline at 2:00 P.M.; -On 12/16/15 at 3:00 P.M. (NN), the resident notified social services that someone (but he/she does not recall who) made sexual allegations against another resident, Resident #1 had a history of [REDACTED]. -On 12/16/15 at 7:00 P.M. (NN), staff documented the resident had behaviors of accusatory sexual abuse per report from 7:00 A.M. nurse; -Staff did not document any Nurses' Notes, Social Service Notes, or Shift Reports on the 7:00 P.M. to 7:00 A.M. shift. Record review Resident #2's 15 minute checks, dated 12/16/15, showed staff did not document the resident's whereabouts from 7:00 P.M. to 8:00 P.M. Observations on 12/17/15 of Resident #2, showed from 8:50 A.M. until 10:00 A.M., he/she stayed in his/her room doing individual activities. Observation on 12/17/15 of Resident #1, showed: -At 8:50 A.M., he/she slept in the chair at the end of the hall in the sitting area outside the social services office; -At 9:40 A.M., he/she walked past the Nurses' Station and sat at the dining room table and looked at a magazine. During an interview on 12/17/15 at 10:00 A.M., CNA F said when coming on shift this morning at 7:00 A.M., the charge nurse did not inform him/her to watch the resident and Resident #2 closely. During an interview on 12/17/15 at 10:15 A.M., Licensed Practical Nurse (LPN) G said: -He/she received report from the night shift nurse, LPN H, that on 12/16/15 Resident #1 had behaviors of accusing sexual abuse and to monitor him/her through every 15 minute facial checks; -All residents were already on 15 minute facial checks, and no one told him/her to monitor the AP any closer. During an interview on 12/17/15 at 10:55 A.M., Resident #1 said: -On Saturday (12/12/15), he/she was sitting in a chair at the end of the hall sometime after shift change (around 7:00 P.M. to 8:00 P.M.), to make a call to his/her grandmother. Normally staff call his/her grandmother, but no one was around. As he/she got up, Resident #2 backed him/her into the corner (which is not visible from Nurses' Station and hall), and put his/her hands down Resident #1's pants and made sexual advances, which made him/her bleed. Observation on 12/17/15 at 11:05 A.M., showed the ADON walked Resident #2 into the neighborhood. The resident went to his/her room and on the way looked at the resident and the surveyor with flat expression. Resident #2 walked back out of his/her room and approached Resident #1 and the surveyor, stood within two feet of where the resident sat, looked at the resident with flat expression and said are you seeking attention? Resident #1 looked at Resident #2 and said no. Resident #2 then said are you sure you're not seeking attention? and turned and walked back to his/her room (located two to three doors from the sitting area). During an interview on 12/17/15 at 11:13 A.M., Resident #1 continued the interview and said: -Resident #2 said if Resident #1 told anyone, Resident #2 would get a knife and kill me; -Resident #1 placed a pad in his/her pants for the bleeding; -Nothing else occurred Saturday night; -He/she felt safe on Sunday and Monday, and he/she stayed in his/her room; -On Tuesday, 12/16/15 at about 7:30 P.M., he/she was on the telephone in the back sitting area, and when he/she hung up the phone and started to walk toward the front, Resident #2 shoved him/her with open hands against wall and said you'll get it; -Resident #1 walked to the front and told CNA A what happened. CNA A said he/she would talk to Resident #2, then CNA A and Resident #1 told LPN B what happened. LPN B said you're lying, I'm not going to report; -On the morning of 12/16/15, Resident #1 went to the social services office and told what happened to Social Services (SS) A, and she said she would look into it; -On 12/16/15 at 12:00 noon, Resident #1 told Admissions and Social Services B what occurred with Resident #2, and they said they would check cameras; -On 12/16/15 at 5:00 P.M., the ADON talked to Resident #1 and said are you telling the truth and he/she replied yes; -Resident #1 said Resident #2 was the only person who caused him/her fear; -Resident #1 does not feel comfortable living on the same neighborhood as Resident #2 since he/she approached him/her with surveyor present; -Resident #1 said Resident #2 could get a knife from a former employee because he/she was friendly with a former employee and still talks to him/her on the telephone. Observation on 12/17/15 at 12:00 P.M., showed the Administrator's office had video screens labeled with different locations of the facility. The screen labeled with Resident #1 and #2's neighborhood was blank. During an interview on 12/17/15 at 12:00 P.M., the Administrator said: -He was not told anything about the video cameras when he was hired and did not know if there were video tapes for the dates/times when the alleged incidents occurred; -He was only supposed to be interim Administrator through the first of December, but the person hired found another position, and he was asked to stay longer; -The DON and the ADON conducted the investigation regarding the alleged incidents; -He did not interview other residents or staff working on the neighborhood. During an interview 12/17/15 at 1:00 P.M., the DON said: -She would have expected the nurse to notify the resident's physician that Resident reported hearing voices and document in the NN; -She would have expected staff to complete a nursing assessment when the resident attempted to cut himself/herself, change the monitoring to one-to-one or every five minutes, and documentation in the NN that reflected details regarding notification of the physician and the skin assessment (the NN was the only place the nurses document on behaviors and assessment); -She would have expected the nurse to document in the NN that the resident had thoughts of self-harm and he/she administered medication, including details of contact with the physician and the guardian, the resident's mental state assessment, and behavior monitoring; -When the resident continued to say he/she wanted to harm himself/herself, the DON would have expected staff to call the physician to determine how to proceed and document that in the NN along with behavior monitoring. During an interview on 12/17/15 at 1:00 P.M., the DON, the ADON and Social Services A said: -After Resident #1 told Social Service A on 12/16/15 about the sexual incidents, Social Services A came to us, and we talked to the resident; -The resident said the first incident occurred on 12/12/15 between 7:00 P.M. and 8:00 P.M., in back hall by social services office; -Resident #1 did not tell anyone on 12/12/15, 12/13/15 or 12/14/15; -Resident #1 said a second incident occurred on 12/15/15, when Resident #2 tried to stick his/her hand down Resident #1's pants, and Resident #1 reported it to CNA A at that time; -We told the resident to stay away from Resident #2 and we would investigate; -We spoke to LPN C and he/she was not aware of the incident until this morning when Resident #1 said someone put their hand in his/her private area but did not say who; -We told LPN C to be sure the nurses and CNA staff check on both residents every 15 minutes (which was not increased monitoring as 15 minute checks were standard for all residents on this neighborhood prior to the incidents); -The Social Services A spoke to the resident's guardian, consulted with the DON, ADON and the Administrator, and at 2:00 P.M. called the state hotline and reported the incident; -We did not interview any other residents or staff on 12/16/15; -On 12/17/15 at 10:24 A.M., we (DON and ADON) spoke to Resident #1 and he/she gave the same information given to the Social Services A, and added that on 12/16/15 during the 7:00 P.M. shift smoke break, CNA D gave Resident #1's cigarettes to Resident #2; -On 12/17/15 at 10:40 A.M., we (DON and ADON) spoke to Resident #2, who said he/she was never alone for any extended period of time with Resident #1, never touched anyone inappropriately, never saw anyone touch anyone else inappropriately, and never had any conversations about sex; -On 12/17/15, the DON called CNA A, and had left a message to call her back; -Currently had not talked to any other residents or staff, but would have expected staff on 12/16/15 to pass on the information to the on-coming shift to check on both residents and for the nurse to ensure the checks where done and documented. During an interview on 12/17/15 at 1:15 P.M., Social Services B said: -On 12/16/15 at 3:00 P.M., Resident #1 and the Admissions Coordinator came and said it was important they speak to Social Services B; -The resident accused Resident #2 of trying to inappropriately touch Resident #1 on 12/15/15, and on 12/12/15 Resident #2 touched Resident #1 inappropriately; -He told Resident #1 these were serious allegations and was he/she sure this happened, and the resident replied yes. During an interview on 12/17/15 at 2:00 P.M., the Admissions Coordinator said: -On 12/16/15 around 1:00 P.M., while on the smoke patio Resident #1 said he/she wanted to talk with her; -The resident came to the Admissions office and reported on 12/12/15 after 7:00 P.M., back by the phone area, Resident #2 touched him/her by putting his/her hand down Resident #1's pants; -He/she asked who the resident told, and Resident #1 said he/she told Social Services A, who told the resident not to go around Resident #2, and if Resident #1 saw Resident #2 to just walk away, and that the investigation started today; -She and Resident #1 spoke to Social Services B, and she and Social Services B told the resident the investigation started 12/16/15. During an interview on 12/17/15 at 6:06 P.M., CNA A said: -On 12/15/15 he/she worked 7:00 P.M. shift and LPN B asked him/her to go see the resident because the resident was biting himself/herself; he/she went to see the resident and saw the resident had a small dot on his/her wrist no other injuries; when he/she asked the resident why he/she was biting himself/herself, he/she replied another resident wanted to do things with him/her and he/she started crying, Resident #2 had bothered him/her and demanded cigarettes; he/she told the resident not to do what Resident #2 wants, and the resident shook his/her head in understanding; -He/she went to LPN B to tell about the resident biting him/herself but is unsure if he/she told the nurse about the other report about Resident #2 since Resident #1 did not say they had done anything, and he/she was busy trying to go back to his/her designated area; -Resident #1 and all other residents on the neighborhood were on 15 minute visual checks; -He/she had not seen Resident #2 act inappropriately with any other residents. Record review of CNA A's written statement showed: -On 12/15/15, he/she worked on the opposite side of the facility from the resident's neighborhood; -LPN B asked him/her to talk to Resident #1 because the resident was trying to hurt himself/herself; -He/she found the resident in his/her room and asked why the resident was trying to hurt himself/herself and the resident said Resident #2 wanted to mess sexually with Resident #1, and Resident #1 did not want him/her to, and Resident #2 kept asking him/her for cigarettes and he/she said no; -He/she told Resident #1 that he/she does not have to do anything with Resident #2, he/she can't make Resident #1 do anything with him/her; -This all took place about 7:30 P.M., he/she and Resident #1 went to LPN B, and he/she told the nurse about the resident hurting himself/herself and that he/she had calmed the resident down; -He/she documented that he/she can't remember if I said anything about the sex, and he/she went back to his/her floor. During an interview on 12/17/15 at 7:06 P.M., CNA D said: -On 12/16/15, he/she worked the 7:00 P.M. shift, and he/she took the residents from the neighborhood to smoke; -Resident #1 and Resident #2 were outside smoking at that time; -When he/she came on shift and throughout the evening, he/she was not given any special instructions on monitoring Resident #1 and Resident #2, he/she just did the normal 15 minute visual checks on all residents. During an interview on 12/17/15 at 10:15 P.M., LPN B said: -On 12/12/15 about 7:15 P.M., the previous nurse administered Geodon to Resident #1; -At about 9:15 P.M., the resident was in the doorway to his/her room, said no one cared about him/her, he/she had thoughts of harming himself/herself, and LPN B administered Geodon per the resident's request at 10:45 P.M.; -He/she passed medications on 12/15/15 at 7:30 P.M., and asked CNA A to sit with the resident, the resident said no one cared about him/her; -CNA A told LPN B the resident said he/she did not want to do things others asked him/her to do, and told the resident you do not have to do anything you do not want to do; -He/she did not ask further questions as it appeared to be upsetting the resident, and thought the resident was upset because he/she had no visitors; -He/she was trained to let the resident vent, to talk, and then report to the DON and Administrator, call the guardian and the physician; -In this case, no one had reported an allegation of abuse or inappropriate behavior; -He/she did not call the resident's physician or guardian about the residents self-harming behaviors. During a telephone interview on 12/18/15 at 8:29 A.M., the resident's guardian/case manager said facility staff contacted his/her office on 12/16/15 to report sexual abuse involving Resident #1. Facility staff did not report the resident was hearing voices and wanted to harm himself/herself. During an interview on 12/18/15 at 1:25 P.M., the Maintenance Director said the facility's video camera was in place but not working for an undisclosed amount of time on Residents #1 and #2's neighborhood. During an interview on 12/18/15 at 3:05 P.M., CNA E said: -On 12/16/15 during the 7:00 P.M. shift, no one told him/her to monitor the Resident #1 and Resident #2 closer. During an interview on 12/21/15 at 12:15 P.M., the Resident #2 said: -Supposedly the incident with the resident happened on the hall and staff would have come to rescue and there are video cameras in the hall; -Resident #2 gave him/her cigarettes after this supposedly happened; -He/she had not touched anyone inappropriately, never forced himself/herself on anyone; -On 12/17/15, the DON interviewed him/her, just addressed the issue, and asked did anything happen in the hallway on a certain date the week prior; -The DON or others never told him/her that he/she had to stay away from the resident; -When he/she walked up to the resident on 12/17/15, he/she did not care who was sitting with the resident, he/she just wanted to know if the resident was seeking attention and effecting others life in wrong way, never threatened the resident, just wanted the resident to know he/she wasting a lot of people's time and energy. During an interview on 1/5/16 at 10:30 A.M., Resident #1's physician said: -He/she would have expected staff to notify him/her that the resident was hearing voices, made statements of wanting to self-harm, and attempted to self-harm, in order for the facility psychiatric consultant to be notified to see the resident; -Facility staff did not contact the physician or the on-call physician until 12/16/15 to inform them of the resident's allegation of sexual abuse. MO 122 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. A visit was completed on 12/21/15. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The facility implemented one-on-one staffing for 72 hours for Resident #1, 15 minute checks for 72 hours for Resident #2, in-service and training for all staff, and auditing of the resident population to ensure there were no other residents that needed a care plan to address inappropriate sexual behaviors. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview, and record review, the facility staff failed to provide appropriate monitoring of bowel patterns to prevent the occurrence and complications of constipation; to follow the physician's orders to administer laxatives, to transfer the physician orders for laxatives onto the Medication Administration Record (MAR) and the Telephone Order Sheet (TOS) to the MAR, which caused a resident who had chronic pain and a quadriplegic, to have complications of vomiting, abdominal distention, increased pain and discomfort from not having a bowel movement in approximately 10 days. The resident's pain pump surgery had to be canceled due to abdominal distention, decrease bowel sounds and a large amount of hard form stool in his/her colon which caused his/her chronic pain to be increased and prolonged his/her hospital stay for one sampled resident (Resident #5); and to correctly identify the interventions needed for the [DIAGNOSES REDACTED].#5, #10, #11, and #13) out of 13 sampled residents. The facility census was 101 residents. Record review of the Nurse Assistant in a Long-term Care Facility Student Reference Manual by the Curators of the University of Missouri, revised November 2001, showed: -Staff was to monitor the frequency and consistency of stools, and provide good peri-care for dependent residents; -Staff should notify the charge nurse if a resident did not have a bowel movement for two days, and were to document all bowel movements per facility policy; -Conditions that caused abnormal bowel function included: --Constipation; --Impaction (a hard mass of stool that forms in the bowel that cannot be passed normally; and liquid stool can pass around the blockage) and/or symptoms of stool incontinence, pain, discomfort, and abdominal distention. --Bowel obstruction, i.e., might be caused by the twisting of the bowel, tumor, or large impaction of stool. Note resident complaints of pain, abdominal distention, and no passing of stool for 10 days. Record review of Mayo Clinic recommendations titled Constipation included the following information: -Constipation most commonly occurs when waste or stool moves too slowly through the digestive tract, causing it to become hard and dry. Chronic constipation has many causes: -Constipation may be considered chronic if you've experienced two or more of these symptoms for the last three months; -Signs and symptoms of chronic constipation include: --Passing fewer than three stools a week; --Having lumpy or hard stools; -Blockages in the colon or rectum may slow or stop stool movement. Causes include: -Bowel obstruction; -Neurological problems can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include: --[MEDICAL CONDITION]; --Spinal cord injury; --Stroke; -Hormones help balance fluids in your body. Diseases and conditions that upset the balance of hormones may lead to constipation, included: --Diabetes; --Overactive [MEDICAL CONDITIONS]; --Underactive [MEDICAL CONDITIONS]; -Factors that may increase your risk of chronic constipation include: --Being an older adult; --Being a woman; --Being dehydrated; --Eating a diet that's low in fiber; --Getting little or no physical activity; --Taking certain medications, including sedatives, narcotics or certain medications to lower blood pressure; -Complications of chronic constipation include: --Stool that can't be expelled (fecal impaction). Chronic constipation may cause an accumulation of hardened stool that gets stuck in the intestines. 1. Record review of Resident #5's Admission Face Sheet showed: - He/she was admitted to the facility on [DATE]; -Was admitted with the following Diagnoses: [REDACTED]. --Chronic pain; --Chronic constipation; --Diabetes Mellitus and --[MEDICAL CONDITION]. Record review of the resident's Bowel Function Care Plan dated 5/22/15 showed: -The problem was he/she had constipation related to immobility and narcotic pain medication; -The goal was that he/she would not exhibit signs and symptoms of constipation; -The nursing interventions included: --Assess the presence or absence of awareness of need to have a bowel movement; --Assess what is the normal pattern for the resident. The resident was not placed on a bowel regime due to his/her incontinence; --Administer a Fleets enema as needed; --Administer Milk of Magnesia (MOM) as needed and as ordered for complaints of constipation and monitor the results; --Monitor/document presence and absence of bowel sounds, abdominal pain, distention, and decreased appetite; --Review medication regime, especially use of medications that influence bowel activity; -Administer Senna medication as ordered and monitor for effectiveness and side effects; -The resident's care plan was not updated from the time of his/her admissions to show he/she had monthly chronic constipation issues that resulted in increased pain and the potential for skin breakdown due to being incontinent; -He/she had a history of [REDACTED]. -The care plan did not reflect if the resident could identify if he/she had a bowel movement on a daily basis and if he/she could be dependable as a competent historian and -The care plan did not show that he/she was on multiple medications that had constipation as a common side effect. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/15/15 showed he/she: -Was cognitively intact; -Could make himself/herself understood by others and he/she could understand the verbal content of others; -Required maximum assistance of two staff persons for all transfers, bathing, and bowel and bladder personal cares; -Was incontinent of his/her bowels; -The record did not show if he/she had a constipation issue; -Had chronic pain with a rating of 10 (scale of one (1) to 10 with ten being the most severe pain); -Had received pain medication and as needed (PRN) pain medication in the past (7) days and -Had received antianxiety and antidepressant medications in the past seven (&) days. Record review of the resident's physician TOS dated 9/18/15 showed the following physician orders: -Readmit the resident to the facility and resume the resident's previous medication orders; -The resident's previous laxative and bowel softener medications included: -- [MEDICATION NAME] Solution (laxative/softener for chronic constipation) 15 milliliters (ml) daily; --[MEDICATION NAME] 24 micrograms (mcg) (for narcotic drug induced constipation) at 8:00 A.M. and 5:00 P.M. every day; --Senna S (laxative), one tablet, every day at 8:00 A.M.; -- [MEDICATION NAME] (stool softer) 100 milligram (mg), one capsule daily as needed; -The resident's previous pain medication included: --[MEDICATION NAME] IR (immediate release opioid narcotic pain medication) 30 mg, every 6 hours as needed; --[MEDICATION NAME] (An opioid narcotic pain medication used to treat moderate to severe pain) 20 mg every 12 hours at 8:00 A.M. and 8:00 P.M., every day; -[MEDICATION NAME] (non-narcotic for pain), 10 mg, one tablet, at 8:00 A.M., 12:00 noon, and 4:00 P.M.; --[MEDICATION NAME] (an anticonvulsant), 20 mg, at 8:00 A.M. and 4:00 P.M., everyday; --[MEDICATION NAME] (non-narcotic pain medication) every 6 hours as needed for pain. and --Desyrl (antidepressant), 150 mg, two tablets at bedtime, every day. Record review of the resident's MAR dated 9/18/15 through 9/24/15 showed there was no physician's order transcribed for the [MEDICATION NAME] and Senna that was ordered on [DATE]. Record review of the resident's Physician Order Sheet (POS) dated 9/25/15 through 10/24/15 showed the following physician's orders: -Continue to administer [MEDICATION NAME] Solution 15 ml daily; -On 10/8/15, [MEDICATION NAME](which is used to relax muscles and help alleviate pain from muscle spasms) 350 mg, two times a day, as needed for muscle spasms; -Continue to administer [MEDICATION NAME] 100 mg, one capsule daily as needed; --On 10/23/15 the [MEDICATION NAME] was changed to one capsule, two times a day; -On 10/23/15 start [MEDICATION NAME] 17 grams, daily for constipation and -There was no physician's order transcribed for [MEDICATION NAME] as ordered on [DATE]. Record review of the resident's MAR dated 9/25/15 through 10/24/15 showed: -There was no physician's order transcribed for [MEDICATION NAME] and Senna as ordered on [DATE] and -He/she did not receive the [MEDICATION NAME] and Senna as ordered from 9/25/15 through 10/24/15. Record review of the resident's POS dated 9/25/15 through 11/24/15 showed he/she had continued on the non-narcotic pain medication, the narcotic pain medication, and the other medications with constipation as a common side effect and an iron tablet (also has common side effect of constipation) was added on 10/20/15. Record review of the resident's Nurse's Notes dated 10/13/15 through 10/19/15 showed: -His/her surgery for [REDACTED]. -The surgery did not occur; -The nurse's notes did not state why the resident's surgery had been canceled; -He/she was receiving an antibiotic for a urinary tract infection [MEDICAL CONDITION] during this time period and -His/her bowel elimination report showed he/she had not had a bowel movement for five days during this time period. Record review of the resident's POS dated 10/25/15 through 11/24/15 showed the following physician's orders: -The Senna and the [MEDICATION NAME] orders had been changed to as needed daily (PRN); -The record showed the [MEDICATION NAME] was not transcribed on the POS and -There was no physician's order to discontinue of the medication. Record review of the resident's MAR dated 10/25/15 through 11/24/15 showed: -There was no physician's order for the [MEDICATION NAME] and Senna on the resident's MAR and there was no order to discontinue the medication and -He/she did not receive the [MEDICATION NAME] and Senna as ordered from 10/25/15 through 10/26/15. Record review of the resident's bowel function record on the resident's Activities of Daily Living (ADL's) flow record dated October 2015 showed the following: -There was no bowel movement recorded from 10/1/15 to 10/3/15 (3 days); -There was no bowel movement recorded from 10/7/15 to 10/10/15 (5 days) and -There was no bowel movement recorded from 10/14/15 to 10/25/15 (11 days). Record review of the resident's Nurse's Notes dated October 2015 showed there was no documentation by the staff of the resident having any bowel movements or receiving additional laxative or stool softer until 10/23/15. Record review of the resident's Nurse's Notes dated 10/23/15 showed: -The resident had complained of constipation and received an order for [REDACTED].>-No results from the laxative were documented in the Nurse's Notes or the resident's bowel movement record. Record review of the resident's MAR dated 10/24/15 showed: -The record showed he/she had [MEDICATION NAME] 8:00 P.M. and -The was no documentation that he/she received his/her other pain medication. Record review of the resident's Nurse's Notes dated 10/24/15 showed: -The resident was found outside the facility vomiting; -The resident complained that he/she was constipated; -The on call physician's was notified and an order for [REDACTED]. Record review of the resident's bowel function record on the resident's ADL sheet dated 10/24/15 showed he/she had one bowel movement; the size and consistency was not documented. Record review of the resident's bowel function record on the resident's ADL sheet dated 10/25/15 showed he/she had four bowel movements; the size and consistency unknown. Record review of the resident's MAR dated 10/25/15 showed: -The resident had [MEDICATION NAME] 8:00 P.M. and -There was no documentation that the resident had received his/her other pain medication. During an interview on 10/26/15 at 4:00 P.M., Licensed Practical Nurse (LPN A) said: -Three residents (including Resident #5) would always report to him/her when they were constipated and needed a laxative; -The staff did not ask and record all the residents' bowel movements on a daily basis; -The residents who are continent tell the staff when they are constipated and -The residents who are cognitive will tell the staff when they need a laxative. During an interview on 10/26/15 at 4:15 P.M., Certified Nursing Assistant (CNA) A said: -He/she would document the bowel movements on the incontinent residents for his/her shift; -The continent residents will tell him/her when they were constipated; -He/she does not ask the residents who are continent if they have had a bowel movement every day on his/her shift; -There are at least three residents (including Resident #5) who tell him/her when they need a laxative and -He/she would report the issue to the charge nurse. Record review of the resident's hospital medical record showed the following: -On 10/26/15 he/she was received at the designated hospital for surgery; -On 10/26/15 the resident's x-ray of his/her abdomen showed a moderate to large amount of retained stool (fecal) material visualized in the colon; -The stool material was nonobstructive and without an acute bowel gas pattern and -His/her surgical procedure for a pain pump insertion for his/her chronic pain had been canceled due to the large amount of retained fecal material in his/her colon. During an interview on 10/27/15 at 12:10 P.M., the Registered Nurse (RN B) from the outside facility hospital said the resident: -Had called the hospital physician on call for the pain clinic on the evening of 10/25/15 and complained of having a lot of pain and was nauseated because of not having a bowel movement for 15 days; -Was instructed to call 911; -Was admitted to the hospital on [DATE] at approximately 1:00 P.M., with complaints of nausea, vomiting, and constipation; -The resident's assessment showed the resident's abdomen was firm and distended with faint bowel sounds; -Was complaining of abdominal and back pain, rating the pain at an eight (8) out of ten (10) being maximum severity; -Received a [MEDICATION NAME] prep which is a strong bowel stimulant used prior to bowel procedures to empty the colon; -X-ray showed the resident was severely constipated with a significant amount of intestinal gas; -Had results from the bowel prep of massive amounts of stool with a mixture of large hard chunks of stool, liquid, and semi soft indicating that the resident had gone several days without a bowel movement; -Pain pump insertion was postponed at this time due to the resident's bowel issues. During an interview on 10/27/14 at 12:30 P.M., the resident said: -He/she was supposed to have the pain pump surgery on 10/14/15 but had to cancel because he/she was too nauseated; -He/she was also taking an antibiotic for an UTI; -He/she had only one small bowel movement in three days during that time and then went another 10 days after that with no bowel movement; -His/her abdomen was distended and was having abdominal pain and he/she had reported these complaints to the staff several times for fifteen days and no one would listen to him/her; -He/she felt that all the issues with his/her constipation caused him/her to have increased pain in his/her spine and now has to wait longer for his/her pain pump which made the pain issues worse; -His/her reasons for getting the pain pump was because of the increasing pain in his/her back and he/she could hardly use the parts of his/her body that did work and it was painful when he/she had to be moved; -He/she already had a problem with skin issues and he/she has to be moved while in his/her bed and moved out of his/her bed; -Now he/she had to postpone the pain pump surgery again because of being constipated; -He/she does not have knowledge of when his/her bowels move all the time and sometimes would not remember from one day to another; -On Sunday 10/25/15, while he/she was still at the facility, he she called the pain physician on call at the hospital and reported his/her condition to the physician because he/she was so sick and wanted to have this surgery, but his/her abdomen was so distended and hard and he/she wanted to know what to do; -He/she was vomiting and nauseated and could not take his/her medications or his/her pain medications; -The physician instructed him/her to call 911 and he/she had called 911; -LPN B said that he/she could not call 911 and if he/she did call, LPN B would turn them away; -The nurse had given him/her an antianxiety medication and it made him/her drowsy; -He/she did not know when the ambulance staff arrived and a CNA told him/her the ambulance came, but the Charge Nurse LPN B had sent the ambulance staff away; -LPN B had given him/her a suppository with no results and after that a bottle of Magnesium [MEDICATION NAME]; -Most of those other laxatives and stool softeners won't work when he/she gets this constipated and -He/she finally had two bowel movements, but his/her abdomen was still distended and firm and he/she was having a lot of back pain. Observation on 10/27/15 at 12:50 P.M., of the resident's abdomen showed his/her abdomen was distended and when the resident pushed on his/her abdomen he/she stating that his/her abdomen was still somewhat firm. During an interview on 10/30/15 at 4:20 P.M., LPN B said: -When a resident complains of constipation, he/she would check the resident's chart to see if there was a laxative ordered for the resident; if not he/she would call the resident's physician for a laxative; -On Saturday 10/24/15, the resident was outside vomiting and when asked what was wrong; the resident had complained of being constipated and requested Magnesium [MEDICATION NAME] and said none of the other laxatives would work for him/her; -The resident's physician was notified and an order for [REDACTED]. -The resident had results from the Magnesium [MEDICATION NAME]; -The ambulance was at the facility for another resident who was being sent out to the emergency room for a psychiatric evaluation. During an interview on 10/30/15 at 6:00 P.M., the resident's physician said: -The resident had chronic constipation and the pressure on the resident's abdomen especially if his/her abdomen became distended could cause an increase in his/her pain; -The resident had several types of laxatives and stool softeners that he/she had ordered for the staff to administer; -The staff was usually very attentive to residents' bowel issues and because his/her nurse practitioner, his/her other on call physician, and himself/herself were at the facility two to three times a week, usually a resident would tell one of them if the resident was having a constipation issue; -The resident had a stool softener that he/she took every day and a laxative, but he/she also had PRN bowel stimulants as needed; -He/she was not aware that the resident's Senna S was not documented on the resident's MAR; -He/she was not aware that the resident had not been receiving the medication [MEDICATION NAME]; this particular medication was given for narcotic induced constipation and the resident would need this medication with the narcotics that he/she had to receive for his/her pain; -Even though the resident was alert and oriented, he/she was not always aware of when he/she had a bowel movement, but in the past, had made it known to staff, when he/she was constipated; -He/she would expect the staff to have a care plan for his/her constipation issues; -He/she would expect the staff to be monitoring the resident's bowel elimination pattern due to the resident's inactivity and chronic constipation issues and -He/she would expect the staff to try a bowel regiment program with the resident. 2. Record review of Resident #10's Admission Face Sheet showed: -He/she was admitted to the facility on [DATE] and readmitted on [DATE]; -Was admitted with the following Diagnosis: [REDACTED]. Record review of the resident's medical record showed no care plan had been implemented for the resident's bowel elimination and the [DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact; -Required total assistance of two staff persons for bed nobilities and transfers; -Required total assistance of two staff persons with toileting needs; -Was frequently incontinent of bowel elimination; -The record did not show if the resident had constipation issues; Was on a mechanical altered diet and -Was on antipsychotic, antianxiety, antidepressant, and diuretic medications, and pain medications. Record review of the resident's Bowel Elimination Record dated 10/1/15 through 10/15/15 showed no documentation of any bowel movements for 10/1, 10/2, 10/3, 10/4, and 10/5 (five days). Record review of the resident's POS dated October and November 2015 showed the following physician's order for the resident to administer Senna, 8 mg, one tablet as needed for constipation. Record review of the resident's MAR dated 10/1/15 through 10/15/15 showed there was no documentation that the resident received the physician's order laxative after three days of not having a bowel movement. Record review of the resident's POS dated 10/25/15 through 11/24/15 showed the following physician's orders: -[MEDICATION NAME] ER, 250 mg, three tablets by mouth at bedtime, -Theragram multivitamin, one tablet daily; -[MEDICATION NAME] (diuretic) 20 mg, one tablet daily; -[MEDICATION NAME] 40 mg, one tablet, daily for GERDs ([MEDICAL CONDITION] reflux disease) and -Calcium [MEDICATION NAME] 500 mg, three times a day (calcium supplement). During an interview on 10/30/15 at 5:00 P.M., the resident said: -He/she did not have control of his/her bowel movements sometimes; -He/she did not know how many days he/she would have gone without a bowel movement; -He/she had hard stools sometimes and was difficult to push out; -He/she would tell the staff when they asked him/her but he/she did not always remember to tell the staff. 3. Record review of Resident #11's Admission Face Sheet showed he/she: -Was admitted to the facility on [DATE]; -Was admitted with the following Diagnoses: [REDACTED].>--[MEDICAL CONDITION] (an irregular and often rapid heart rate that commonly causes poor blood flow to the body); --Constipation (recorded as the secondary diagnosis) and --[MEDICAL CONDITION]. Record review of the resident's medical record showed no care plan had not been implemented for the resident's bowel elimination and the [DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS dated [DATE] showed he/she: - Was moderately cognitive impaired; -Was totally independent of his/her self-cares; -Was always continent of his/her bowel movements; -The record showed that he/she did not have constipation issues and -Had received an antianxiety, hypnotic, and diuretic medication for the past seven days. Record review of the resident's POS dated 10/25/15 through 11/24/15 showed the following physician's orders: -[MEDICATION NAME] 750 mg, one tablet, three times a day; -Risperidal 0.5 mg, one tablet, two times a day for [MEDICAL CONDITION]; -[MEDICATION NAME] 600 mg, one tablet, two times a day for mood disorders; -Theragram multivitamin with iron, one tablet daily; -[MEDICATION NAME] 75 mg, one tablet, daily for depression; -[MEDICATION NAME] 40 mg, one tablet, daily and -The POS did not show a laxative was ordered for this resident. Record review of the resident's bowel function on the resident's ADL flow sheet dated 10/1/15 through 10/26/15 that was received on 10/27/15 at 2:00 P.M. showed the following: -There was no bowel movement recorded from 10/1/15 through 10/6/15 (6 days) and -There was no bowel movement recorded from 10/9/15 through 10/15/15 (7 days). Record review of the resident's bowel function on the resident's ADL flow sheet dated 10/1/15 through 10/15/15 that was received on 11/2/15 at 2:00 P.M showed: -On 10/1/15, the record showed the resident was in the hospital; -From 10/2/15 through 10/4/15, there was no bowel movement recorded; -On 10/5/15, the record showed the resident was in the hospital; -From 10/6/15 through 10/15/15 showed documentation that the resident had a bowel movement every third day and -There was no ADL flow sheet received for 10/16/15 though 10/26/15 at this time. Record review of the resident's Nurse's Notes dated 10/1/15 through 10/4/15 showed no documentation of him/her having a bowel movement, complaining of constipation or receiving medication for not having a bowel movement after three days and documentation of the resident's physician being notified of the bowel issues. Record review of the resident's Nurses Notes dated 10/4/15 showed he/she had been found unresponsive in his/her wheelchair with a very low blood pressure and was transferred to the emergency room and returned on 10/6/15 at 10:15 A.M. Record review of the resident's Nurse's Notes dated 10/9/15 through 10/12/15 showed no documentation of the resident having a bowel movement, complaining of constipation or receiving medication for not having a bowel movement after three days and documentation of the resident's physician being notified of the resident's bowel issues. On 10/13/15 at 8:30 P.M., the nurse's notes showed the resident was having more episodes of urine and bowel incontinence; and the resident's bowel elimination record did not show any bowel movements recorded for the time period of 10/9/15 through 10/15/15. 4. Record review of sampled Resident #13's Admission Face Sheet showed he/she: -Was admitted to the facility on [DATE] and readmitted on [DATE]; -Was admitted with the following Diagnoses: [REDACTED]. --[MEDICAL CONDITION] and --[MEDICAL CONDITION]. Record review of the resident's medical record showed that a care plan had not been implemented for the resident's bowel elimination or constipation. Record review of the resident's quarterly MDS dated [DATE] showed he/she: - Was cognitively intact; -Required one staff person assistant with toileting cares; -Was always continent of his/her bowel movements; -The record showed that he/she did not have a constipation issue and -Had received antipsychotic and antianxiety medication the past seven days. Record review of the resident's Bowel Elimination Record dated 10/1/15 through 10/27/15 showed inconsistent documentation of his/her bowel movements with several intervals of two to three days of missing documentation to indicate the resident's bowel pattern. Record review of the resident's POS dated 9/25/15 through 10/24/15 showed the following physician's orders: -[MEDICATION NAME] 5 mg, one tablet every morning for depression; -[MEDICATION NAME] 30 mg, one tablet at bedtime for depression; -[MEDICATION NAME] 0.1 mg, two times a day for hypertension; -[MEDICATION NAME] 320 mg (a calcium channel blocker), one tablet daily for hypertension; -The record showed the resident did not have a laxative order for constipation. Record review of the resident's Nurse's Notes dated 10/1/15 through 10/27/15 showed there was no documentation of when the resident had a bowel movement. During an interview on 10/30/15 at 6:40 P.M., the resident said: -The staff did not ask him/her when he/she had a bowel movement; -He/she did not know how many days he/she would go without having a bowel movement; -Sometimes he/she would have a hard stool, but he/she did not know if he/she told the staff or not and -He/she did not know if he/she had taken a laxative. 5. During an interview on 10/30/15, the acting Director of Nursing (DON) said: -He/she expected the staff to monitor all the residents' bowel patterns; -He/she expected the licensed staff to closely monitor the residents who were being administered narcotics and other medications that have common side effects of constipation; -He/she expected the staff to closely monitor the bowel patterns of residents with certain [DIAGNOSES REDACTED]. -He/she expected the staff to monitor the bowel patterns of residents with limited activity; -There are several residents who will tell the staff when they are constipated; -The residents with constipation issues should have a care plan implemented and all assessments regarding bowel elimination should indicate the resident's bowel issues. -There was a physician's protocol available for constipation for the staff to use. MO # 639 MO # 678

Based on interview and record review, the facility staff failed to provide protective oversight for one (Resident #12) of eight sampled residents who was physically attacked by Resident #1; to provide the nursing staff with appropriate training to deal with the physical aggressive behaviors of Resident #1, who is a known physically aggressive resident who had physically attacked two staff persons and became physically threatening with another staff person. The facility census was 101 residents. Record review showed the facility did not provide a policy, procedure or an inservice for the training of the staff regarding residents who have aggressive physical behaviors, impulse control, opposition defiant disorder (a pattern of disobedient, hostile, and defiant behavior toward authority figures), and intermittent explosive disorder (an impulse-control disorder characterized by sudden episodes of unwarrented anger). Record review of the National Institute of Mental Health resources titled Schizophrenia Disorder included the following information: -The disorder is a chronic, severe, and disabling brain disorder that has affected people throughout history; -People with the disorder may hear voices other people don't hear; -They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated; -People with schizophrenia may not make sense when they talk, and may sit for hours without moving or talking; and -Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking. 1. Record review of Resident #1's Admission Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's Department of Mental Health Level I and II Preadmission Screening and Resident Review (PASSR; used for nursing home admission or if already admitted for a significant change in their physical and mental status) determination sheet dated 3/5/15, showed he/she: -Was determined to have a serious mental illness (SMI); -Had an intellectual disability and developmental disabilities; -Required nursing facility level of services; -Was not recommended for a short term nursing facility stay; -Information to consider related to level of services that the resident would need included the following: --He/she required a higher level of supervision and monitoring related to his/her aggression, self-injury, behaviors, past elopements, and sexually inappropriate behaviors; --He/she was placed in a facility exclusively for the same like gender for [AGE] years related to his/her aggressive nature and history of sexual aggression, and it was recommended that the optional long term skilled care environment for him/her would be a secured, all same gender unit or facility; --He/she had primary [DIAGNOSES REDACTED]. ---Axis II (personality disorder) was mild mental retardation, mixed personality disorder, psuedoseizures (fake seizures); --Axis III (medical or neurological problems that may be relevant to the psychiatric problems) was seizures verses epilepsy; -As a result of the major mental disorder the resident has functional limitations in the following areas: --Difficulty interacting appropriately/communicating effectively with others; --A history of altercations, evictions, and fear of strangers; and --He/she avoids interpersonal relationships and was socially isolated; --Has difficulty concentrating and sustain focused attention to complete common tasks; --Has difficulty in adapting to changes associated with family or social interactions; --Manifest agitation and exaggerated signs and symptoms associated with the illness; --Withdraws from a situation. -The resident's individual needs for assessment of level of services for identifying supports and assistance included the following: --Monitoring for aggression, trigger events, violence, and signs of impending mood changes, safety, elopement, self-injury behaviors, and mental status and behavioral status; --Monitor for his/her complex medication regiment and check for cheeking medications; --He/she requires intervention by mental health or judicial systems. --He/she had 20 plus years of history of SMI [DIAGNOSES REDACTED]. --He/she had legal guardianship due to his/her SMI. Record review of the resident's Social Services Admission assessment dated [DATE], showed: -He/she was admitted with Schizoaffective disorder, seizure disorder, COPD and a past history of alcohol abuse; -No documentation of the resident's primary stressors in the past 12 months; -He/she had no issues with mood disorders the past 12 months; and -No documentation of the resident's assessment and recommendations for services. Record review of the resident's admission Minimum Data Set (MDS; a federally mandated assessment tool required to be completed by facility staff for care planning) dated 6/29/15, showed he/she: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 (normal range 13-15); -Was able to understand the verbal content of others; -Was able to make himself/herself understood by others; -Was oriented to person, place, and time and had no issue with memory recall; -Was not affected by various mood disorders in the last two weeks that included: depression, no interest in doing things, trouble falling asleep, feeling tired, poor appetite, and trouble concentrating; -Had not exhibited potential indicators for behaviors that included: physical and verbal behaviors that were directed to others and other behaviors not directed to others; -Was totally independent of all activities of daily living (ADL's; how a person self-performs his/her care) and all mobilities; -Had [DIAGNOSES REDACTED]. -The record did not show the resident had exhibited being easily annoyed, short tempered, and attempted to harm himself/herself in the past two weeks prior to admission (he/she had recently been admitted /discharged from the hospital inpatient psychiatric unit for behaviors, attempt for self-harm, and being verbally/physically aggressive to others). Record review of the resident's Nurse's Notes dated July 2015, showed: -The resident had several episodes of becoming angry and throwing himself/herself on the floor or exhibiting signs and symptoms of being unresponsive and tremors. At each incident the resident's vital signs (temperature, pulse, respirations and blood pressure) were obtained and the nursing assessment would determine if the resident would be transferred to the emergency room for evaluation; -At least two times the resident was transported to the emergency room and returned with no evidence of seizure activity. Record review of the resident's Smoking assessment dated [DATE], showed: -He/she had no desire to stop smoking; -He/she loved to smoke; -Staff was unsure if the resident would display manipulative behaviors to obtain more cigarettes's if the resident was out of cigarettes; and -He/she displayed behaviors for when he/she did not have cigarettes during his/her admission process. Record review of the resident's Behavioral Care Plan dated 7/3/15, showed: -His/her only behavior disorder was faking seizures and elopement risks; -No interventions for the staff to follow for physical and verbal aggressive behaviors; -No documentation of the resident's multiple behaviors and aggressive physical altercations; -No documentation of staff interventions for the resident's behaviors of impulse control, opposition defiant disorder, intermittent explosion disorder, major depression, mental retardation, and mixed personality disorder; -No documentation for the resident's primary needs for cigarettes and tobacco chew that prompted the resident's behaviors and the interventions to prevent the behaviors that occurred with the resident's need for cigarettes and tobacco chew. Record review of the resident's Care Plan titled Psychotropic Drug Use dated 7/7/15, showed he/she received psychotropic medications for the [DIAGNOSES REDACTED]. The staff interventions included: -Assess and record effectiveness of drug treatment; -Assess if the resident's behavioral symptoms present a danger to the resident and others; intervene as needed; -Monitor the resident's behaviors and response to his/her administration of psychotropic and antianxiety medications; -Document the resident's behaviors in a quantitative and objective perspective. Record review of the resident's Nurse's Notes dated 7/4/15, showed the following: -On 7/4/15 at 7:00 P.M., the resident had a verbal altercation with another resident that resulted in a physical confrontation with the resident with closed fists; -When the charge nurse intervened the resident raised his/her closed fist to the staff person and attempted to strike at the staff person; -The resident's behaviors escalated and the resident was running down the unit hallway, yelling, slamming room doors, and physically threatening staff and other residents; -After several attempts to redirect the resident, the police dispatch was notified and the resident was transported out of the facility to the police station; -At 9:20 P.M., the charge nurse was notified that the resident had been released from the police station and the facility staff had to locate and return the resident to the facility; and -He/she was placed on close monitoring with one-on-one at times. Record review of the resident's Nurse's Notes on 7/5/15 at 6:00 P.M., showed the following: -He/she was found outside the facility building standing on the ledge of the second story of the facility: -He/she had removed the window screen; -He/she had told the staff he/she was angry with his/her parents due to a conversation that the resident had earlier that day; -No documentation of the resident's one-on-one monitoring for the past 24 hours; and -No documentation of the staff interventions to prevent further elopements through the facility's windows. Record review of the resident's Nurse's Notes dated 7/7/15, showed: -The resident physically attacked a staff person in the morning time who was trying to keep the resident from fighting another resident; -The resident was upset because he/she wanted to smoke but it was not his/her smoke break time; -The staff escorted the resident back to his/her room from the window he/she was trying to climb through; -The resident came out of his/her room and grabbed the charge nurse's neck; -The other staff members restrained the resident and removed his/her hands from the charge nurse's neck and the resident was placed on one-to-one observation; -Around noon the enrichment staff person went to the resident's room to assist with the issue and the resident became violent putting his/her hands on the staff person's throat and punching the staff person; -The police was dispatched; -The resident was transferred to hospital psychiatric unit for evaluation and the guardian was notified by phone; -The resident remained in the psychiatric hospital for eight days and had a medication adjustment and close monitoring on the unit; -The record showed there was no documentation for the monitoring of the resident by the staff for the time period of the resident becoming upset and the attack on the charge nurse. Record review of the resident's Nurses's Notes dated 7/19/15, showed: -The resident was found with the opposite gender in the bathroom; -There was no documentation regarding the resident behavior; -The resident was brought out of the other resident's room and instructed not to repeat the behavior; -The record showed there was no documentation for updating the resident's behavior on the care plan. Record review of the resident's Nurse's Notes dated 7/24/15, showed the resident had behaviors often through the morning and was angry and started throwing things on the wall, flipping his/her mattress, pacing and growling, banging his/her head on the wall and threatening to cut himself/herself because he/she did not have cigarettes to smoke; -The Social Service Worker (SSW) removed two safety pins from the resident after he/she made the threats to cut himself/herself; -The resident was given cigarettes and made a verbal agreement to not hurt himself/herself and staff; and -No documentation regarding the verbal agreement with staff. Record review of the resident's Nurse's Notes dated August 2015, showed: -He/she had two unwitnessed fall episodes with no injuries and no documented behavioral issues, but two seizure type episodes; -On 8/10/15, the charge nurse spoke with the legal guardian regarding the resident asking for tobacco chew seven to ten times a day and cigarettes. The guardian stated that the resident was restricted to tobacco chew four times a day and alternate with the cigarettes; -There was no further documentation in the nurse's notes regarding the cigarette issue and how the issue was resolved. Record review of the resident's Nurse's Notes dated 9/7/15, showed: -He/she was informed by staff of the cigarette policy and he/she stated he/she did not agree with the policy and wanted to talk with another staff member; -While talking to the Certified Medication Technician (CMT), he/she became very upset and started yelling and being confrontational with the staff and hitting the CMT; -He/she would not stop hitting the staff person with verbal request and started double punching with closed fists approximately 20 times; -With the assistance of other staff, the resident and the CMT were separated and the CMT walked away; -The emergency department was notified and the police dispatch and the resident was escorted out of the facility with the police and ambulance staff, and he/she was sent to an outside the facility psychiatric unit; -The resident's legal guardian was notified by phone; -The legal guardian said the resident goes off and starts fighting when he/she does not get his/her own way; -The record showed there was no documentation of the follow-up with the resident and staff to resolve the issues regarding the resident's desire to smoke and to obtain the necessary cigarettes that caused the resident's behaviors. Record review of the resident's Physician order [REDACTED].>-Ativan (used to treat anxiety) 0.5 mg, one tablet, four times a day, for anxiety, effective order date of 9/23/15; -Haldol (used to treat mental illness such as schizophrenia, behavior problems and agitation) 5 milligrams (mg), two tablets, by mouth, two times a day for psychosis, effective order date of 10/9/15; -Haldol 5 mg, injections every two hours as needed for agitation, effective order date 10/09/15; and -Depakote 500 mg, one tablet by mouth daily, for mood disorder, effective order date of 10/9/15. During an interview on 10/26/15 at 11:00 A.M., CMT A said: -On 9/7/15, the resident had physically attacked him/her; -The resident wanted to go smoke and he/she did not have any cigarettes available; -He/she explained to the resident that he/she could not go out right now and there was no staff available, and the nurse would have to call his/her family and request additional cigarettes (at that time the CMT did not know the family lived so far away); -The resident became very angry and started yelling and slammed the medication cart door and attacked the CMT on his/her left side; -He/she had put his/her arm up to keep the resident away from him/her; -He/she kept talking to the resident and asking him/her to calm down and then the nurse arrived and tried to redirect the resident; -Then the resident followed him/her and started jumping on his/her back; -Certified Nursing Assistant (CNA) A had returned to the dining room and stood between the CMT and the resident; -As he/she began to walk away, the resident came around the CNA and started attacking him/her again, and this time both the nurse and the CNA came between us; -He/she left the memory care unit and notified the SSW; -After the police department arrived, he/she pressed charges and the resident was taken to the psychiatric unit; -On 10/28/15, he/she went to court and neither the resident's guardian nor the resident appeared. He/she was told that the case was sent to a mental case court and be handled at that level and the resident would be find help in that direction; -He/she had been an employee of the facility about two years and he/she had attended an inservice on conflict management which included the behaviors that residents could have and how to redirect and handle the situation; -Usually, he/she has been successful with residents with using redirection and sometimes the nurse would have to administer a medication; -The unit would do one-on-one monitoring or fifteen minute checks with a resident when a resident was not calming down; -One-on-one monitoring was when the staff would monitor and observe the resident's location and behavior at all times; -Fifteen minute checks was when the staff would monitor and observe the resident's location and behavior every 15 minutes. During an interview on 10/30/15 at 1:15 P.M., the SSW said: -The resident had been at the facility about 6 months; -He/she visited with the resident almost daily; -The resident would usually have an appropriate conversation with him/her and liked to talk; -There were two situations that had occurred because the resident was out of cigarettes; -When the resident was out of cigarettes, he would have issues with everyone; -If someone tried to redirect him/her, the resident would act out like he/she was mad; -The resident did have fake seizures, but staff always took his/her vitals and followed through with assessments and monitoring; -He/she had talked with the resident's former case manager, because the resident's father was his/her legal guardian and the case manager handled his/her issues; -He/she had told the case manager that the resident needed more support from his/her father by either providing more cigarettes or funding so that the cigarettes could be purchased; -The case worker told him/her that the father would not take the resident back home; -The resident's step mother was very ill and she was not in good health; -He/she had an episode with the resident in August 2015 that the resident had become physically threatening with him/her, but it was how he/she handled the situation that made the resident aggressive; -In September 2015, the resident had attacked an employee and was sent out for an evaluation and returned after two weeks; -Since the resident had returned, his/her behavior had improved and there had been no more issues until this incident; -Even though the employee pressed charges at the time, he/she told the SSD later that he/she may drop the charges because he/she probably provoked the resident by not handling the situation better; -Most of the residents at the facility have behaviors; -The facility takes residents with behaviors and tries to provide a safe place for them to live; -The staff were inserviced often on how to manage residents with behaviors and especially with aggressive behaviors; -The residents receive specific medications for their behaviors and adjustments are made as necessary; -Residents are sent out for psychiatric evaluations whenever the staff were unable to redirect them. 2. Record review of Resident #12's Admission Face sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].>-Unspecified Dementia without behaviors; -Anxiety disorder; and -His/her parent was the Health Care Durable Power of Attorney (DPOA). Record review of the resident's Care Plan Conference dated 7/23/15, showed he/she: -Was independent with all ambulation's, transfers, and cares; and -Continued to struggle with anger management issues. Record review of the resident's Therapy Care Plan dated 7/23/15, showed the resident had physician's orders [REDACTED]. Record review of the resident's Behavioral Care Plan dated 7/23/15, showed a problem of his/her history of taking others personal property and claiming it was his/hers, and he/she destroyed items in the process of taking the item without being caught. The staff interventions included: -Avoid over-stimulation such as noise, crowding, other physically aggressive residents; -Maintain proper supervision when resident on and off secure unit; -Monitor the resident for changes in behavior that might warrant a change in freedom of movement; -Reassess care plan as needed if/when issues arise; and -No documentation of an update regarding the resident's issues of 10/23/15. Record review of the resident's Nurse's Notes dated August 2015 showed: -He/she had multiple incidents of being verbally aggressive with residents and staff; -His/her psychiatrist was notified to evaluate the resident's behaviors; and -The record showed that there was no documentation of monitoring the resident for his/her safety. Record review of the resident's Nurse's Notes dated September 2015, showed the resident had multiple incidents of verbal confrontation with other residents and was usually redirected. Record review of the resident's Nurse's Notes dated 10/16/15, showed: -He/she had a verbal confrontation with another resident and there was an issue of physical contact by the other resident when he/she tried to push Resident #12; -This required the staff intervention of separating the two residents; -No documentation of monitoring the resident for his/her safety. Record review of the resident's Nurse's Notes dated 10/21/15, showed he/she: -Had become increasingly more verbally and physically abusive towards other residents; -Staff were unable to redirect the resident; -The psychiatrist was notified of the resident's behaviors. -The record showed that there was no documentation of monitoring the resident for his/her safety. Record review of the resident's Medical Record dated 10/21/15, showed he/she had a written agreement between the facility and himself/herself for his/her verbal and physical aggression towards other residents. The terms of the agreement included: -He/she as well as his/her visitors will follow all the facility rules and regulations; -He/she will not hit any other residents or staff; -He/she will not verbally abuse other residents or staff; -Social Services will meet with him/her to assist with his/her coping skills; -He/she will see the facility psychiatrist quarterly to assist with his/her behaviors and remaining calm; and -Violation of the agreement could result in the resident receiving a 30 day notice or immediate discharge. Record review of the resident's Care Plan Conference dated 10/22/15, showed he/she: -Continued to be independent with all ambulation, transfers, and cares; -Had no documentation of his/her issue with anger management; and -Had no documentation of staff monitoring the resident for his/her safety. Record review of the resident's POS dated 10/25/15 through 11/24/15, showed physician's orders [REDACTED].>-Ativan 0.5 mg, two times a day, for anxiety; and -Cymbalta 30 mg, one tablet daily for depression. Record review of the resident's medical record dated 10/23/15, showed a summary of the incident that included the following: -Resident #12 had went into Resident #1's room, and Resident #1 started yelling and hit Resident #12, putting Resident #12 in a headlock type hold around his/her throat and kicked him/her. Record review of the resident's Nurse's Notes dated 10/23/15, showed he/she: -Had returned from the emergency room after the physical confrontation with Resident #1; -Was alert and oriented to person, place, time and events; -Stated to the nurse that he/she thought Resident #1 was fighting himself/herself and he/she tried to help and Resident #1 accidentally hit me; -The resident had a small raised area over his/her right eye and no other bruising or redness; -He/she complained of his/her ankle hurting but no other change than before the incident. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was cognitive intact with a BIMS of 14; -Was totally independent of all cares, ambulation, and activities; and -Did not have any physical or verbally aggressive behaviors toward others. During an interview on 10/30/15 at 5:20 P.M., Licensed Practical Nurse (LPN) B said: -He/she had witnessed part of the incident with the physical attack of Resident #12 (of the opposite sex) on 10/23/15; -The incident started when the resident was told that he/she had to wait until it was time for the smoke break at 5:15 P.M., -The resident had stayed in the area and was seen by staff; -He/she was passing his/her medications; -It was discovered the resident did not have any cigarettes and the CNA told the resident that he/she did not have any cigarettes and no one could go to the store for him/her at that time because the supper meal was being served; The resident confronted the LPN who repeated what the CNA had said and also restated that staff would go out as soon as possible; -The resident left the dining room and went to his/her room; -About ten minutes later a loud crash was heard from the resident's room that is next to the dining room; -The resident was found by staff on the floor holding Resident #12 in a choke hold and punching his/her back and the side of his/her chest; -The staff separated the two residents, the ambulance was called for Resident #12, and the police was called for Resident #1; -When the police arrived Resident #1 had calmed down and was talking appropriately to the police officer; -One-on-one monitoring was when the staff would monitor and observe the resident's location and behavior at all times; -Fifteen minute checks was when the staff would monitor and observe the resident's location and behavior every 15 minutes. During an interview on 10/30/15 at 6:30 P.M., the resident's physician said: -The staff does a very good job of monitoring the residents and their behaviors and they notify him/her and his/her staff with issues all the time; -The resident's behaviors and psychosis were usually well maintained and he/she had impulsive behaviors as does many of the residents here, and sometimes those behaviors are acting out at the same time and you will have altercations; -Sometimes how the staff would respond to the resident can trigger an altercation; -Aggressive actions, such as an immediate discharge have to be taken for all the residents safety when a behavior becomes uncontrollable by using the current interventions. During an interview on 11/1/15 at 8:30 A.M., Detective A (a Crisis Intervention office with the Police Department) said: -On 10/23/15 at 5:30 P.M., the police officers were dispatched to the facility; -The resident was arrested for physically attacking Resident #12 by putting the resident in a choke hold and throwing him/her to the floor, hitting, and strangling the resident; -At 6:45 P.M., the resident was taken to the Metro Detention Center and was issued a summons for the assault; -At 7:15 P.M., the resident complained of feeling like a seizure was starting to occur; -The process for a medical emergency was if an arrested person cannot post bond within four hours and there is a medical emergency, the arrested person is issued a signature bond, and that is waived and the person is taken to the emergency room ; -At 8:15 P.M., the resident was taken by ambulance to the hospital; -On 10/24/15 at 8:54 A.M., the facility charge nurse LPN C notified the police dispatch that the resident was outside the facility and was verbally threatening the staff and the residents inside the facility; -On 10/24/15 at 9:01 A.M., the resident's legal guardian was notified the police dispatch that the resident was standing outside the facility and had been kicked out and that the resident could not be by himself/herself and needed his/her medications; -The police dispatch notified the emergency services and the resident was transported to the emergency department at 10:54 A.M. 3. During an interview on 11/3/15 at 8:30 A.M., the resident's former Department of Health and Senior Services (DHSS) Caseworker A said: -He/she first met the resident in February 2015; -He/she had closed the resident case in May 2015 after his/her parents became the legal guardians; -He/she initiated the Level II Mental Health Screening on 3/12/15 and it was approved on 3/16/15, stating the resident qualified for mental health services; -The resident had a history of [REDACTED]. -From January 2015 to May of 2015, the resident had been admitted to 17 facilities in Missouri; -Some of the admissions were for a few days up to a couple of weeks and some for as long as two months; -Various reasons were given for his/her discharge from the facilities that included Against Medical Advice (AMA), aggressive verbal and physical behaviors that included physical harm to individuals, and inappropriate sexual behavior; -He/she did not know when or how the resident arrived at the current facility; and the last information that he/she received was Resident #1 was in Saint Louis; -He/she had witnessed explosive physical behavior towards his/her parents and brother, and inappropriate behavior towards himself/herself; -He/she had witnessed inappropriate public sexual behavior; -He/she had witnessed behaviors conducive to self-imposed injuries; -The resident would exhibit fake seizure like activity because he/she enjoyed riding in the ambulance and to be taken to a hospital; and the legal guardian said the resident had never had a seizure in all his/her childhood or a real seizure in his/her adulthood; -When he/she had contacted the facility SSW through the legal guardian's request, he/she had provided the above information to the SSW so the facility would be fully aware of the resident's history of behaviors and activities. During an interview on 11/3/15 at 4:50 P.M., Police Officer A said: -Resident #12 , of the opposite sex, who had been attacked was taken to the hospital by ambulance, but he/she was not certain of the extent of the injuries; -Resident #12 told the police officer that Resident #1 put him/her in choke hold, was punching his/her back, and pulled him/her down to the floor and he/she was kicked; -Resident #1 was taken to the police station. During an interview on 11/4/15 at 11:30 A.M., the SSW said: -He/she knew that the resident had a history of [REDACTED]. -He/she knew that the resident had physically attacked members of his/her family prior to the resident's aggressive behaviors at the facility; -With this resident, the aggressi

Based on observation, interview and record review, the facility staff failed to provide supervision and monitoring, to prevent one confused and dependent resident (Resident #1) with a known history of wandering and repeatedly putting things in his/her mouth, from ingesting oven cleaner, a hazardous substance that contains dangerous caustic chemicals. On 3/8/14, staff transferred the resident to the hospital for evaluation and treatment. The resident was admitted to the Intensive Care Unit (ICU), required a tracheostomy (the surgical formation of an opening into the trachea through the neck especially to allow the passage of air) due to severe damage from chemical burns to his/her throat and esophagus (a muscular tube connecting the throat (pharynx) with the stomach; is about eight inches long and is lined by moist pink tissue called mucosa), and mechanical ventilation (ventilator). This incident had the potential to affect 21 residents who resided on the facility's secured behavior unit. The facility census was 95 residents. Record review of the facility's admission policy for the behavioral unit, undated, showed in part: -Philosophy: To provide the maximum quality of care for our residents. We will endeavor to raise the functional capacity of our residents through structured activities, medical and nursing interventions, and the maintenance of a safe environment... This care results in the exchange of information that educates and supports family and staff and results in the most effective care of the residents... -Purpose: The Behavioral Unit is designed to meet the needs of the individuals with various forms of mental illness while providing the highest quality of care. Gregory Ridge Living Center's philosophy advocates treating the whole person and affirming the dignity of the individual. -Criteria for placement: Residents must meet the following criteria, in part: --Primary or secondary [DIAGNOSES REDACTED]. --Residents that require a highly structured environment, frequent promoting and cueing for Activities of Daily Living (ADL's) and or behavioral redirection. --Each potential resident is assessed prior to admission for cognitive, functional and behavioral status. Record review of information obtained on 3/11/14 from www.ncbi.nlm.nih.gov/pubmedhealth/PMH 34/?report=printable regarding sodium hydroxide poisoning showed the following, in part: -Sodium hydroxide is a very strong chemical that is also known as lye and caustic soda. This article discusses poisoning from touching, breathing in (inhaling), or swallowing sodium hydroxide. -Sodium hydroxide is found in industrial solvents and cleaners...including oven cleaners. -Symptoms included in part, throat swelling...burns of the esophagus and stomach...drooling...severe pain in the throat. -If the chemical was swallowed, immediately give the person water or milk, unless instructed otherwise by a health care provider. Do NOT give water or milk if the patient is having symptoms (such as vomiting, convulsions or a decreased level of alertness) that makes it hard to swallow. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool used in care planning, dated 2/5/14, showed the resident, in part: -Has adequate hearing. -Does not hear well. -Sometimes understands. -Has severe cognitive impairment. -Has behaviors that included physical symptoms directed at others and other behavioral symptoms not directed toward others such as physical symptoms. -Rejects care and wanders daily. -Ambulates independently. -Requires extensive assistance of one staff for eating. -Has [DIAGNOSES REDACTED]. -Has a feeding tube. Record review of the resident's care plan start date of 5/24/13, regarding behavioral symptoms showed the resident has socially inappropriate/disruptive behavioral symptoms as evidence by pacing, getting in other people's "personal space" and taking his/her clothes off. He/she will also lie down on the floor. This care plan has interventions that included: -Administer medications as ordered. Monitor and record effectiveness, report any adverse side effects. -Assess whether the behavior endangers the resident and/or others. Intervene as necessary. -Maintain a calm environment and approach to the resident. -Praise resident when behavior is appropriate. -When resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs. (e.g., pain, hunger, toileting, too hot/cold, etc.) Review of the resident's care plan dated 5/29/13 and updated 8/15/13 showed staff identified the resident's behavior risks for injury and elopement and planned the following care; -Redirect resident as needed. -Convey acceptance of resident during periods of inappropriate behavior. Record review of the resident's entire care plan showed staff did not plan interventions to address the resident's known history of repeatedly putting things in his/her mouth. Staff did not plan intervention that included supervision to address the known behavior. Record review of the resident's Physician order [REDACTED]. -Additional [DIAGNOSES REDACTED]. -Medications included Geodon 80 milligram (mg) capsule per tube two times daily for psychosis, Lorazepam 1 mg per tube three times daily for agitation/anxiety, Lorazepam 2 mg tablet per tube every four hours as needed for anxiety, Keppra solution 100 mg/milliliter (ml), take 20 ml per tube at 8:00 A.M. and 8:00 P.M. for seizures, Gabapentin solution 250 mg/5 ml take 16 ml per tube three times daily for seizures, and Depoprovera 150 mg IM every three months for sexual obsession. Record review of the resident's nurse's notes dated 3/8/14 at 10:00 P.M. written by Licensed Practical Nurse (LPN) A, showed the following: -The resident was observed upon entry to the unit at 6:30 P.M. pacing, appeared drowsy. Staff provided assistance with pulling up pants. Attempted to lay the patient down in bed two times without success. -At 6:50 P.M., heard yelling and screaming coming from the dining room, this writer and an off-going LPN had just completed narcotic count, dietary staff were yelling that the resident had drank some "cleanser." -This writer ran to the resident and escorted him/her to the pantry to administer milk orally. The resident's face was reddened, the resident was grabbing at his/her throat then himself/herself in the head. The resident was very combative with nurses while giving care. The resident swallowed milk without difficulty. More milk was given via gravity in the resident's gastric tube ([DEVICE]/feeding tube, an artificial tube used to give nutrition to the stomach). -911 was immediately called by another nurse when the resident was brought to pantry. This writer remained with the resident, providing care and verbal comfort. The resident was unwilling to remain seated, the writer walked with the resident up and down the hallway while waiting for the ambulance. The resident was drooling and burping, respirations were mildly labored, the resident was taken off of the unit to meet with the ambulance in the outer hallway. The resident remained defiant and combative requiring multiple people to put the resident on the gurney for transport to the hospital. -The ambulance left the building at 7:05 P.M. -The administrator was notified at 7:10 P.M. -The resident's family was notified at 7:15 and 7:20 P.M. -The physician service was notified and the nurse talked to the Nurse Practitioner. Informed the Nurse Practitioner of the course of action and the resident's transportation to the emergency room (ER). -At 7:50 P.M., the ER physician called regarding what chemical the resident ingested. The chemical material safety data sheet (MSDS, a sheet that explains the product, and its chemical make-up, and what to do in case of an emergency) was faxed to the emergency room . The ER nurse stated that due to the resident's extreme combativeness he/she was placed in a chemically induced coma. The patient required multiple different medications and leather restraints to ensure his/her safety. The ER nurse stated the resident was going to be admitted to the Intensive Care Unit (ICU), but they did not have an admitting [DIAGNOSES REDACTED]. -At 9:15 P.M., the Administrator was notified with the hospital update. -At 11:00 P.M., spoke to the ER nurse for update on the resident who remains in theER on ICU hold, they are unable to move the resident due to his/her combativeness. -At 6:15 A.M. (on 3/9/14), the nurse called the hospital and was informed the resident was now in the ICU. The nurse spoke to the ICU nurse and was notified to speak with the resident's family to receive information about the resident's condition or obtain a pass code per facility privacy laws. Record review of the Administrator's typed statement of telephone conversation with LPN A, regarding the incident with Resident #1, part of the facility's investigation packet, dated 3/8/14, showed the following: -On 3/8/14 at approximately 7:30 P.M., LPN A called the Administrator for notification that a resident ingesting oven cleaner on the secured unit. After speaking with the staff involved, it was determined that they reacted appropriately. The dietary staff had the oven cleaner on their cleaning cart, capped and closed, they turned around for approximately 10 seconds to clean off the table and when they turned back around they noticed the resident had a bottle of oven cleaner in his/her hands, and threw it on the ground. The dietary staff began yelling out for the nursing staff, which immediately responded to the resident and began encouraging him/her to drink milk orally and inserted via his/her [DEVICE]. During this time, the residents baseline remained the same. 911 was called while they were coating the resident's esophagus/stomach with milk. The nurse attempted to send the bottle of the ingested chemical and the MSDS sheets with the medics, however, during the process, the medics forgot to take those items. LPN A notified the hospital asking if they needed the bottle of oven cleaner, and they did not need the bottle. LPN A did fax over the MSDS sheets to the hospital staff. -LPN A spoke with the nurse and the physician at the hospital on numerous occasions for continuation of care purposes. During one of the calls, the nurse had informed LPN A that they needed to admit the resident to ICU, but did not have an admitting [DIAGNOSES REDACTED]. LPN A explained to the nurse that those behaviors are the resident's baseline and he/she cannot be taken out of those restraints because he/she will pace the halls and be combative with staff. LPN A informed the nurse they would have to chemically restrain the resident in order to move him/her to the ICU due to his/her behaviors. Record review of the Administrator's second written statement dated 3/8/14, part of the facility's investigation packet, showed: -On 3/8/14, after the nurse notified this writer, LPN A called for the dietary team to come to the nurse's station. -The Administrator interviewed the two dietary employees over the speaker phone with LPN A present on the call. -The dietary employee, Dietary Aide A explained to the Administrator that he/she had the oven cleaner on his/her cart, while he/she was cleaning and he/she had just turned around for a second. This writer explained to the dietary team that if they walk away from the cleaning cart to clean, they are to take the chemicals with them. -The Administrator then called the Unit Manager/Staffing Coordinator and informed him/her of what took place. The Unit Manager/Staffing Coordinator works on Sundays, therefore the Administrator directed him/her to have a training session with all employees on 3/9/14 on the use and storing of chemicals. The training is still ongoing at this time. An all staff meeting with be held on 3/12/14 and the MSDS sheets/chemical storage/safety will be on the agenda. -The Administrator and the Director of Maintenance completed a walk thru of the building on Monday, 3/10/14. During the walk thru, it was determined that there was a need for a locked chemical cabinet on 3S in the kitchen are for dietary's cleaning chemicals. This will eliminate the need of the chemicals on their cleaning carts. -During the interviews, it was explained by the Dietary Aide that he/she brought the bottle of Oven Jell upstairs to clean the 3N steam table because the wells were "dried up and burnt". Record review of a written statement by LPN C dated 3/8/14, part of the facility's investigation packet, showed: -At approximately 7:00 P.M. (on 3/8/14), during the change of shift this nurse heard screaming for help while nurse was in the medication room searching for another resident's medication. The nurse quickly came out of the medication room, saw LPN A in the kitchenette with the resident. LPN A screamed to call 911. While LPN C called 911, LPN A remained at the resident's side encouraging the resident to drink milk and also gave the resident milk via his/her [DEVICE] site. Meanwhile, the resident remained combative with staff. The resident had not signs and symptoms of respiratory distress, no gasping for air, breathing without problem. The resident was sent as soon as possible for evaluation and treatment. -The family, physician and director on call was made aware. Later informed by LPN A the resident accidentally drank cleaning chemical while in the dinning room witnessed by the dietary staff. Again, did not witness resident drink chemical agent. Record review of the a written statement by LPN B, dated 3/8/14, part of the facility's investigation packet, showed: -On Saturday, 3/8/14, at change of shift after counting narcotics-the nurse heard a staff screaming, "Come get him/her, he/she's drinking something off the cleaning cart." When noticed resident, he/she was holding his/her head and gasping for air. LPN B got milk to assist with drinking. Later flushed the [DEVICE] with milk approximately 240 cubic centimeter (cc). 911 was notified. Resident transferred via ambulance assist to the hospital ER. The resident was able to ambulate, skin color was better. Physician and family notified. Record review of the written statement by Dietary Aide A, dated 3/8/14, part of the facility's investigation packet, showed: -He/she took the chemicals to 3N to clean the steam table. After he/she was done with that, he/she followed Dietary Aide B over to 3S to help him/her bus and clean the tables. -The resident was digging in the trash barrel for food, so he/she asked the certified nurse's assistants (CNAs) if the resident had eaten. They said yes and the Dietary Aide went back to cleaning when Dietary Aide B yelled, "No". Dietary Aide A looked up and the resident had the cleaner in his/her mouth then he/she dropped it. We then went for help. Record review of the written statement by Dietary Aide B, dated 3/8/14, part of the facility's investigation packet, showed: -When he/she and Dietary Aide A were on 3S, they started to clean the tables after he/she wiped off a table, he/she turned around and saw the resident drinking out of a cleaning bottle. The dietary aide shouted the resident's name and rushed to him/her. By that time the resident threw the bottle and started to rub his/her face. The dietary aide called for the nurse, they took it from there. Record review of the MSDS sheet for Oven Jell, found in the facility's investigation packet, showed, in part: -Hazard statement: corrosive. Causes eye and skin irritation. Contains material that may cause target organ damage, based on animal data. -Potential acute health effects: Ingestion- harmful if swallowed. -Target organs: Contains material which may cause damage to the following organs; lungs, upper respiratory tract, skin, eye, lens or cornea. -Ingredients- sodium hydroxide. -First aid measures for ingestion: wash out mouth with water. Do not induce vomiting unless directed to do so by medical personnel. Record review of the resident's history and physical report from the hospital, dated 3/8/14, showed in part: -The patient presented to the ER after he/she was noted to have ingested oven cleaner. The patient was acutely agitated, although this appears to be his/her baseline. -While in the ER, the patient was noted to have blistering around mouth and in posterior oropharynx (part of the pharynx, the part of the digestive and respiratory tracts situated between the cavity of the mouth and the esophagus) that is below the soft palate and above the epiglottis (yellow elastic cartilage that ordinarily projects upward behind the tongue) and is continuous with the mouth. The patient's oxygen saturation remained between 95% to 100% on room air. Record review of the resident's hospital gastrointestinal lab reports dated 3/8/14, showed in part: -Impression: Grade 2 A esophageal injury to any area that was examined by the upper endoscope (a flexible fiberoptic tube instrument for visualizing the interior of a hollow organ or part (as the bladder or esophagus) for diagnostic or therapeutic purposes). The patient had severe mucosa edema, hyperemia (excess of blood in a body part) and exudates (the material composed of serum, fibrin, and white blood cells that escapes from blood vessels into a superficial lesion or area of inflammation) which were easily sloughed off leaving bleeding submucosa. Due to concerns of perforating the mucosa, the endoscope was not advanced any further. -Plan: The patient should start on peg tube feedings. A KUB (x-ray of the stomach) should be ordered and monitored for any problems with peg tube feeding. The stomach was not examined in this patient. Damage to the mucosa of small bowel may still be present. Record review of the resident's hospital consultation due to caustic ingestion evaluation of the patient's upper airway injury, dated 3/9/14, showed in part: -The patient over the course of the day today began having more dribbling and difficulties breathing and therefore was intubated. -Procedure: A flexible fiberoptic laryngoscope (an endoscope for visually examining the interior of the larynx) showed minor [DIAGNOSES REDACTED] (abnormal redness of the skin due to capillary congestion) without exudate or necrosis (dead tissue). There is some white exudate versus ulceration on his/her posterior (sitting behind) pharynx. The epiglottis is noted to be very thickened and [DIAGNOSES REDACTED]tous. -Assessment and plan: From an upper airway standpoint, the patient should remain intubated. The patient may need a tracheotomy if there is significant edema present in the glottis (the space between one of the true vocal cords and the arytenoid cartilage on one side of the larynx and those of the other side) or supraglottis (occurring or situated above the glottis). Record review of the resident's hospital consultation regarding positive blood cultures dated 3/10/14, showed: -The patient had a temperature of 38.3 Celsius (100.94 F) on 3/9/14, two sets of blood cultures were obtained, one culture is growing a gram positive coccus suggestive of Staphylococcus (gram-positive spherical bacteria), treatment with Vancomycin (an antibiotic) was initiated on 3/10/14. Observation on 3/11/14 at 8:45 A.M., showed two dietary staff cleaning the dining area on 3S. They were cleaning off tables, had two bussing carts and a trash barrel with them. There were no cleaning chemicals on the carts. During an interview on 3/11/14 at 9:00 A.M., the Director of Maintenance said: -On Monday (3/10/14), he/she and the Administrator completed a walk through of the building and determined that he/she needed to put locking cabinets in both of the kitchenettes so dietary staff can place cleaning chemicals in there when not using the chemicals. -He/she has made the two cabinets and there are locks on them. -Usually the oven cleaner is kept in the main kitchen downstairs locked up, however the dietary aides bring it up to clean the steam tables when it was needed. Dietary Aide A brought it up to clean the steam table in the 3N kitchenette. Observation on 3/11/14 at 9:05 A.M., showed a small locking cabinet in both the 3S and the 3N kitchenettes, the cabinets currently held sanitizing liquid used to clean the tables. Observation on 3/11/14 at 9:20 A.M. during a tour of the facility showed no hazardous chemicals accessible to the residents. During an interview on 3/11/14 at 10:20 A.M., the Administrator said: -The oven jell is not a cleaner the dietary staff usually brings upstairs, but they did on Saturday (3/8/14) to clean the steam table in the 3N kitchenette that had dried and burned on food substances. -They found they needed locking cabinets in the the 3N and 3S kitchenettes. Both locations have steam tables. -He/she has a call into their contracted chemical company to see if they could change some of the chemicals to less hazardous chemicals. -He/she completed education with the dietary staff immediately after the incident. Have started individual training on MSDS sheets and keeping chemicals locked up at all times when not in use. -Dietary Aide A had cleaned the steam table on 3N and placed the cleaner on his/her bussing cart. Dietary Aide A and B finished cleaning in the 3N dining room and proceeded to the 3S dining room to clean/bus the tables. Dietary Aide A and B were cleaning the tables when the resident got the oven cleaner bottle off of the cart and drank from it. -He/she said the hospital is no longer sharing information with them regarding the resident's condition. They do know he/she is in the ICU in a chemically induced coma due to his/her behaviors. -It is unknown how much cleaner the resident ingested. Observation on 3/11/14 at 10:30 A.M., showed the Oven Jell bottle of oven cleaner in a plastic bag in the Administrator's office. The bottle had a cap that had a flip up lid. The cap also appeared to have the capability to be a safety locking cap, however it was easily unscrewed at this time. The Administrator said Dietary Aide A told him/her the cleaner usually has a spray lid on it, but this one had been taken off. During an interview on 3/11/14, at 2:30 P.M., Dietary Aide A said: -He/she has been employed at the facility since 9/13. He/she typically works 6:00 A.M. to 2:30 P.M.. He/she was working an extra shift on 3/8/14 from 4:00 P.M. to 8:00 P.M. -When he/she started, he/she did receive training on the cleaning chemical, the MSDS sheets, etc. -He/she does not usually bring the oven cleaner upstairs when cleaning the third floor dining areas, however on Saturday (3/8/14), the 3N steam table well had dried and burned-on food, so he/she needed to clean it. -Once done cleaning the steam table, Dietary Aide B was done cleaning the tables in the 3N dining area and they went to the 3S dining area to bus and clean the tables. -They got to 3S dining area between 6:30 P.M. and 7:00 P.M. -When they first arrived, the resident was trying to get into the trash barrel grabbing food. He/she told nursing staff, not sure who, and asked if the resident had eaten. He/she was told the resident had eaten. -They proceeded with bussing and cleaning the tables. -The cart was about 10 feet or so from him/her at the entrance of the dining area. Dietary Aide B was about 5 feet from the resident and the cart. He/she heard Dietary Aide B tell the resident, "No", he/she turned around and saw the resident with the bottle up and then the resident threw the bottle on the ground. They yelled for nurses. He/she picked up the bottle and gave it to the nurses. He/she ran downstairs to get the MSDS sheet from the book. He/she was nervous, upset, and was not able to find it so he/she came back up stairs. All in a big book in alphabetical order. When he/she came back up, the nurses had the resident on the ground having the resident drink milk. The ambulance came and the nurse took the resident to the ambulance attendants. -The resident had acted liked his/her stomach was hurting him/her afterwards. -Normally, the oven cleaner is not on his/her cart. He/she has only put that on the cart when he/she needs to clean the steam tables. -He/she had his/her back turned from the cart for about two to three minutes cleaning tables. When they got to 3S, he/she kind of lost track of the cleaner being on the cart. Having the locking cabinets in those two kitchenettes will make it much easier to keep the chemicals locked up when not using them. -The bottle of oven cleaner had the flip top lid, he/she was not able to open the lid so he/she took the lid off when he/she used it on 3N. He/she thought the lid was back on it securely. Usually there is a sprayer on the oven cleaner bottle, but it was not on this one. -He/she feels terrible, he/she knows that's a dangerous chemical in that oven cleaner. During an interview on 3/11/14 at 3:30 P.M., LPN A said: -He/she was coming on duty for the 7:00 P.M. to 7:00 A.M. shift and got there about 6:40 P.M. (on 3/8/14). -He/she was counting narcotics with the day shift medication nurse when they heard frantic yelling and screaming from the dining room. Once he/she figured out what the yelling was about they went to the dining area. They cannot see into the dining area from the nursing station. The dietary staff told them the resident had drank some of the oven cleaner. The resident was grabbing at his/her throat. He/she immediately took the resident to the pantry and gave him/her milk to drink to coat his/her throat. They also put milk in the resident's [DEVICE]. -LPN C came out of the medication room and he/she yelled for him/her to call 911. -The resident started drooling, but did not vomit. -The resident was up walking, grabbing at his/her throat, his/her face was red. The resident was also hitting his/her self in the head. -Dietary staff showed him/her the bottle of oven cleaner, knew that was very caustic. That was why he/she and co-worker thought to have the resident drink milk. The nurse practitioner confirmed that was the correct thing to do for the resident, too. -The resident was pacing and he/she was walking with the resident. He/she heard the ambulance and took the resident off of the unit to go meet them up front. It took four of them to get the resident on the gurney, they had to restrain him/her. -The resident's breathing was somewhat strained, but he/she had been walking and was agitated. -Most of the time dietary was done cleaning the 3S dining area when he/she comes on duty at 7:00 P.M.. He/she had not seen that cleaner on their carts previously. He/she thinks it was a freak accident. -The incident happened just before 7:00 P.M., at about 6:50 P.M.. -He/she spoke with the ER physician about what chemical it was the resident drank and faxed to the ER the MSDS sheet. -He/she also spoke with the ER nurse a few times, informed them about the resident's behaviors of being combative, constantly pacing, and the resident's high tolerance of medication. He/she was aware the ER was planning on chemically sedating the resident in order to admit him/her to the ICU. -The resident was constantly up and down, pacing the halls, was known to pick up things and throws them to the floor, pours things on the desk or on the floor. The resident was in constant motion. During an interview on 3/11/14 at 4:00 P.M., Hospital ICU Nurse A said: -They attempted to scope the resident on 3/10/14, but were unable to advance the scope past his/her throat due to chemical burns in throat and esophagus, and swelling. -The plan is to complete a broncoscopy and laryngoscope on 3/13/14 and likely place a tracheotomy at that time. -He/she is sedated now for treatment purposes, with propofol. He/she has Ativan and Morphine ordered for seizures and agitation. He/she has had a seizure today. He/she is on Vancomycin for possible staph infection in his/her blood. Observation on 3/11/14 at 4:25 P.M., showed the resident laying in a hospital bed, sedated and on a ventilator. During an interview on 3/12/14 at 8:30 A.M., CNA A said: -He/she has been employed at the facility since January 2014. -The resident paces all the time, they will walk with him/her to feed him/her and give him/her drinks. -The resident is usually combative when they try to change him/her. -The resident grabs items; drinks on tables, plates, forks, juice. He/she will try to drink or eat others beverages and food. He/she will grab papers and drink off of the desk, try to drink them. They will try to stop him/her and redirect him/her and get him/her his/her own drink or snack. -When the resident is up and about they keep track of him/her, following him/her because he/she also has a behavior of pulling his/her pants down or exposing himself/herself. They remind the resident to keep his/her pants pulled up and help pull his/her pants up. During an interview on 3/12/14 at 9:20 A.M., CNA B said: -The resident has behaviors of pulling down pants, scratching himself/herself, he/she is combative with cares when trying to change him/her or when nurses are doing something with his/her peg tube. He/she paces often, grabs things like paper, grabs others food and tries to eat it, grabs others beverages and tries to drink them. -When the resident grabs others food or drink, try to redirect him/her and get him/her his/her own food or drink. -They follow the resident up and down the hall trying to feed him/her. Sometimes he/she gets really hungry and he/she will eat and eat. Will sit for a few seconds and then back up pacing. -One time he/she grabbed a resident's cigarette and ate it. He/she has also eaten paper before as well. He/she tried to stop him/her, redirect him/her. Observation on 3/12/14 at 9:30 A.M. while sitting at the nursing station on 3S, showed a sign that stated both CNAs were not to leave the unit at the same time. During an interview on 3/12/14 at 10:25 A.M., CNA C said: -He/she came in on 3/8/14 to the unit at about 7:03 P.M.. He/she did not see the resident, he/she was already gone. He/she got to the unit before his/her CNA counterpart, he/she was a little later than he/she was to the unit. -The resident walks the hall all the time when he/she is not sleeping. The resident can be combative/aggressive with cares. -The resident is known to grab at drinks, either drink them or throw them to the floor. -He/she has not seen him/her grab unsafe items. -When the resident is being aggressive and is walking they follow him/her and watch him/her closely to prevent him/her from hitting. -At times he/she may be in a good mood, he/she may sit in the dining area for 5-10 minutes and the CNAs will sit with the resident. During an interview on 3/12/14 at 10:43 A.M., the resident's physician said: -He/she was not on call over the weekend and has been out sick the past two days, he/she was not aware of the resident drinking the oven cleaner. -The resident constantly paces, he/she has not been aware of the resident getting into closets or other resident's rooms. -This year he/she has a new behavior of pulling down his/her pants and exposing himself/herself. -Last year the resident was grabbing items off the nurse's desk and throwing them on the floor. More of a sweeping action of all items on the top of the desk. He/she feels the resident is somewhat mischievous. -He/she was not aware of the resident drinking or eating things. Hard to get him/her to eat, have to offer him/her items. He/she has not ever really seen the resident act hungry. -He/she was not aware of the resident grabbing and eating a resident's cigarette. -The resident grabbing the cigarette and drinking the oven cleaner is a behavior that is totally unexpected. Seems that keeping cleaners away from this resident and all residents is what is needed. -He/she has not seen cleaners accessible on the housekeepers' carts. They are locked. During an interview on 3/12/14 at 11:25 A.M., Dietary Aide B said: -He was working 10:30 A.M. to 7:00 P.M. on 3/8/14. -They were cleaning the dining room.

Based on observation, interview and record review, facility staff failed to provide protective oversight, failed to follow the facility's elopement prevention policy, failed to identify the significance of risk factors and implement preventative elopement interventions, failed to provide an initial care plan to prevent unauthorized exit from the facility and failed to adequately provide supervision, monitoring and assessment for one sampled resident (Resident #18) out of 17 sampled residents and three closed records. The resident had [DIAGNOSES REDACTED]. The resident's legal guardian placed the resident in the facility due to wandering behavior and the the inability to make decisions for himself/herself. The facility had assessed the resident at risk for elopement. On 04/16/12, the resident left the facility without staff knowledge. When the evening shift staff discovered the resident missing, they notified the Administrator, Director of Nursing (DON) and the police. On 04/17/12, an off-duty nurse saw the resident 4.9 miles from the facility and attempted to get the resident to return to the facility but the resident ran into a house. The police informed the facility staff the house was a crack house and police would have to enter the house to get the resident out. Facility doors were alarmed but no alarms sounded on 04/16/12 when the resident eloped, however, a resident room window had the screen pulled out. Also, the facility failed to complete an Elopement Risk Assessment one sampled resident (Resident #13). The facility failed to assess two residents (Resident #7 and #10) to determine if the residents were at risk for elopement. The facility census was 98 residents. Record review of the facility's Policy and Procedure for Prevention of Elopement dated 9/01/01 and revised 2/15/12 showed: -Each resident who was independently mobile either by ambulation or wheelchair should be assessed upon admission, quarterly and with change in condition that may impact their off grounds privileges using the facility Elopement Risk Assessment form to determine the supervision required to leave the facility grounds. Resident's who score at risk for elopement will have heightened monitoring (15 minute checks) for the first 72 hours after admission to establish a baseline and determine if an at what level the person is an elopement risk. -Residents identified with significant risk factors that were beyond the facility's environmental capabilities (unsecured facilities) should be evaluated for transfer to a more secure facility. -A plan of care should be developed and implemented for each resident identified as having the potential to leave the facility unauthorized or requiring supervision for off ground privileges. -An album will be kept at a secure location known to staff that contains a photograph and identification information about each resident who may be at risk for elopement. -Only facility employees will have access to facility door codes. -The album should be updated as the resident's appearance changes. -A check will be completed of all alarmed doors and resident alarms to ensure proper functioning. -Signs such as "STOP" or "DO NOT ENTER" may be posted at each exit door as a possible deterrent to cognitively impaired residents. -Activity programs should include plans for diversion and redirection during periods of increased wandering and exit seeking behaviors. -A sign out sheet should be utilized for all residents leaving the facility for a leave of absence, medical appointment, activity, etc. to ensure staff is aware of residents not in the facility. The sign out sheet will include the resident's name, responsible party, time leaving the facility and time returned. Staff should verify the person requesting to take the resident out of the facility was authorized to do so. -A notion of residents out of the facility should be made on the 24 hour Nursing Report to communicate absences from shift to shift. -The facility would not be responsible for residents during their absence from the facility when they have been signed out. 1. Record review of Resident #18's Missouri Court Case Net inquiry dated 3/28/12 showed the resident('s): -Family member was his/her court appointed legal guardian and conservator. -Legally incapacitated and disabled. Record review of the resident's Level I Preadmission Screening and Resident Review (PASRR, a required form used by the Missouri Department of Health and Senior Services (DHSS) to meet the federal mandate, 42 CFR 483.Subpart C, and reviewed by the Missouri Department of Mental Health (DMH) if screening requirements are met to determine level of services appropriate for residents with serious mental illness or mental retardation) dated 3/28/12 showed the resident: -Had the following Diagnoses: [REDACTED]. --Alcohol abuse. --Polysubstance abuse. --Tobacco use disorder. --Homeless person. -Was a flight risk and was non-complaint with medications. -Had a poor memory. -Severely confused, wandered and was suspicious. -Needed maximum supervision for safety. -Blind in one eye. -Incontinent at times. -Required prompting with activities of daily living (ADL's: grooming, bathing, and hygiene). -Needed maximum monitoring related to being a flight risk, wandering, and unable to take care of himself/herself when symptomatic. -Unable to advocate for himself/herself due to mental condition and delusions. -Had a legal guardian. -Required a Level II PASRR screening. --Note: This document was obtained from the resident's admission file on 4/19/12 at 4:40 P.M.. The document was not in the resident's medical record. The document was in the Social Services Director/Acting Administrator office. Record review of the resident's hospital medical records printed on 3/29/12 showed the resident('s): -admitted to the hospital on [DATE] after the State of Missouri Social Services department was involved. -Found wandering in the street, poorly kept, and smelled of urine. -Had been admitted by the State of Missouri Social Services department for poor living conditions and neglect. -Guardian was no longer able to take care of him/her and was transferring guardianship over to the State of Missouri. -Had a [DIAGNOSES REDACTED]. -Had grandiose delusions (a thought process characterized by fantastical beliefs that one is famous, wealthy or powerful). -Had substantial thought disorganization. -Had been admitted related to medication non-compliance and exacerbated schizophrenia, alcohol abuse and polysubstance abuse. -Unable to give the day, month or year. -Thought he/she made billions of dollars a day. -Isolated himself/herself. Record review of the resident's Level II PASRR Evaluation dated 4/3/12 completed by the a Department of Mental Health Representative showed: -The resident had the following Diagnoses: [REDACTED]. --Alcohol abuse. --Polysubstance abuse. -The resident had a family member as his/her legal guardian. -The resident had the following historical symptoms including a long history of mental illness and substance abuse with multiple hospitalization s. Known symptoms include grandiose delusions, poor ability to care for himself, living in deplorable conditions, and wandering, disorganized, tangential thought processes with loose associations. -The resident had the current symptoms indicating a psychiatric disorder which included grandiose delusions. -The resident had a long history of alcohol abuse and stated he/she had a waiver signed by his/her doctor to use crack cocaine. -The resident's legal guardian was recently admitted to a skilled nursing facility. The legal guardian was transferring guardianship to the Public Administrator. -The resident was alert and orientated with poor judgment and incoherent or illogical thought processes. -The resident did not make good decisions. -The resident had the following problematic behaviors including refusal of medications. wandering, alcohol and drug use, and seclusiveness. -Withdrawn with little or no interaction with others. -The resident thought he/she was a medical doctor. -The resident had very poor thought processes and very poor judgment. -The resident was mildly anxious and moderately delusional. -The resident had difficulty interacting appropriately or communicating effectively with others. -The resident had akathisia (inability to remain motionless). -The resident required interventions by mental health or the judicial system. -The resident required nursing home placement including a secured unit. --Note: This document was obtained from the resident's admission file on 4/19/12 at 4:40 P.M.. Record review of the resident's New Admission Memorandum dated 4/11/12 showed: -The resident had the following medical impressions: --Schizophrenia. --Disorganized thought process tangential with loose associations. --Poor insight. --Poor judgment. --Left eye blindness. --Alcohol abuse. --Polysubstance abuse. --Non-compliance with medications. -The resident had a family member as his/her legal guardian. -The resident's legal guardian lived in a nursing home and was seeking to transfer the guardianship to the Public Administrators office. --Note: There was no information regarding the resident's risk factors for elopement. Record review of the resident's Admission Nursing assessment dated [DATE] showed the resident: -Independent with transferring and ambulated independently. -Independent with shaving. grooming, and dressing. -Had adequate vision in his/her right eye but the left eye had no documentation. -Continent of bowel and bladder. -Disoriented to time, place, and person. Record review of the resident's Elopement assessment dated [DATE] showed: -Does the resident have a history or previous elopement attempts? --Answer: unknown. -Has the resident attempted to leave the facility? --Answer: no. -Does the resident wander? --Answer: no. -Does the resident have a [DIAGNOSES REDACTED].? --Answer: no. -Does the resident have an active mental Diagnosis: [REDACTED]. -Is the resident not accepting of situation or placement? -Answer: no. -Has the resident had any recent mental changes? --Answer: yes. -Has the resident had any recent psychotropic medication changes? -Answer: yes. -Has the resident stated they were leaving the facility? --Answer: no. -Is the resident's appearance that of a visitor? --Answer: yes. -A score of 3 or more (yes answers) indicated the resident was at risk of elopement. The resident scored 4 which determined the resident was at risk for elopement. --Note: The Level II PASRR screening indicated the resident wandered, was a flight risk, and had recent mental changes. Record review of the resident's Off Ground Privileges assessment dated [DATE] showed the resident: -Had no memory impairment. -Had no problems with decision making. -Had no problems with safety awareness. -The staff did not mark yes or no in the following areas: --Change in medication that could affect elopement potential. --Change in behaviors. --Any [DIAGNOSES REDACTED]. --A history of alcohol or substance abuse. -The resident was assessed to not have off ground privileges. -The resident was only allowed off grounds with supervision. -The resident was an elopement risk. Record review of the resident's Patio Privileges assessment dated [DATE] showed the resident: -Was independent with mobility within the facility. -Was physically capable of climbing. -had a history of [REDACTED]. -Was only allowed on the patio with supervision. Record review of the Resident's Nurse's Notes dated 4/11/12 at 6:30 P.M. showed: -The resident was admitted to the facility. -The resident was alert and oriented with confusion. Record review of the resident's Admission Care Plan/Interim dated 4/11/12 showed: -The document had not been completed including the elopement risk area. Record review of the resident's physician's orders [REDACTED]. -Haloperidol 20 milligram (mg) by mouth at bedtime for Schizophrenia. -Haloperidol 10 mg by mouth daily for Schizophrenia. -Cogentin 1 mg by mouth twice a day for extrapyramidal symptoms (EPS-a group of involuntary movements which include akathisia caused by antipsychotic medications including Haloperidol). Record review of the resident's Medication Administration Record (MAR) dated April 2012 showed: -The resident received the following physician ordered medications on 4/16/12 at 8:00 A.M.: -Haloperidol 10 mg by mouth. -Cogentin 1 mg by mouth. -The resident did not receive the following physician ordered medications on 4/16/12 at bedtime. -Haloperidol 20 mg by mouth. -Cogentin 1 mg by mouth. --Certified Medication Technician (CMT) A initialed and circled his/her initials on the front of the MAR. The back of the MAR had not been completed to show why the Haloperidol and Cogentin had not been administered to the resident. Record review of the Resident's Nurse's Notes dated 4/12/12 at 11:30 A.M. showed: -The resident was confused and pleasant. -The resident ambulated independently in the halls. -The resident requested to go to the hospital this morning. -Registered Nurse (RN) A told the resident he/she could not leave the building until evaluations and monitoring were completed. -The resident was fine with the explanation. Record review of the Resident's Nurse's Notes dated 4/12/12 (not timed) showed: The resident was adjusting well to his/her new surroundings. Record review of the Resident's Nurse's Notes dated 4/13/12 at 8:45 A.M. showed: -The resident stated he/she was adjusting well to the facility and surroundings. -The resident was on 72 hour admission monitoring. -The resident could ambulate independently. Record review of the Resident's Nurse's Notes dated 4/13/12 (not timed) showed: -The resident was still on 72 hour admit status. --Note: There was no further documentation about the resident. Record review of the Resident's Nurse's Notes dated 4/14/12 (no time) showed: -The resident remained on admission follow up and was adapting well. Record review of the Resident's Nurse's Notes dated 4/15/12 at 6:30 A.M. showed: -The resident had been walking around. Record review of the Resident's Nurse's Notes dated 4/16/12 on the 7:00 P.M. to 7:00 A.M. shift showed: -The note was written by Licensed Practical Nurse (LPN) B. -The resident was noted to be absent around 11:15 P.M. -Room checks were completed and other units were notified. -A code "yellow" was called. -Facility wide checks were completed including the first floor and laundry area. -A perimeter check of the exterior was completed. -The Director of Nursing (DON) and the police department were notified. -An attempt was made to contact the resident's legal guardian. Record review of the Social Services Progress Note dated 4/16/12 showed the resident: -Had been admitted to the facility from the hospital on [DATE]. -Had a family member as his/her legal guardian. --Note: There was no information regarding the resident's psychosocial background, elopement risk assessment or risk factors regarding the risk of elopement. Record review of the facility untitled document dated 4/17/12 showed: -The document had been written by the Assistant Administrator. -The resident was unable to be located in the facility on 4/16/12 around 11:15 P.M. -The resident had been seen on foot at another location (4.9 miles from the facility). -Facility staff went onsite to where the resident was along with the police. -The resident was seen going into a house. -The police informed the facility staff the house was a "crack house". -The police attempted to get the resident out but the gentlemen that answered the door was uncooperative. -The facility later contacted the resident's legal guardian who stated the resident needed to be removed from the house and placed in a locked treatment facility. -The police stated there was nothing else the facility could do. -The police would notify the Fugitive Arraignment Unit to let them know the legal guardian's wishes. Record review of the Resident's Nurse's Notes dated 4/17/12 at 3:15 P.M. showed: -The resident's legal guardian had been contacted regarding the resident's departure from the facility. -A missing persons report had been filed with the police department. -The facility had self reported the elopement to the the Department of Health and Senior Services (DHSS). During an interview on 4/17/12 at 3:15 P.M., the Assistant Administrator said: -The resident had eloped from the building on 4/16/12. -The last time the resident was seen was around dinner time on 4/16/12. -The inside of the facility and the outside of the facility were searched. -The police were called and a missing person report had been filed. -No alarms had gone off at the front door or anywhere else in the building. -He/she was unsure how the resident got out of the building. -The building has coded doors and was a locked building. -He/she thought the resident went out the front door by following someone outside. -The Maintenance Director was in the process of checking the resident room windows. -He/she had been reviewing the video tapes for the front door. -The resident had a legal guardian. -The resident was confused. -The resident thought he/she was a medical doctor. -At this time, he/she had not put additional interventions in place to prevent other resident's from eloping from the building. During an interview on 4/18/12 at 8:44 A.M., the Social Services Director/Acting Administrator said: -The resident's legal guardian was in a nursing home. -He/she had not obtained the legal guardianship papers upon admission. During an interview on 4/18/12 at 8:55 A.M., the Assistant Administrator said: -He/she had reviewed all of the facility video tapes of the exit doors. -He/she had not seen the resident leave through a facility door. -The windows and screens had been looked at by the Maintenance Director. -A window had been found with a chain was not hooked into the window to prevent it from opening all of the way. -The screen looked to be unscrewed from the outside. -The resident would have been able to fit through the window. -No staff or residents saw him/her leave the building. -No door alarms had went off. -Two CNA's had been written up for not doing rounds on 4/16/12 in the evening. -The resident had been spotted by an employee of the facility walking down the road on 4/17/12 in the evening and possible heading to a liquor store. -The employee was not working at the time. -The employee tried to get the resident to go with him/her. -The resident would not go. -The resident went into a known drug house on that street. -The employee called the facility. -The facility spoke with the resident's legal guardian who stated he/she wanted the resident picked up and put into a drug treatment center. -The Social Services Director/Acting Administrator went to the house along with the police. -The police stated to the Social Service Director/Acting Administrator the police department would then take over. -The police could not make the resident leave the house until an investigation was started. During an interview on 4/18/12 at 12:00 P.M., the Assistant Administrator said: -He/she expected the staff to complete the 72 hour monitoring on a new admission to assess the resident's elopement risk. -The resident should have 15 minute checks documented for the first 72 hours. -The 15 minutes checks had not been completed on this resident. -The facility elopement policy should have been followed. -The facility kept an elopement risk book at the nurses station for all residents at risk of elopement. -For each resident that was an elopement risk there should be a patio assessment, off ground privileges assessment, elopement risk assessment, and a picture of the resident should be in the elopement risk book. -The book should have all of the assessments and the resident's picture in it within 72 hours if the resident was an elopement risk. -The previous DON had been responsible for the book but had not been updating the book correctly. -The previous DON had been fired. Record review of the facility's undated Elopement Risk Book reviewed on 4/18/12 at 12:10 P.M. showed: -A white binder with elopement written on the outside of the binder. -There was no elopement risk assessment, patio assessment, off ground privileges assessment, or picture of the resident in the book. -The book contained a list of resident's at risk of elopement. The form was dated 11/14/11 with a total of ten residents on the list. There was one resident handwritten on the form for a total of 11 residents at risk of elopement. -The resident's information had not been updated into the Elopement Risk Book. --Note: There were no other updated lists of resident's or pictures of resident's who were at risk of elopement. During an interview on 4/18/12 at 12:25 P.M., CMT B said: -He/she was administering medications to the resident's on 4/16/12 on the day shift until 7:00 P.M. -He/she remembered seeing the resident go to the patio around 5:00 P.M. to smoke a cigarette. -The resident never spoke very much and usually kept to himself/herself. -The resident normally stayed in his/her room. -He/she was unaware of the resident's cognition status or if the resident was an elopement risk. -The Certified Nursing Assistant's (CNA's) do rounds every two hours to check on the and locate the residents. -The rounds were not scheduled for any certain times. During an interview on 4/18/12 at 12:50 P.M., Resident #8 said: -The resident would ask for him/her for cigarettes. -He/she would always give the resident cigarettes. -The resident stopped asking him/her for cigarettes on 4/14/12. -He/she found it strange when the resident stopped asking for cigarettes. -The resident did not talk much. -He/she last saw the resident sometime on Monday but did not see the resident in the dining room at dinner time. During an interview on 4/18/12 at 1:20 P.M., Nurse Practitioner (NP) A said: -His/her physician's group just started at the facility about a week ago. -The resident had not been seen by the group. -He/she was assigned to the resident. -He/she was notified of the resident's elopement from the facility. -He/she had been called by LPN B on the night of 4/16/12 and had been told about the elopement. -LPN B stated all floors were checked and outside perimeter checks had been completed. -He/she expected the facility to update the resident's care plan and individualize it. -The resident's psychosocial assessment should have been completed and tied into the care plan. -He/she expected the facility to complete one hour checks on resident's that were high risk for elopement. -He/she expected the facility policy on elopement to be followed. -He/she was new to the building and was getting familiar with policies and procedures. Observation on 4/18/12 at 2:10 P.M. showed: -Room 305 was down the hall from the resident's room. -There was a 4 foot wide by 1 1/2 foot wide window. -The window had a handle and pulled inward to open it. -There was an 7 inch chain that would prevent the window from being fully opened. -The chain was not secured in the side of the window to prevent it from opening all of the way. -The window could open the width of 1 1/2 foot. -There was a screen that was help onto the window on both sides by a screw. -The screen was screwed in from the outside. -One of the screws on the right side of the window was unscrewed. -The screen could swing open and allow a large gap. During an interview on 4/18/12 at 2:10 P.M., the Maintenance Director said: -The screen would have to be unscrewed from the outside. -The resident could have easily went through the window. -He/she checked all the screens on a monthly basis. -The windows and screens were checked 3 weeks ago and there were no broken chains or detached screens. -He/she did not keep logs of the window and screen checks. -No alarms had gone off in the building the day or in the evening the resident eloped from the building. -If an alarm went off the staff would call a maintenance person to come and reset it. -The staff cannot reset the door alarms. -The facility doors were all alarmed and locked. -There were no alarms on the windows in the building. During an interview on 4/18/12 at 2:20 P.M., Supplemental Resident #115 said: -He/she resided in Room 305. -He/she did not see anyone in his/her room messing with the window. -He/she did not know the resident. Observation on 4/18/12 at 2:22 P.M. of the resident's room showed: -The room number was 309. -The resident's name was not on the door. During a telephone interview on 4/18/12 at 2:38 P.M., LPN B said: -He/she was the charge nurse on the 7:00 P.M. to 7:00 A.M. shift on 4/16/12. -During shift change he/she thought the resident had walked by the nurses station. -He/she had not seen the resident all evening. -The CNA's were responsible for doing two hour rounds and reporting if a resident was not found. -He/she thought the CNA's were doing the rounds. -He/she did a head count of all residents around 11:00 P.M. and at 11:15 P.M. he/she could not locate the resident. -A code yellow was called and the inside of the building and the perimeter of the building were searched. -He/she called the legal guardian but had trouble getting ahold of him/her because he/she lived in a nursing home. -He/she notified the resident's physician, the DON, the Assistant Administrator and the police. -The resident was not found. -He/she believed the resident had intact cognition. -The resident did not speak very much and mainly stayed in his/her room. -If a resident was an elopement risk he/she expected the CNA's to check on the resident at least hourly. -If someone was an elopement risk he/she would post a note at the nurses station. -He/she was unaware of an elopement book that was kept at the nurses station with a picture of the resident. -He/she was unaware of the 72 hour monitoring and 15 minute check procedures for resident's that were at risk of elopement. -He/she would watch the resident for the first few days after admission. During a telephone interview on 4/18/12 at 3:05 P.M., CNA A said: -He/she worked on 4/16/12 on the 7:00 P.M. to 7:00 A.M. shift. -He/she came into work around 6:55 P.M. -The last time he/she had worked was the previous weekend and the resident was admitted after that. -He/she had not been told there was a new admission on the men's hall. -The CNA from the previous shift was already gone. -He/she had completed rounds about every two hours to check and count the residents. -The resident's room did not have his/her name on the outside of the door. -I thought it was an empty bed. -There were no documented rounds for the residents. -He/she found out when a code yellow was called by LPN B. During a telephone interview on 4/18/12 at 3:30 P.M., CNA B said: -He/she had worked on 4/16/12 on the 7:00 P.M. to 7:00 A.M. shift. -He/she knew the resident had been admitted to the facility. -When he/she came to work he/she did not see the resident. -He/she did 2 hour rounds at 7:00 P.M., 9:00 P.M., and 11:00 P.M. -He/she did not see the resident on any of the rounds. -He/she did not report this to the charge nurse because he/she did not know the resident was missing. -He/she found out the resident was missing when a code yellow was called by the charge nurse. During an interview on 4/19/12 at 12:35 P.M., the Acting Administrator and DON said: -The social services department was responsible for completing the psychosocial assessments upon admission and the information should be tied into the initial care plan. -When a new resident came into the facility he/she expected the nurse to notify the Social Services Director/Acting Administrator to update the Elopement Risk book. -The Social Services Director/Acting Administrator was responsible for putting the assessment in the Elopement Risk book along with the resident's picture. -The previous DON had been fired for not performing job duties including updating the Elopement Risk book. -The facility staff were in process of updating the Elopement Risk book. -The new DON had been there for about one month. During an interview on 4/19/12 at 1:26 P.M., LPN A said: -The resident stayed in his/her room and would come out for meals and was normally very quiet. -The longer you spoke with the resident you could tell he/she was confused and delusional. -The resident thought he/she was the medical director at a hospital. -On the first day after he/she was admitted , he/she asked to go home and get his/her check to go shopping. -The facility policy was the resident was not allowed to go out of the building for the first 72 hours. -He/she was unaware of 15 minute written checks for the first 72 hours after admission. -There was no set schedule for monitoring the resident's at risk of elopement. -He/she was unaware if the resident was an elopement risk. -He/she could check the Elopement Risk book to see if the resident was allowed out of the building. -When a nurse assesses a new resident to be an elopement risk, he/she reported the information to the DON so the Elopement Risk book could be updated. During an interview on 4/19/12 at 1:54 P.M., CNA C said: -He/she had worked on the 7:00 A.M. to 7:00 P.M. shift on 4/16/12. -He/she did not know the resident very well. -The resident was at breakfast and lunch. -The resident was dressed in a red/burgundy suit jacket in the afternoon. -The resident spent the afternoon between 2:00 P.M. and 4:00 P.M. either sitting on the heater bench by the front door or pacing from the dining room to his/her room crossing the front door. -That was the last time he/she saw the resident. -He/she did not report the resident missing because he/she thought the resident was in his/her room. -If a resident was missing he/she would report it to the charge nurse. -There was a big activity shopping trip sometime in the afternoon. -There were a lot of resident's that went out the front door. -The resident probably walked right out the front door with the group. -He/she was unaware of any monitoring that was completed on the residents. -He/she was just told to watch the front door to make sure the residents did not go out. -He/she had not been trained on the elopement policy and was unaware of what code yellow meant. -He/she was unaware of the Elopement Risk book. During an interview on 4/19/12 at 2:18 P.M., the Medical Director said: -He/she was new to the facility and only had been in the building for two days. -He/she could not really give much feedback about facility issues at this time. During a telephone interview on 4/19/12 at 2:30 P.M., the resident's Legal Guardian said: -He/she was the resident's legal guardian. -The resident had a history of [REDACTED]. -The resident had ran away from another facility that was not locked. -It took a long time to catch up to the resident. -The resident was admitted to the facility from the hospital. -He/she requested the resident go to a locked facility because the resident would get out. -He/she had been contacted by the facility and was told the resident got out and was now in a dope house. -He/she lived in a nursing home now and was ill. -This had caused him/her to be very stressed. -He/she was in the process of turning the guardianship over to the state. During an interview on 4/19/12 at 3:44 P.M., CMT A said: -He/she had worked on 4/16/12 on the 7:00 P.M. to 7:00 A.M. shift. -He/she was passing medications to the resident. -The resident did not talk much and was blind in his/her left eye. -He/she had locked his/her keys in the medication cart which put the medication pass behind. -He/she did rounds on the resident's when he/she came on shift. -He/she did not remember seeing the resident at all. -He/she went to give the resident his/her medication at 9:15 P.M. and the resident was not in his/her room so he/she did not give the resident his/her medication. -He/she did not report the reside

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on 5/04/2012. Based on observation, interviews and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. There had been no resident elopements since the exit of 4/20/12. Facility staff had received training regarding the elopement prevention policy and procedures. The resident elopement prevention notebook was up to date and accurate. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview, and record review, facility staff failed to assure staff provided emergency dental services for one of 17 sampled residents (Resident #7) who had teeth in poor condition when staff failed to make a follow-up emergent dental appointment after the resident returned from an emergency room visit related to his/her pain caused by his/her teeth. The facility census was 98 residents. Record review of the website http://www.mayoclinic.com showed: -A tooth abscess is a collection of pus that's caused by a bacterial infection in the inner part of your tooth. -A tooth abscess usually occurs as a result of an untreated dental cavity, or a crack or chip in your tooth that allows bacteria into the inner tooth. -treatment for [REDACTED]. -Leaving a tooth abscess untreated can lead to serious, even life-threatening, complications. -A tooth abscess won't go away without treatment. If the abscess ruptures, the pain may decrease significantly, but dental treatment is still needed. If the abscess doesn't drain, the infection may spread to your jaw and to other areas of your head and neck. It may even lead [MEDICAL CONDITION], a widespread, life-threatening infection. 1. Record review of Resident #7's Face Sheet 3/1/12 showed the resident: -admitted to the facility on [DATE]. -Had the following Diagnoses: [REDACTED]. --Mental [MEDICAL CONDITION] (a disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits). --Chronic [MEDICAL CONDITION]: (a [MEDICAL CONDITION] infection of the liver and cause inflammation and even death in serious situations; can be caused by needle sharing and/or unprotected sex). --Asthma: (a respiratory disorder characterized by recurring episodes of shortness of breath, wheezing on expiration and/or inspiration caused by [MEDICATION NAME] of the bronchi, coughing, and thick secretions). --Toxic effects of tobacco use. --Suicide and self inflicted injury. --Obesity. -Had child like behavior. -Had a Public Administrator as his/her legal guardian. Record review of the resident's Physician's Order Sheet (POS) dated 3/1/12 showed: -The resident had the following Diagnoses: [REDACTED]. --Borderline personality disorder: (a personality disorder marked by a long-standing pattern of in relationships, behavior, mood, and self-image that can interfere with social or occupational functioning or cause extreme emotional distress). --[MEDICAL CONDITION]. --[MEDICAL CONDITION]: (an infection of the liver that is caused by [MEDICAL CONDITION], is transmitted by contaminated blood or blood derivatives in [MEDICAL CONDITION], by sexual contact with an infected person, or by the use of contaminated needles and instruments. The disease has a long incubation and symptoms that may become severe or chronic, causing serious damage to the liver). --[MEDICAL CONDITION]. --Overweight. -Had the following physician ordered medications: --Tylenol 650 milligrams (mg) every 4 hours as needed for pain or fever. --[MEDICATION NAME] HCL 50 mg every four hours as needed for pain or fever. --[MEDICATION NAME] 500 mg three times per day as needed for pain. -Had the following physician's order: --May see a dentist for dental care. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -The resident received the following physician ordered medications: --[MEDICATION NAME] 500 mg on 3/1/12 at 9:00 P.M. with no indications for use. --Tylenol 650 mg on 3/2/12 at 8:00 P.M. with no indications for use. --[MEDICATION NAME] 500 mg on 3/8/12 at 7:05 A.M. with no indications for use. --[MEDICATION NAME] 500 mg on 3/9/12 at 3:10 P.M. with no indications for use. --[MEDICATION NAME] 50 mg on 3/16/12 at 6:25 P.M. for a headache. --[MEDICATION NAME] 50 mg on 3/18/12 at 4:00 A.M. for pain. --[MEDICATION NAME] 50 mg on 3/22/12 at 4:00 A.M. with no indications for use. --[MEDICATION NAME] 500 mg on 3/24/12 at 8:00 P.M. for pain. Record review of the resident's admission Nurse's Note dated 3/1/12 on the 7:00 A.M. to 7:00 P.M. shift showed no information regarding the resident's mouth or teeth condition. Record review of the resident's Admission Care Plan dated 3/1/12 showed: -The oral/dental status section contained the following information to be completed by facility staff: --Dentures, oral care twice a day, assess oral cavity, evaluate needs for dental exam, and mark dentures for personal identification. ---None of the areas were completed. Record review of the resident's admission Minimum Data Set (MDS)(a federally mandated tool required to be completed by facility staff) dated 3/8/12 showed the resident: -Had intact cognition. -Had no information listed under the oral/dental section. -Independent with hygiene, dressing, and eating. Record review of the resident's Comprehensive Care Plan dated 3/9/12 showed no information regarding the resident's teeth. Record review of the resident's POS dated 3/25/12 showed: -The resident had the following physician ordered pain medications: --Tylenol 650 milligrams (mg) every 4 hours as needed for pain or fever. --[MEDICATION NAME] HCL 50 mg every four hours as needed for pain or fever. --[MEDICATION NAME] 500 mg three times per day as needed for pain. --[MEDICATION NAME] inject one milliliter/5 milligram, intramuscular (IM-injection/shot) as needed for agitation. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] --[MEDICATION NAME] 875 mg tablets: take one tablet by mouth twice a day for 10 days. The medication had been given to the resident from 4/2/12 through 4/12/12. --[MEDICATION NAME] 5/500 tablets: take one or two tablets by mouth every 4 to 6 hours as needed for pain. The medication had not been given to the resident. -The resident received the following physician ordered medications: --[MEDICATION NAME] 500 mg on 3/25/12 at 12:00 A.M. with no indications for use. --[MEDICATION NAME] 50 mg on 3/26/12 at 2:00 P.M. with no indications for use. --Tylenol 650 mg on 3/29/12 at 4:00 P.M. with no indications for use. --[MEDICATION NAME] 50 mg on 4/8/12 at 4:00 P.M. for head pain. Record review of the resident's Nurse's Notes dated 4/1/12 at 5:45 P.M. showed: -The resident asked to go to the hospital for front tooth pain. -A staff member told the resident to try some as needed pain medication first. -He/she would add the resident to the list of resident's that needed dental services. -The resident was upset. -The staff member explained the facility needed a doctors order to send him/her to the hospital. -The resident was angry and started throwing the facility treatment book and pushing the treatment cart. -The facility staff were unable to give IM [MEDICATION NAME] due to the resident's uncontrollable aggressive movement. -The resident continued to hit, kick, scratch, and twist the staff members arm. -911 was called. -The police came and handcuffed the resident. -The resident was sent to the hospital in an ambulance. -The resident's physician and Public Administrator (legal guardian) were notified. --Note: No assessment was completed of the resident's mouth or teeth. Record review of the resident's hospital emergency room , psychiatry report, dated 4/1/12 showed the resident('s): -Came to the emergency room for a visit. -Had been yelling at the facility staff because they would not give him/her pain medication related to his/her tooth pain. -Agitated, alert and oriented, and in pain. -admitted to hitting and scratching at staff. -Pain had been going on for awhile and he/she had requested to go to the hospital. -Had poor dentation with diffused tooth decay. -No threat to himself/herself or suicidal. -Now calm and not expressing anger and there were no grounds for a psychiatric admission. Record review of the resident's After Care Instructions from the emergency room dated 4/1/12 showed: -The resident had been seen for dental cavities. -The resident may feel pain with drinking hot liquids, eating sweets, or chewing. -The resident would be provided with pain medication. -It was very important to follow up with the dentist. -The recommended follow up time with a dentist was as soon as possible, ideally in 2-3 days. -The resident had a dental abscess (A pus enclosed in the tissues of the jaw bone at the apex of an infected tooth root(s). Usually the abscess originates from a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by untreated tooth decay, cracked teeth or extensive periodontal disease). -Symptoms of a dental abscess include tooth pain, swelling of gums, and pus may drain from the tooth. -The resident was discharged back to the facility with the following medications: [REDACTED] --[MEDICATION NAME] 875 milligram (mg) tablets: take one tablet by mouth twice a day for 10 days. (A medication to treat an infection). --[MEDICATION NAME] 5/500 tablets: take one or two tablets by mouth every 4 to 6 hours as needed for pain. Record review of the resident's Telephone Orders Sheets dated 4/1/12 through 4/11/12 showed no physician's order for immediate dental services. Record review of the Nurses Note's dated on 4/1/12 at 9:15 P.M. showed: -The resident returned from the hospital and wanted to take a shower. -The resident wanted to take a shower and started quarrelling with another resident about who would take a shower first. -The resident hit the other resident in the jaw and was hitting and pulling the tables in the dining room. -The resident was given [MEDICATION NAME] IM 1ml/5mg. --Note: The [MEDICATION NAME] IM injection was not documented in the resident's MAR. -The staff continued to watch the resident for 30 minutes. -The resident took a shower at 11:30 P.M. -The resident had no more behaviors. --Note: There was no documentation related to the condition of the resident's teeth or a dental appointment. Record review of the resident's Nurse's Notes on 4/3/12 at 4:00 P.M. showed: -The resident continued on antibiotics therapy for a tooth ache with no adverse reactions. Record review of the resident's Nurse's Notes on 4/4/12 showed: -The resident continued on antibiotics therapy for a tooth ache with no adverse reactions. Observation on 4/13/12 at 12:45 P.M. of the resident's mouth showed: -His/her upper four front teeth had blackened, heavily decayed areas with a white build up around the gum line. -The gum line was red and swollen. During an interview on 4/13/12 at 12:45 P.M., the resident said: -He/she was angry and upset one evening because his/her mouth hurt badly. -He/she was not allowed to go to the hospital and get his/her teeth looked at. -The pain was bad. -He/she started throwing items and was finally sent to the hospital. -The facility was suppose to set up a dental appointment but no one has told him/her if an appointment had been made. -His/her teeth hurt badly, especially while eating and drinking. -He/she asked for pain medications sometimes for the pain in his/her mouth. -He/she touched his/her front teeth and flinched in pain and cried out "it hurts". During an interview on 4/12/12 at 10:42 A.M., Licensed Practical Nurse (LPN) E said: -The resident had teeth in poor condition. -His/her front teeth were decayed and blackened. -The resident would sometimes complain about his/her teeth hurting. -Sometimes, he/she would give the resident pain medications for the tooth pain. -The facility had a list of residents that needed to be seen by a dentist. -The facility had a list that was kept at the nurses station for resident's that needed dental services. -The resident did not get put on the list for dental services. -He/she could not locate the list. -There was no physician's order for emergent dental services but an order should have been obtained when the resident came back from the hospital. -The social services department coordinates the dental visits. -The social services department should have been notified of the resident's decayed teeth. During an interview on 4/17/12 11:20 A.M., the Social Services Director/Acting Administrator said: -He/she had not been notified of the poor condition of the resident's front teeth. -He/she should have been notified so he/she could call the dentist. -The dentist could have assisted in setting up emergent dental services for the resident. During an interview on 4/20/12 at 11:36 A.M., the Director of Nursing said: -He/she expected the nursing staff and social services department to obtain dental services as needed for the resident. Note: A dental policy was requested but not obtained from the facility.

Based on observation, interview and record review, the facility staff failed to adequately supervise and assess one resident (Resident #14), who had a history of [REDACTED].#14 from having two unauthorized exits from the building on 10/23/11, and one attempt to exit from the building on 10/23/11; failed to ensure all facility alarmed doors were secured and alarmed which allowed two residents (Resident #15 and Resident #16), who both had a history of [REDACTED]. to the facility from an unauthorized absence for one resident (Resident #14); and failed to update the care plan for two residents (Residents #14 and #15) with specific and measurable interventions to address wandering and exit-seeking behaviors of nine sampled residents who were assessed as an elopement risk. The facility census was 80. Record review of the facility's Policy and Procedure for Prevention of Elopement dated 9/01/01 and revised 2/11/11 showed: - Each resident who was independently mobile either by ambulation or wheelchair should be assessed upon admission, quarterly and with change in condition that may impact their off grounds privileges using the facility Elopement Risk Assessment form to determine the supervision required to leave the facility grounds. - Residents identified with significant risk factors that were beyond the facility's environmental capabilities (unsecured facilities) should be evaluated for transfer to a more secure facility. - A plan of care should be developed and implemented for each resident identified as having the potential to leave the facility unauthorized or requiring supervision for off ground privileges. - An album will be kept at a secure location known to staff that contains a photograph and identification information about each resident who may be at risk for elopement. - The album should be updated as the resident's appearance changes. - A check will be completed of all alarmed doors and resident alarms to ensure proper functioning. - Signs such as "STOP" or "DO NOT ENTER" may be posted at each exit door as a possible deterrent to cognitively impaired residents. - Activity programs should include plans for diversion and redirection during periods of increased wandering and exit seeking behaviors. - A sign out sheet should be utilized for all residents leaving the facility for a leave of absence, medical appointment, activity, etc. to ensure staff is aware of residents not in the facility. The sign out sheet will include the resident's name, responsible party, time leaving the facility and time returned. Staff should verify the person requesting to take the resident out of the facility was authorized to do so. - A notion of residents out of the facility should be made on the 24 hour Nursing Report to communicate absences from shift to shift. - The facility would not be responsible for residents during their absence from the facility when they have been signed out. Review of the facility's Policy and Procedure for Alarm Checks dated 2/3/05 with a revision date of 2/1/11 showed the purpose was to ensure resident and door alarms were properly functioning to protect the safety of facility residents. The procedures included: -All door alarms should be checked for proper functioning. -Nursing would be responsible for checking the functioning of all door alarms at the beginning of each shift. -The door alarm check sheet would be kept in the form of the narcotic count book at each nurses station. -Any non-functioning units would be reported to the maintenance department immediately. -Maintenance would conduct weekly alarm checks and record in the maintenance log. -The Administrator and Director of Nursing should be notified immediately of non-functioning door alarms. -Interventions shall be implemented to protect the safety of the residents until the door alarm has been repaired. This may include a staff member sitting at the non-functioning door until repair was completed. Record review of an undated statement found in the front of the facility's Elopement Risk book showed: - It was the facility's mission statement to properly assess and plan care for residents upon admission and on a quarterly basis thereafter to determine the amount of supervision that may be required to leave the facility grounds. - Elopement was defined as when a resident wanders away, walks away, escapes or otherwise leaves a care giving facility or environment unsupervised, unnoticed and/or prior to their scheduled discharge. 1. Record review of Resident #14's undated face sheet (a medical record that contains all the resident information that is placed in the front of each chart) showed: - The Public Administrator (PA) was the resident's court ordered guardian. - The resident had [DIAGNOSES REDACTED]. - The resident's original admitted to the facility was 7/08/10. - The resident's current admitted was 9/16/10. Record review of Resident #14's undated Elopement Risk Record showed the resident: - Cognitively impaired with poor decision making skills. - Able to ambulate independently. - Verbalized the desire to leave the facility. - had a history of [REDACTED]. - had a history of [REDACTED]. Record review of the resident's Admission History and Physical dated 9/20/10 showed: - After the resident left the facility, he/she was found passed out with a facial fracture and sun burns on his/her arms. - The resident had a history of [REDACTED]. Record review of the resident's Psychiatric Evaluation dated 12/30/10 showed the resident: - Required maintenance care and support for mild depression and alcohol induced dementia. - had a history of [REDACTED]. - Had limited insight and judgement. Record review of the resident's Nurse's Notes (NN) dated 1/26/11 at 9:30 P.M., showed: - Another resident reported to staff that Resident #14 was walking around outside the building by the front door. - The resident was intoxicated and stumbling around. - Facility staff assisted the resident back into the building and confiscated a bottle of Vodka. - The resident was cursing with slurred speech. - The resident told the facility staff he/she knew the door code to get out of the building. - The facility Director of Nursing (DON) instructed the staff to temporarily move the resident to a more secure unit for his/her safety. - The resident did not have any apparent injuries. - The resident's guardian (PA) was notified. - It was not known how long the resident had been gone or how far he/she went before he/she was found right outside the front door. Review of website, www.wunderground.com, showed: - The mean temperature for 1/26/11 was 24 Fahrenheit (F). - The maximum temperature was 30 F. - The minimum temperature was 17 F. Record review of the resident's NN dated 1/27/11 showed: - The resident was transferred to a more secure unit due to elopement risk. - Staff were to be aware of the resident's movements at all times. Record review of the resident's NN dated 2/19/11 showed the resident was transferred back to the less restricted unit. Record review of the resident's NN dated 3/21/11 showed: - The resident left the building unaccompanied and without permission. - Three staff persons followed the resident and redirected him/her back into the building. - Staff educated the resident that his/her guardian instructed the resident was not able to leave the facility by him/herself. - The resident went to bed without any conflict when he/she came back into the building. - Staff put the resident on every 15 minute checks. - The resident's physician was notified. - The resident did not leave the facility property, however it is not known where on the property he/she was found. Review of the website, www.wanderground.com, showed the minimum temperature for 3/21/11 was 53 F. Record review of the resident's care plan dated 3/22/11 showed: - The resident attempted to elope from the facility. - The goal was for the resident not to attempt to elope. - Staff were to watch the resident by the front door and redirect when the resident was found by the door. - Note: There were no updates to the plan of care after any subsequent unauthorized absences until after the resident's last elopement on 10/23/11. Record review of resident's Psychiatric Evaluation dated 6/28/11 showed the resident continued to request and make statements to get him/her released from guardianship. Record review of the resident's Social Service Progress Notes dated 7/08/11 showed the resident's guardian approved: - For the resident to be allowed one 15 minute unescorted outing a day on the day shift. - The approval was for a two week trial period. - The outings would be extended and expanded with appropriate behavior. - The approval would be immediately revoked with any abuse of the privilege. Record review of the resident's Social Services Notes dated 7/14/11 showed: - The resident went out on pass and stayed out two hours longer than allowed. - Staff reported the resident was intoxicated when he/she returned. - The resident was told his/her privileges were revoked as per the instruction of the guardian. - The revocation was posted at the nurse's station and in the resident sign out book. Review of the website, www.wunderground.com, showed: - The mean temperature for 7/14/11 was 82 F. - The maximum temperature was 91 F. - The minimum temperature was 75 F. Record review of the resident's Care Plan dated 8/04/11 showed: - A problem identified the resident leaving the building and coming back inebriated. - The goal was for the resident not to drink alcohol while residing at the facility. - Staff were to monitor the resident's behavior daily to ensure he/she was not drinking alcohol. - Staff would provide emotional support when needed. - Nursing would teach the resident what could happen when mixing alcohol with the medications the resident was taking. - Nursing would monitor and maintain safety if the resident came back to the facility intoxicated from pass. Record review of the resident's NN dated 8/05/11 showed: - The resident returned from a pass to the store (half a block from the facility) with unsteady gait, slurred speech and aggressive language and behavior toward staff. - Staff saw a bottle of alcohol stuffed in the resident's pants. - The resident refused to give the bottle to the staff at first, but with continued intervention by staff he/she gave them the bottle. - The resident continued to yell at staff and other residents. - The resident pushed chairs. - Staff called the police. - The police refused to take the resident because he/she had not actually hit anyone. - The resident went to sleep for a few hours and then came back out of the room yelling and threatening staff. - The police were called again. - The police talked to the resident for 20 to 25 minutes and left. - The resident went to bed and slept the rest of the night. Record review of the resident's Elopement Risk assessment dated [DATE] showed the resident left the facility and came back inebriated (intoxicated). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff used in the care planning process), dated 9/22/11, showed the resident: - Had moderately impaired organized thinking. - Did not exhibit any wandering behavior. Record review of Resident #14's physician's orders [REDACTED]. - Celexa 40 mgs. twice a day (a medication to treat depression). - Vicodin one tablet every six hours as needed for pain (a narcotic pain medication that contains 7.5 mgs of hydrocodone and 750 mgs of Acetaminophen). Record review of the resident's NN dated 10/23/11 at 4:20 P.M. showed: - A staff person told Licensed Practical Nurse (LPN) B that another resident told him/her that this resident had put a chair up to the fence on the patio and went over the fence. - LPN B went out of the building and found the resident and brought him/her back to the building. Record review of a facility incident report dated 10/23/11 at 4:20 P.M.. showed: - Another resident told staff Resident #14 put a chair up to the fence on the patio and jumped over the fence. - LPN B and another staff person immediately went to look for the resident. - The resident was found across the street from the facility. (Note: The facility was approximately 15 feet from the street. The street was a regular two lane residential street. The apartments across the street start about 15 feet from the curb and are about a half block square) - Staff walked the resident back to the facility. - Staff monitored the resident for elopement. (Note: There was no documentation of how the resident was to be monitored.) - The resident climbed out a window at the back of the men's hall. - LPN B tried to catch the resident, but the resident ran into the woods next to the facility parking lot. (Note: This was approximately 60 feet from the gated patio that the resident climbed over. This was the patio for residents' use. The residents had the door code to access the patio without staff.) - Staff called 911, the facility DON, the resident's physician and guardian. Record review of a typed report provided by the facility DON showed: - On 10/23/11 at 4:40 P.M., it was reported by another resident that Resident #14 had jumped over the fence from the patio. - The resident was found at a house. - The resident returned to the facility with the staff. Record review of the resident's NN dated 10/23/11 at 5:40 P.M. showed: - When the staff brought Resident #14 back to the facility, the resident was pacing around the facility and patio. - LPN B instructed the Certified Medication Assistant (CMT) to monitor the resident outside. - When LPN B returned from providing treatment to another resident, staff told him/her the resident was attempting to get out of a window in the back hall. - When LPN B got to the outside of the building where the resident had gone through the window, the resident had gone into the woods. - LPN B called 911, the resident's physician and guardian (PA) and the facility DON. During an interview on 10/31/11 at 11:12 A.M., CMT A said that on 10/23/11: - Resident #14 jumped out of the window and ran into the woods on 10/23/11, before staff could stop him/her. - When the resident jumped over the fence, CMT A was at the front desk. - The residents were allowed to go out on the patio without staff to get air. - The residents were given the door code to the patio to let themselves out and in. - The patio area was gated. - Another resident came in and said Resident #14 went over the fence. - CMT A did not remember who the resident was who told him/her this. - After the staff had escorted the resident back in the building, the resident was out on the patio again. - CMT A observed the resident put a chair to the fence and the resident climbed on the chair appearing to try and go over the fence again. - CMT A went out on the patio and talked the resident into coming back in the building. - CMT A told LPN B about the incident. - The resident was not officially on a 1:1 observation, however staff watched him/her. - The resident went back to the man cave (sitting area) on the men's unsecured unit. - A resident said Resident #14 was trying to go out of the window in the unit. - CMT A did not remember who the resident was who reported this. - Residents were usually put on a 1:1 observation when they attempted to elope. Review of a website, www.wunderground.com, showed the outside temperature on 10/23/11 at 4:54 P.M. was 77 F. Record review of a typed report provided by the facility DON showed: - The staff notified the DON on 10/23/11 at 6:00 P.M. that the resident went out a window in the unit and ran into the woods toward Swope Park (a 1,805 acre heavily wooded urban park). - The staff notified the police and the resident's guardian (PA). Record review of a typed report provided by the facility DON showed: - On 10/23/11 at 7:00 P.M., CMT A was on his/her way home when they saw the resident hitch-hiking - CMT A stopped and stayed with the resident until the police came. - The resident had a bottle of Vodka. - The police took the resident back to the facility. - The resident smelled of alcohol and was belligerent and could not remember who people were that were familiar to him/her. - The resident went back to the unit and stood in front of the window he/she had gone out of earlier. - The DON stepped between the resident and the window. - The staff and the resident walked back to the nurse's station. - The resident was aggressive and belligerent with the staff and the ambulance staff when they transported him/her from the building. Record review of the Physician's Telephone Orders dated 10/23/11 at 7:55 P.M. showed an order to send the resident to the emergency room for evaluation and treatment secondary to elopement and drunkenness. Record review of the NN dated 10/23/11 at 8:30 P.M. showed: - The resident was returned to the facility by the police at 7:50 P.M.. - The resident appeared drunk, very restless and confused. - The physician on call for the resident's physician was called and an order to send the resident to the emergency room was received at 7:55 P.M.. - Staff placed a call to the resident's guardian (PA) emergency number at 8:10 P.M.. - An ambulance transported the resident at 8:15 P.M.. Record review of the NN dated 10/23/11 (no time) showed the facility received a call from the hospital emergency room nurse saying the resident did not meet admission criteria and would be returned to the facility. Record review of the NN dated 10/23/11 at 11:45 P.M. showed: - The resident returned from the emergency room . - The resident accused the staff of lying. - Staff placed the resident on a 1:1 observation. Record review of a typed report provided by the facility DON showed: - Resident #14 was returned to the facility from the emergency room (on 10/23/11) due to him/her not meeting the hospital criteria for admission. - The resident was quiet and slept during the night. Record review of the resident's care plan dated 10/23/11 showed: - The resident was an elopement risk due to wandering behavior and cognition impairment. - The resident left the building via the patio fence. - The goal was for the resident not to wander from the facility and would not sustain any injury from leaving the facility. - The resident would not leave the building unescorted. - The resident would adhere to facility policy. - Staff would monitor the residents location at all times. - If the resident continued to attempt to leave the facility, staff would send him/her to the emergency room . Record review of a typed report provided by the facility DON showed: - Staff informed the resident on 10/24/11 at 7:00 A.M., he/she could not leave the building or go to the patio by him/herself. - The DON spoke to the resident's guardian (PA) and the facility Acting Administrator (ADM). - Referrals would be sent to a more restricted facility. During an interview on 10/31/11 at 8:50 A.M., the facility DON said: - The staff called him/her on 10/23/11 (no time given) and said Resident #14 jumped over the fence. - The staff called again and said the resident went out the window. - He/she went to the facility and helped the staff keep an eye on the resident. - He/she did not ask the staff if there was a staff person on the patio with the resident when he/she went over the fence. - He/she thought the resident would go to bed and "sleep it off" when they brought him/her back the first time. - The resident was acting different than usual. - When CMT A got off work and was driving home, he/she saw the resident hitch hiking. - The resident would not go with the staff person back to the facility. - CMT A called the police. - The resident went back to the facility with the police. - Facility staff sent the resident to an emergency room and he/she was returned to the facility. - Staff took turns sitting by the window that the resident went out until the next day when chains were put on the window to prevent the window from opening wide enough for someone to get out. - Staff monitored the resident on 1:1 observation until he/she was transferred to a more secure facility. - The resident was not put on 1:1 observation until the last time he/she was brought back to the facility on [DATE]. During an interview on 10/31/11 at 11:12 A.M., CMT A said: - Resident #14 jumped out of the window on 10/23/11 (no time given) and ran into the woods before staff could stop him/her. - When the resident jumped over the fence, CMT A was at the front desk. - The residents were allowed to go out on the patio without staff to get air. - The residents were given the door code to the patio to let themselves out and in. - The patio area was gated. - Another resident came in and said Resident #14 went over the fence. - CMT A did not remember who the resident was that reported this. - After the staff had escorted the resident back in the building, the resident was out on the patio again. - CMT A observed the resident put a chair to the fence and climb on the chair appearing to try and go over the fence again. - CMT A went out on the patio and talked the resident into coming back in the building. - CMT A told LPN B about the incident. - The resident was not officially on a 1:1 observation, however, staff watched him/her. - The resident went back to the unit. - A resident said Resident #14 was trying to go out of the window in the man cave on the unsecured men's unit. - CMT A did not remember who the resident was who reported this. - It was CMT A's opinion Resident #14 had been drinking alcohol and was not acting like him/herself. - Residents were usually put on a 1:1 observation when they attempted to elope. During an interview on 10/31/11 at 11:20 A.M., the facility DON said: - He/she was not aware of the second time Resident #14 attempted to go over the fence. - If he/she had known about the incident he/she would expect the staff to put the resident on 1:1 observation. - Staff watched the resident. - He/she helped the staff watch the resident. - Staff could not "sit right on" the resident. - When the DON was watching the resident and had to go do something, he/she told another staff person to watch him/her. - He/she thought the resident would go to bed and sleep it off. During an interview on 11/02/11 at 2:20 P.M., LPN B said: - He/she remembered seeing Resident #14 on the men's unit on 10/23/11, before the resident jumped over the fence. - A resident came and said the resident jumped over the fence. - LPN B and another staff person found the resident across the street from the facility. - Staff called the resident's doctor, guardian and the facility DON. - Staff monitored the resident when he came back to the facility. - LPN B stayed with the resident "most of the time". - LPN B asked CMT A to watch the resident when he/she had to go and do treatment for [REDACTED]. - LPN B had seen Resident #14 drunk before and it was his/her opinion the resident was not drunk at that time. It was his/her opinion the resident had been drinking. - The resident was being monitored on 15 minute checks. - LPN B did not know where the facility 15 minute check sheets were kept, so no sheets were filled out. - LPN B was concerned about what the resident might do so he/she instructed the staff to keep an eye on him/her. - When Resident #14 went out the back window, LPN B was with another resident doing a treatment. - He/she thought CMT A was on the patio with the resident. - CMT A did not tell LPN B about the resident's second attempt to go over the fence. - If LPN B knew about the second attempt, he/she would have put the resident on a 1:1 observation and called the resident physician to see about getting the resident transferred. During an interview on 11/02/11 at 2:30 P.M., CMT A said he/she: - Was at the front desk on 10/23/11 (no time stated) when a resident came and said Resident #14 was trying to go out of the window. - Ran to the back where the windows were. Observation on 11/02/11 at 2:30 P.M. of the man cave (sitting area) on the men's unit where Resident #14 resided showed: - Windows along the north wall of the area. - The bottom section of the windows had a pane that opened into the facility from the top. - There was a chain preventing the windows from opening all the way. - There was a bar on the outside of the building in front of the windows. Observation on 11/02/11 at 2:45 P.M. of the patio area showed: - The facility wall on two sides of the patio. - An iron fence and gate around the other two sides of the patio. - At the top of the fence and gate were pointed rods that bent in toward the patio. - Some of the bars had the points broken off. - There were gaps between the bars between sections of the fence. - There was an eighteen inch gap between the bars between the right side of the gate and the fence. During an interview on 11/02/11 at 2:48 P.M., CMT A said that on 10/23/11: - Resident #14 put a chair to the area between the gate and the fence and attempted to go over the fence. - CMT A saw the resident and talked him/her into going back into the facility. - CMT A told LPN B about the incident. - He/she was driving home after he/she got off work and saw the resident five blocks from the facility on Cleveland Street. - The resident was in front of the large fountain in front of the old entrance to Swope Park. - CMT A attempted to get the resident to go back to the facility with him/her, but the resident would not go. - CMT A called the police and stayed with the resident until the police got there. During an interview on 11/02/11 at 3:02 P.M., Registered Nurse (RN) A said: - He/she was at the facility when the police brought the resident back to the facility on [DATE]. - The facility DON was in the building. - Because the resident was aggressive, the nurse called the physician and got an order to send him/her for a psychiatric evaluation. - Two hours after the resident left for the hospital, hospital staff called and said the resident did not meet admission criteria and they were sending him/her back to the facility. - The resident returned to the facility after 11:00 P.M., and was placed on a 1:1 observation. - The resident watched TV and the staff watched with him/her. - Staff watched the window the resident went out all night. - After the resident went to bed, he/she slept all night. - The resident did not smell of alcohol, but it was the RN's opinion he/she was drunk because he/she was aggressive and did not know staff. - It is the facility protocol to put a resident who paced or was talking about eloping on a 1:1 observation. During an interview on 11/8/11 at 10:55 A.M., Physician A said: -His partner was notified of both elopements by the resident. -He did not expect to be notified of elopement attempts, but would expect to be notified each time a resident left the facility unattended. -Any immediate intervention for an elopement should be individual to the resident. -Interventions could include as needed (PRN) medication for agitation, 15 minute checks and 1:1 observation. -Interventions should be done, but individualized to the resident involved. -The resident had a history of [REDACTED]. -Two months ago the resident had no signs of wanting to elope from the facility. -Did not believe the facility staff could have predicted or prevented the elopement of the resident. -The resident was determined to leave the facility. 2. Record review of Resident #15's facility undated face sheet showed an admission date of [DATE] with [DIAGNOSES REDACTED]. The face sheet listed a public administrator (PA) as the resident's responsible party. Review of the resident's care plan dated 4/20/11 identified the resident required varying levels of supervision/assistance for completion of activities of daily living (ADL). The resident was sometimes resistive to help and wanted to do things for him/herself. Review of the approaches showed an update of 10/13/11 which noted the resident was found outside on the ground. **Note: The care plan showed no additional approaches, interventions or directives for the staff regarding the resident's need for increased supervision due to behaviors of wandering and exit-seeking related to the update of 10/13/11. Review of the resident's Elopement Risk assessment dated [DATE] noted the resident: -Is cognitively impaired with poor decision-making skills, -Had verbally expressed the desire to go home, -had a history of [REDACTED]. -had a history of [REDACTED]. -Wandered aimlessly. -The assessment noted interventions which included exit and stairwell alarms, placement in a secured unit and frequent monitoring. -The assessment was signed and dated by the Director of Nursing (DON). -Note: The resident's medical record showed no elopement assessments prior to 7/8/11. Review of the resident's Nurses' Notes (NN) showed on 7/2/11 at 11:15 A.M., the resident was found outside the break room door, located next to the smoke room. The resident was sitting in his/her wheelchair, was alert and oriented with confusion. An assessment found no injury to the resident, and the resident had no complaints of pain or discomfort. The resident was assisted back into the building and placed on 15 minute checks by the staff. The Director of Nursing (DON), physician and PA were notified of the incident. Review of the facility's Incident Report dated 7/2/11 and timed 11:15 A.M., noted the resident was found outside the break room door. The resident was found by staff when taking other residents out to smoke. The resident was last seen at 11:00 A.M., by the nurses' desk and had asked the staff for a soda and a cookie. The resident was found outside in his/her wheelchair, was alert and oriented with confusion. The resident stated he/she wanted to catch the bus and go home. The resident had no complaints of pain or discomfort and was assisted back into the building. An assessment found no injury to the resident and 15 minute checks were initiated on the resident. The report noted the DON, physician and PA were notified of the incident. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff used in the care planning process), dated 9/30/11, showed the resident: -Is severely cognitively impaired for daily decision making skills, -Inattentive, and had disorganized thinking which fluctuated, -Had behaviors of hallucinations and delusions, -Had daily episodes of physical and verbal behavioral symptoms which were directed towards others, -Had daily episodes of other behavioral symptoms not directed towards others, -Did not reject care, -Did not wander, -Required supervision with transfers, -Did not walk in his/her room or in the corridor, -Independent in locomotion while on the unit with supervision of the staff required, -Could not move independently of