Every finding on record at Hickory VLG NRSG & RHB

Based on observation, interview and record review, the facility failed to ensure a clean, sanitary environment in the facility's common areas. These failures affect all 69 residents that reside within the facility. Findings include: Resident Roster (6/16/25) documents in part that 69 residents reside within the facility. R2's Minimum Data Set (MDS) dated [DATE], documents in part a brief interview of mental status (BIMS) summary score of 13, indicating R2 is cognitively intact. On 6/16/25 at 9:31 AM, R2 stated that the facility is never cleaned or repaired, just look around this place. It makes me feel bad, like I am in a prison. You can tell they don't care about me or the other people. On 6/16/25 at 10:09 AM, a facility tour was conducted with V1 (Administrator) and the following observations were affirmed with V1: dirt-stained floors within dining room, dirt stained floors within the hallways, dried brown substances dripping on the walls underneath the bulletin board in main hallway, dried yellow stain from an unidentified yellow liquid throughout the entrance to the gentleman's restroom, dried red stain with approximately 3 feet in diameter from an unidentified red liquid in the group room. V1 stated that, the floors (of the facility) have definitely seen better days. V1 explained that floors and common areas should be cleaned daily and was unable to identify the substances that caused the stains. On 6/17/2025 at 9:40 AM, bathroom [ROOM NUMBER]'s toilet bowl was covered with a brown substance, brown substance was dried and smeared on the toilet seat, and an odor of feces was observed coming from the room. V10 (Activity Aide) observed the bathroom and affirmed that the brown substance was fecal matter and that the bathroom needed to be cleaned. On 6/17/2025 at 9:45 AM, the same approximately 3-foot red stain was observed within the group room. 2 additional approximately 1.5-foot splattered, dried red stains were observed under 2 other tables within the group room, as well as a 1-foot dried brown stain under another table on top of one of the red stains. Surveyor began to walk towards the table nearest to the activity director's desk and the surveyor's shoes began to stick to the ground. No wet substances were noted where the surveyor walked. V10 affirmed that the surveyor's shoes could be heard sticking to the ground and observed the dried stains under the table. V10 did not know how long the stains had been present for. V9 (Activity Director) stated that V9 thought the stains were possibly from the cranberry juice that is served at breakfast. V9 stated that the housekeeper already mopped the floors today after breakfast. Maybe the stains will come up if they mop again. On 6/17/2025 at 10:03 AM, the same dried yellow stain was observed in the entrance of the gentleman's restroom. Review of facility policy titled, Housekeeping Services Policy (effective 1/1/2025) documents in part, It is the policy of this facility to maintain a clean, (odor) free, comfortable and orderly environment in all healthcare and public areas, which meet the sanitation needs of the facility and residents' rights for a safe, clean, comfortable home-like environment . Review of document titled, Resident's Rights for People in Long Term Care Facilities authored by the Illinois Long-Term Care Ombudsman Program/Illinois Department of Aging, documents in part, .Your facility must be safe, clean, comfortable and homelike .

Based on interview and record review the facility failed to refer a resident with mental health diagnosis for PASARR level 2 screening for one of three residents (R61) reviewed for PASARR screening/assessments. Findings include: 3/20/25 V8 (Social Service Director) said R61 was not referred for PASARR level two screening. V8 said it was an error, R61 has SMI diagnosis, it was an oversite. R61 face sheet shows R61 was diagnoses with depression on 11/18/24. R61 MDS section I dated 1/2/25 for diagnosis denotes depression.

Based on interview and record review the facility failed to follow their policy and maintain an accurate account of the resident personal funds for one of three residents (R14) reviewed for resident funds. Findings include: On 3/18/25 at 11:12am R14 said he only receives 30 dollars a month, R14 said he's not sure of his trust fund statement, R14 said he's not sure about his account balance. On 3/20/25 at 10:36pm V22 (Business Office Manager) said R14 has a resident trust fund account. V22 presents documentation denoting R14 has 1510.13 dollars in his resident trust fund account, print date 3/20/25. V22 said the 1510.13 is R14's total balance. During a follow up interview V22 said R14 only has 754.00 dollars in his trust fund account. V22 said she has not been keeping an accurate account of R14's resident trust fund. Facility policy titled RESIDENT PERSONAL TRUST FUNDS dated 4/2024 denotes in-part, purpose: It is the practice of this facility to hold, safeguard, manage and account for personal funds if any resident requests facility to establish personal funds account in their behalf and deposits money with the facility in an interest-bearing account. Specifications: To establish guidelines and maintain a system for protecting resident funds which assures a full and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. Responsible Party: Administrator, Business Office Manager and Social Service Director. Resident personal funds will be maintained in the Business Office. Accounts and records will be maintained in accordance with the American Institute of Certified Public Accountants' generally accepted accounting principles. 10. The Business Office Manager will make arrangements for an interest-bearing account which will be used for the sole purpose of resident personal funds and will ensure that such accounts remain separate from any facility operating accounts. Interest shall be allocated to each resident's account at the end of each month in proportion to the resident's closing balance for that month. 11. The Business Office Manager will audit the Trust Fund account /cash and balance the personal funds bank account monthly. Upon the exit of this survey the facility failed to provide documentation of the accurate account for R14 resident trust fund.

Based on interviews and record reviews, the facility failed to effectively supervise a resident with history of alcohol abuse. This deficient practice affected one resident (R1) out of three reviewed for supervision of an avoidable incident. R1 was able to go out into the community independently, while on a restricted community pass, somehow obtain two 1.0-liter bottles of mouthwash with alcohol, and being hospitalized later with an alcohol level of 183 (normal range is 0-10) and subsequently expiring the follow day. The Death Certificate documents the cause of death cardiopulmonary arrest due to acute kidney failure and alcohol abuse. The Immediate Jeopardy began on 1/12/25 when R1 was found yelling and screaming and with altered mental status. V1 (Administrator) and V2 DON (Director of Nursing) were notified of the immediate jeopardy on 02/04/2025 at 10:45AM. The surveyor confirmed by onsite observations, interviews, and record reviews that the immediacy was removed on 2/4/2025 but remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 2/1/25, V2 DON stated that V2 worked the floor 3-11PM shift on 1/12/25. V2 stated that V2 came in prior to the start of shift and made rounds on all the residents. V2 stated that V2 rounded on R1 first because V2 was informed R1 was exhibiting behaviors of screaming and lying in bed with his pushcart on top of him. V2 stated that when V2 rounded, R1 was lying in bed without his cart. V2 stated that R1 exchanged words with his roommates that day, but no physical altercation occurred. V2 stated that R1 was transported to the hospital just prior to shift change. V2 stated that R1 had an independent community access pass. V2 stated that the nurse is expected to check the residents' belongings when the resident returns from outside pass. On 2/3/25 at 10:45AM, V2 stated that residents are able to have mouthwash in their rooms. V2 stated that R1 was not observed by staff drinking the mouthwash. On 2/3/25 at 11:35AM, V2 stated that V2 spoke with the nurse and there was 1/3 of the liquid in the alcohol-based original mouthwash bottle, the cap was broke, so it was tossed out. V2 stated that it was a bigger bottle of mouthwash, one liter size. V5 CNA (Certified Nurse Aide) stated that V5 was assigned to R1 that day. V5 stated that R1's roommate informed V5 that R1 keeps hollering. V5 stated that V5 rounded on R1 and asked R1 if he was okay, R1 responded he was okay. V5 stated that later R1's roommates again were complaining about R1's yelling. V5 stated that V5 rounded on R1 again. V5 stated that this time V5 found an empty bottle of mouthwash on the floor. V5 stated that V5 immediately informed the nurse. V5 stated that V5 is unsure how much mouthwash R1 drank if any. V5 stated that the nurse informed her to get R1 ready because R1 was getting sent out to hospital for psychiatric evaluation. V5 stated that another staff member assisted her in getting R1 dressed and then R1 left facility. On 2/3/25 at 11:00AM, V5 CNA stated that when V5 did morning rounds, R1's roommates were complaining that R1 was hollering all night. V5 stated that later the housekeeper went into R1's room to empty garbage, then told V5 he was soiled. V5 stated that she went into R1's room and found the empty bottle of mouthwash. V5 stated that it was a large bottle with a brown label on it. V5 stated that V5 brought the empty bottle to the nurses' station and gave it to V3. V5 stated that another staff member assisted V5 with providing incontinence care to R1. V5 stated that R1 typically does his care himself and is not incontinent. V5 stated that when R1 is not lucid he is very combative. V4 RN (Registered Nurse) stated that V4 worked 3-11PM shift on 1/12. V4 stated that R1 was gone before she arrived at work. V4 stated that one of his diagnoses is screaming out. V4 stated that when R1 exhibited this behavior before and R1 informed V4 that he was having a nightmare. V4 stated that R1's screaming/moaning was increased on 1/12 and that is reason they sent him out. V3 LPN (Licensed Practical Nurse) stated that V3 was working day shift on 1/12/25. V3 stated that R1 was yelling out, talking about stuff that did not make sense, and arguing with his roommates. V3 stated that R1 had a pushcart he used when walking. V3 stated that R1 put the cart in bed on top of him. V3 stated that V3 was able to remove cart from R1's bed and place it away from R1 so R1 would not put it back in bed. V3 stated that V3 exited R1's room and notified the psychiatric physician who gave an order to send R1 to the hospital for evaluation. V3 stated that V3 notified V2 and called the hospital to give verbal report. V3 stated that R1 was transported by an outside ambulance service. V3 stated that R1 had an independent community access pass. V3 stated that the residents' bags are searched upon returning from independent pass. V3 stated that residents go to the nurses' station to have their bags checked. On 2/3/25 at 10:00AM, V3 stated that she was in and out of R1's room because he was yelling all day. V3 denied seeing a bottle of mouthwash on 1/12. V3 stated that she is unsure time she last saw R1, but R1 was alert and oriented x 4 at that time. On 2/3/25 at 10:30AM, V6 (Social Services) stated that R1 did not have an independent pass to go out into the community. V6 stated that R1 was hospitalized a couple of times due to behaviors. V6 acknowledged that R1's care plan is correct and R1 was not able to go out on independent pass, R1 could go out on supervised pass with family, friends, or staff. V6 stated that with supervised pass, the person picking up the resident has to come into facility and sign resident out and then back in again upon returning. V6 was informed that this surveyor was given independent pass sign out sheets for R1 for December and January. V6 responded that R1 was able to go out on independent pass. V6 was unable to articulate how a resident would have a restricted community pass and an independent community pass at the same time. On 2/3/25 at 12:00PM, V8 (Nurse Practitioner) stated that anyone with alcohol abuse should not have access to alcohol or alcohol-based products. V8 stated that he is not sure how much mouthwash R1 drank on 1/12. R1's ambulance run sheet, dated 1/12/25, notes at 3:29PM a request for transport to the hospital for R1 due to behaviors was made by facility staff. The outside ambulance crew arrived at R1's bedside at 4:09PM. R1's nurse reported that R1 drank a full bottle of mouthwash and started to drink a second one before staff found R1. R1 is also reported to be alert and oriented x 4. The crew's assessment noted R1 to be alert and oriented x 1, skin cold, diaphoretic, mental status - slowed processing/response, confused, lungs with increased respiratory effort and breaths shallow. R1's hospital medical record, dated 1/12/25, notes when R1 presented to the emergency room , R1's respirations were very slow and sluggish and R1 was unresponsive. R1's pupils were poorly responsive. Oxygen saturation level 75% on room air. Narcan 2mg (milligrams) was administered sublingual and R1's breathing improving but still unresponsive. Narcan 2mg administered intravenously and R1 was intubated and placed on mechanical ventilator. Blood pressure gradually started to build up to 109/60 from 62/40. Arterial blood gas results showed severe metabolic acidosis. Poison control was contacted. R1's alcohol level was 183 (normal range is 0-10). The physician's narrative notes R1 is evaluated for drug overdose and respiratory difficulty including but not limited to mouthwash overdose. An urgent nephrology consultation was ordered for persistent severe metabolic acidosis and acute kidney failure. R1's laboratory results showed potassium level 6.1 (normal range is 3.5-5.1), creatinine (kidney function) level 4.21 (normal range is 0.6-1.2), and blood sugar level 41 (normal range 70-99). R1's death certificate, dated 1/13/25, notes cause of death cardiopulmonary arrest due to acute kidney failure and alcohol abuse. R1's community pass sign out sheets were provided by V1 (Administrator).They are dated 12/9/24 - 12/15, 12/27 - 12/30, and 1/2/25 - 1/13. These sheets document that R1 went out on independent passes 12/9, 12/10, 12/13, 12/30, and 1/3. R1's POS (physician order sheet), dated 1/12/25 at 12:41PM, notes an order to transfer R1 to the hospital for a psychiatric evaluation. R1's involuntary petition for hospitalization , dated 1/12/25 at 1:04PM, notes R1 was seen drinking mouthwash, staring off, and staring at wall. R1's substance use/abuse care plan, dated 9/4/24, notes R1 has a history of alcohol and illegal drug abuse. R1's community access observation, dated 11/27/24, notes R1 with history of public intoxication. R1 may not access the community independently related to safety factor. R1's community access care plan, dated 9/4/24, notes R1 may not access the community independently due to physical function and therapy goals. R1 may access the community with supervision. R1's mouthwash was identified as an original mouthwash with 26.9% alcohol by volume (the equivalent of 54 proof alcohol). It also contains eucalyptol, menthol, methyl salicylate, and thymol. The National library of medicine, dated 11/2/2023, notes poisonous ingredients in mouthwash that can be harmful in large amounts are: alcohol and methyl salicylate. Symptoms of mouthwash overdose include, but not limited to drowsiness, low body temperature, low blood pressure, low blood sugar, rapid heart rate, and rapid shallow breathing, slowed breathing, unconsciousness, and unresponsive reflexes. Per the National Library of Medicine, nonalcoholic ingredients of this mouthwash are phenolic compounds (eucalyptol, menthol, and thymol), and large-volume mouthwash ingestion will produce exposure in the toxic range of these ingredients. The phenolic compounds in mouthwash may contribute to severe metabolic acidosis, multiorgan system failure, and death. These compounds in addition to alcohol may account for the adverse effects associated with massive mouthwash ingestion. This facility's community pass policy, undated, notes approving or denying resident's independent community access or supervised community access related to, but not limited to identified risk factors in-which would place a resident in jeopardy of abuse, neglect, dehydration and any physical or psychological harm. If a resident exits the facility independently without a pass it will be assessed or evaluated to be determined whether it's an elopement, unauthorized departure, or against medical advice due to the presented risk factors. Level 1 pass privilege: resident can only access the community if he/she is accompanied by staff, family member, friend, and/or responsible party. Responsible party to inform staff the duration of pass. This facility's prohibited items policy, undated, notes residents are prohibited from possessing or having in their room any item that may pose a threat to the safety of residents. The list includes, but not limited to alcohol and potentially poisonous chemicals. The Immediate Jeopardy that began on 1/12/25 was removed on 2/4/25 when the facility took the following actions to remove the immediacy. 1. Ambulance was contacted for R1 nonemergent transfer to the hospital for behaviors. R1 was evaluated at the emergency room . 2. Facility identified residents who are at risk for obtaining contraband. This was determined by diagnosis of history of substance abuse. Independent passes were reviewed. Current substance abuse was assessed. For residents who are at risk for obtaining contraband, facility interventions include: a. Residents were interviewed and asked if they were in possession of any contraband. All residents interviewed denied having any contraband. b. Residents consented for room search with resident present and no contraband was identified. c. Residents have been offered counseling with facility counselor. d. Facility will conduct random checks with resident present to ensure no contraband is in room. Random checks will be completed once per week. e. Staff will check residents' bags upon return from out on pass to ensure no contraband is in bags. Any items identified as contraband will be removed from bags and placed in social service office. f. Alcohol based mouthwash will be considered contraband for residents with a substance abuse diagnosis. 3. Starting 2/4/2025 at 1pm, DON and Administrator will educate staff including staff on leave and on vacation on facility's prohibited (contraband) items. a. Staff will complete test to gauge understanding of teachings. 4. Starting 2/4/2025 at 1pm, All facility staff including staff on leave and on vacation will be educated and trained on signs and symptoms of alcohol intoxication and alcohol poisoning. a. Staff will complete test to gauge understanding of teachings. 5. Starting 2/4/2025 at 1pm, DON will in-service all nurses including nurses on leave and on vacation on Change of Condition Policy. a. Staff will complete test to gauge understanding of teachings. 6. Residents who have an independent pass and DX of substance abuse will be re-assessed for Community Pass. Started on 2/4/25 at 12pm and Completed by Social Service Director on 2/4/2025. 7. Residents who go out on pass supervised or independent will be subject to a of search bags that were brought in. a. Prohibited items will be removed immediately and kept at social service office. b. Staff will inventory bags brought in from community. c. Designee will review items that were brought in the next day for compliance. 8. Starting 2/4/2025 at 1pm, Social service will provide list of residents who are on Community Pass Restriction to Nurses to communicate any updates to ensure residents who are on restriction do not leave for independent pass. a. Nurses will be in-serviced on process. Starting 2/4/2025 at 1pm. b. It is not a new procedure to notify nurses of resident's pass privilege. Community Pass Policy Updated to reflect notification to nurses of resident's pass privilege. c. Community Pass Privilege or Restriction of Community Pass will be documented in the resident's physician orders. Community Pass Policy updated to reflect documentation in physician orders of pass status. 9. Facility held resident counsel to discuss facility's prohibited and contraband items. All residents attended. Completed 2/4/2025. a. Residents will complete test to gauge resident's understanding of teachings. 10. Facility will place the list of prohibited items at the back entrance to inform family and visitors. 11. Medical Director made aware of IJ on 2/4/2025 at 12pm. 12. Administrator coordinator or designee will conduct QA studies: a. A QA study will be performed at random weekly to ensure residents who are at risk of obtaining contraband do not have prohibited items in room. The QA will be completed weekly for 3 months. b. A QA study will be performed random twice weekly to ensure staff knowledge of signs and symptoms of alcohol intoxication and alcohol poisoning. The QA will include 5 staff members twice weekly for 3 months. c. A QA study will be performed random twice weekly to ensure residents do not bring in prohibited items from the community. The QA will include 5 residents twice weekly for 3 months. d. A QA study will be performed random twice weekly to ensure that a physician order reflecting residents community pass privilege is up to date, reviewing community pass logs to ensure residents sign in and out from pass, and to ensure nurses are aware on who is restricted from community pass. e. QA audits will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. 13. An emergency QAPI was conducted on 2-4-2025 at 11am. 14. Date of Completion: 2/4/2025

Based on interview and record review, the facility failed to supervise one resident who was identified as a high fall risk as well as dependent on staff for bed mobility and toileting, by leaving the resident on their side unattended on an elevated bed (approximately 3 feet). This affected one of three (R1) residents reviewed for falls. This failure resulted in R1 having an unwitnessed fall, being transferred to the hospital, and sustaining a pelvis fracture. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, depressive disorder, bilateral osteoarthritis of knees, restless leg syndrome, and fibromyalgia. R1's Brief Interview for Mental Status score dated 11/20/24 documents a score of 14/15 which indicates cognitively intact. R1's restorative program observation dated 11/20/24: toileting hygiene documents dependent on staff. Dependent helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Mobility roll left and right documents: dependent on staff. Dependent helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. R1's fall risk observation dated 11/20/24 documents: high risk for falls. Facility reportable dated 12/27/24 documents: On 12/25/24 R1 had witnessed fall while staff was providing care. Staff was providing incontinence care when resident rolled out of bed. R1 reported pain on 12/27/24, MD notified and orders to send to hospital. Xray positive for pelvic fracture. Under occurrence resolution: Staff was in-service on bed mobility and incontinence care. Staff will provide care to R1 with two staff members. On 1/9/25 at 3:47pm V3 (Certified Nursing Assistant, CNA) said around 7:00pm V3 provided incontinence care to R1. V3 said she raised the bed to waist level (V3 self-reported she was 5 feet 9 inches) and when she turned R1 to her side she observed the linen was wet. V3 said she left R1 on her left side and went to get linen from the dresser. V3 said when she was at the dresser her back was to the resident and then she heard R1 fall from the bed. R1's hospital record dated 12/27/24 documents: pelvis xray acute fracture noted in the left pubic bone, extending to the left superior pubic ramus. Facility accident management meeting form documents under root cause: Certified Nursing Aide, CNA was providing care in patient's bed. CNA rolled patient on her side and stepped away from the patient and she rolled onto the floor. New interventions: When providing care in bed CNA should always roll patient towards them and not away from them. CNA should position resident in the middle of bed before rolling patient to their side. Witness statement for V3 (CNA) documents: V3 went to provide care to R1. V3 raised the bed to waist level and turned R1 to the window. I stepped away to the dresser to grab a sheet because when V3 turned R1 she saw the bed was wet too. V3 said when she turned back around, she saw that R1 had fell . On 1/10/25 11:10AM, V2 (Director of Nursing, DON) said staff should not leave a resident unattended during care. Staff should never turn their back to a patient due to safety and fall risk. Facility in-service record sheets documents under information provided: CNAs in serviced on bed mobility. Residents should be in the middle of the bed. When rolling a resident to their side you should pull the resident to you and then roll them on their side. Always have another CNA with you when providing bed mobility. CNAs were in serviced on incontinence care. All supplies should be at the bedside when providing care. Never walk away from a patient when providing care in the bed to retrieve supplies. Always have another CNA with you when providing care.

Based on interview and record review, the facility failed to follow their notification of change guidelines by not immediately reporting one resident's (R1) fall to the physician and resident representative for one of three residents reviewed for notification. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, depressive disorder, bilateral osteoarthritis of knees, restless leg syndrome, and fibromyalgia. R's1 Brief Interview for Mental Status score dated 11/20/24 documents a score of 14/15 which indicates cognitively intact. Facility reportable dated 12/27/24 documents: On 12/25/24 R1 had witnessed fall while staff was providing care. Family and physician notified on 12/27/24. Facility witness statement by V5 (Nurse) dated 12/27/24 documents: I did not notify anyone. On 1/9/25 at 5:07PM, V5(Nurse) said she received report from R1's aide that she rolled out of bed on Christmas day. V5 said she went to the room and saw R1 on the floor next to low bed. V5 said she forgot to complete an incident report or notify the family, physician, and management. V5 said if a resident has a fall, they are supposed to notify the family, physician, and management but she just forgot. V5 said she did not tell anyone else about the fall. On 1/10/25 11:10AM, V2 (Director of Nursing, DON) said for any resident fall the nurse should notify the family, Medical Doctor or representative, and Director of Nursing on the day event occurs. Fall and notification should be documented in medical record. V5 failed to follow this procedure and was terminated because of this failure. On 1/14/25 at 10:30AM, V13 (Medical Doctor, MD) said he expects staff to notify him or his staff of any falls on the day of the incident. Facility event report for R1 dated 12/31/24 documents: event date 12/25/24 fall in resident room. Under notifications to physician and resident representative it documents no. R1's progress notes do not document any notification to the family or medical doctor on 12/25/24. Facility notification of change guideline dated 10/1/21 documents: It is the practice of the facility that changes in a resident condition or treatment are immediately shared with the resident and/or representative and are reported to and consulted with the attending physician. Facility employee report dated 12/27/24 documents: V5(Nurse) failed to report a fall incident to the Director of Nursing on 12/25/24.

Based on interview and record review, the facility failed to adequately ensure a resident (R2) was free from abuse. This failure applied to two (R1, R2) of two residents reviewed for abuse. Findings include: R1 is a [AGE] year old male who originally admitted to the facility on [DATE] and later discharged on [DATE]. R1 has multiple diagnoses including but not limited to the following: schizoaffective disorder, bipolar disorder, psychoactive substance abuse, depression, psychosis, auditory hallucinations, and suicidal ideations. R2 is a [AGE] year old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: COPD, Alzheimer's disease, CAD, type II DM, osteoarthritis, depression, bipolar disorder, and anxiety. Per Minimum Data Set (MDS) dated [DATE], shows R2 has a brief interview of mental status (BIMS) of 14 meaning resident is cognitively intact. On 12/18/2025 at 10:47AM, R2 was interviewed regarding incident on 11/22/2024 with R1. R2 said I was in my room with R3 when R1 came to the doorway. R1 briefly left and later returned. R2 said this is the first time I've interacted with this resident. R2 said I went to the door to see what R1 wanted when he asked me for a hug. He leaned in, hugged me, and gave me a kiss on the cheek. R2 said this was something I did not want to happen, and I it was an inappropriate behavior. R3 witnessed this interaction and asked R1 to leave. I immediately told V5 (Certified Nursing Assistant) and V4 (Licensed Practical Nurse) what had happened. R2 said it caused me to feel a bit uneasy. During the course of this survey, V4 and V5 were both interviewed. Witness statements dated 11/25/24 from R2 and R3 were reviewed. It is to be noted that interviews and witness statements are consistent with interview from R2. On 12/18/2025 at 11:51AM, V1 (Administrator) was interviewed regarding incident with R1 and R2 on 11/22/2024. V1 said V4 notified me that R1 had come into the doorway of R2's room and kissed R2 on the cheek. I was told that R3 was a witness to the incident, therefore I interviewed R2 and R3. I was unable to interview R1 due to him being sent to the hospital and he did not return to the facility. V1 said R2 and R3 were interviewed separately, and their stories were consistent. They are both alert and oriented. I did substantiate the abuse allegation since R2 and R3 corroborated the incident. Facility Abuse Policy with most recent revision date of 10/2022 states in part but not limited to the following: This facility affirms the right of our residents to be free from abuse. This facility is committed to protecting our residents from abuse by anyone including other residents. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault including non-consensual or non-competent to contact sexual activity.

Based on interviews and record reviews the facility failed to follow their policy and procedures for abuse reporting by not ensuring an incident of resident-to-resident abuse was reported to the administrator or to the state agency. This failure applies to two of six residents (R4 and R6) reviewed for abuse. Findings include: R4 is a [AGE] year-old female with a diagnosis's history of Bipolar Type Schizoaffective Disorder, Schizophrenia, Epilepsy, and Dementia who was admitted to the facility 07/01/2024. R4's progress note dated 09/19/2024 documents a Certified Nursing Assistant attempted to give brief to R4, she then turned around and scratched her arm. She also scratched another resident on her arm as well as she was walking by. On 09/24/2024 at 10:18 AM, V4 (Certified Nursing Assistant) stated R4 has scratched a resident before. V4 stated R4 can become physically aggressive at times based on how she is approached by staff or if residents are saying things to or around her that she doesn't like. R6 is a [AGE] year-old female with a diagnosis's history of Post Traumatic Stress Disorder, Bipolar Disorder, Depression, Anxiety Disorder, Blindness in One Eye, and Seizures who was admitted to the facility 07/11/2024. R6's progress notes dated 09/19/2024 did not include documentation of her being scratched by another resident. Review of the facility's abuse investigation reports from September 2024 on 09/24/2024 did not include a report of R4 scratching R6. On 09/25/2024 at 11:38 AM V1 (Administrator) reported that R4 scratched R6 on 9/19/24. V1 stated she was sending an initial reportable now. V1 stated the nurse on duty will be counseled on reporting/communicating any incident to the Administrator (Abuse Coordinator) and Director of Nursing immediately. The facility's Abuse Policy received 09/24/2024 states: Employees are required to report any incident of potential abuse to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported (to the state agency) within 24 hours.

Based on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not implementing approaches that would reduce the chances of abuse and by not identifying a resident's behaviors that can lead to abuse. This failure applies to four of six residents (R1, R2, R4, and R6) reviewed for abuse. Findings include: R1 is a [AGE] year-old male who was admitted to the facility 02/26/2024 with a diagnosis's history of Schizoaffective Disorder, Schizophrenia, Psychotic Disorder with Delusions, Generalized Anxiety Disorder, Major Depressive Disorder, Violent Behavior, and Drug Induced Secondary Parkinsonism. R1's Level II PASRR (Preadmission Screening and Resident Review) dated 02/26/2024 documents: He has a history of physically acting out towards peers. - A good day is Waking up, eating breakfast, getting sun light, running (partaking in sports), being able to have some peace without people bothering you. - He does not like becoming agitated, verbal aggression, and isolation. - To provide the best care for you, others need to be not being aggressive/loud or being very impulsive loud. - A bad day is Bullying from peers, people overstepping boundaries and personal space, becoming aggressive. Behavior and Symptoms include: - Serious difficulty interacting with others. R1's current care plan initiated 02/27/2024 documents he has violent behavior related to Schizoaffective disorder, Bipolar type and has a history of aggressive behavior. R1's progress note dated 09/09/2024 documents at 4:35am, he was in the hallway with his roommate shouting and very aggressive, he was the aggressor, he voiced that his roommate was shouting, calling him the F word and telling him to turn down his volume and so he got upset and punched him. The Victim (R2) had a little abrasion because he was trying to get away from him and he missed his step and sat on the floor. R2 is a [AGE] year-old male with a diagnosis's history of Bipolar Disorder, Atherosclerotic Heart Disease and Pleural Effusion who was admitted to the facility 07/31/2023. R2's progress note dated 09/09/2024 documents at 4:35am, he was in the hallway sitting on the floor with his roommate, the roommate was shouting and very aggressive, resident was the victim, he voiced that his roommate was playing a very loud music on his phone, and he called him the F word, and told him to turn his volume down and so his roommate got upset and punched him. Abuse Investigation Report dated 09/09/2024 documents R1 and R2 were in a physical altercation resulting in R2 sustaining a small abrasion to the left elbow. Witness statement from R1 dated 09/09/2024 documents at around 4:30 AM he and his roommate R2 had a verbal altercation that resulted in R1 hitting R2 in the face, R1 stated he did not want to remain in the room with R2, he is unable to get any sleep and was listening to music which led R2 to become verbally aggressive to him resulting in him hitting R2. Witness statement from R2 dated 09/09/2024 documents at around 4:30 AM he asked his roommate R1 in a verbally aggressive way to turn down his music and while attempting to use the bathroom R1 punched him multiple times in the face, he moved into the hall and lost his balance and fell . Witness statement from R3 (Roommate) dated 09/09/2024 documents he did not witness R1 and R2 fighting, he heard them argue for a minute. On 09/24/2024 at 10:28 AM, R2 stated on 09/09/2024 R1 was playing his music loud and he used vulgar and aggressive communication when he told him to shut it off. R2 stated he then went to the bathroom and R1 cut off R2's television so R2 couldn't see it. R2 stated R1 began throwing punches at him after returning from the bathroom. R2 stated R1 attacked someone else after this incident and was sent out of the facility. R2 stated R1 is going to end up in jail because of his behaviors. On 09/24/2024 at 1:05 PM R2 stated he was not educated on how not to trigger R1 to aggression or violence before becoming his roommate. R2 stated if he had been made aware he would have approached R1 very differently about his music on 09/09/2024. R2 stated the facility doesn't help with anything. On 09/24/2024 at 2:05 PM V7 (Psychosocial Services Rehabilitation Director) confirmed that if residents have a history of aggressive behavior, any potential roommates will be educated of what triggers their aggression. V7 stated he could not locate any documentation of education being provided to R2 and R3 regarding R1. V7 stated that during the time R2 was admitted to the room R1 was not exhibiting any behaviors. V7 stated he believes R1's triggers for aggression are wanting to go home, family life and certain family members. V7 stated prior to R1's incident with R2 he didn't have any triggers and was fine. R1's progress notes from June - September 2024 document he exhibited multiple instances of mood instability and was hospitalized five times within two months due to depressive, agitated, and aggressive behaviors. On 09/24/2024 3:58 PM V1 (Administrator) responded yes definitely when asked by surveyor is it important that residents be informed about triggers for potential roommates with a history of aggressive behavior. R4 is a [AGE] year-old female with a diagnosis's history of Bipolar Type Schizoaffective Disorder, Schizophrenia, Epilepsy, and Dementia who was admitted to the facility 07/01/2024. R6 is a [AGE] year-old female with a diagnosis's history of Post Traumatic Stress Disorder, Bipolar Disorder, Depression, Anxiety Disorder, Blindness in One Eye, and Seizures who was admitted to the facility 07/11/2024. R4's Level II PASRR (Preadmission Screening and Resident Review) dated 06/30/2024 documents: Her mental health symptoms in the past have included: -Being easily upset. -Rapid emotional changes throughout the day. -She is currently easy to annoy. -She is currently able to easily upset when you are unable to make your needs known. -She yells and screams at others when she is unable to communicate her thoughts. R4's current care plan does not include a care plan or interventions for her behaviors identified in her Level II PASRR screening from 06/30/2024. R4's progress note dated 09/19/2024 documents a Certified Nursing Assistant attempted to give brief to R4, she then turned around and scratched her arm. She also scratched another resident on her arm as well as she was walking by. On 09/24/2024 at 10:18 AM V4 (Certified Nursing Assistant) stated R4 has scratched a resident before. V4 stated R4 can become physically aggressive at times based on how she is approached by staff or if residents are saying things to or around her that she doesn't like. On 09/24/2024 at 3:29 PM V7 (Psychosocial Services Rehabilitation Director) stated the behaviors listed in R4's Level II PASRR from June 2024 should be included in her care planning. V7 stated he is behind in updating care plans. On 09/25/2024 at 11:38 AM V1 (Administrator) reported that R4 scratched R6 on 9/19/24. The facility's Abuse Policy received 09/24/2024 states: This facility affirms the right of our residents to be free from abuse. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse. This will be done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. The facility desires to prevent abuse by establishing a resident sensitive environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment - As part of the resident's life history on the admission assessment and comprehensive care plan, staff will identify residents who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse.

Based on interviews and record reviews the facility failed to follow their policy and procedures for care planning by not preparing a comprehensive care plan including residents identified preferences, problems, risk factors, and needs. This failure applies to two of six residents (R1 and R4) reviewed for care planning. Findings include: R1 is a [AGE] year-old male who was admitted to the facility 02/26/2024 with a diagnosis's history of Schizoaffective Disorder, Schizophrenia, Psychotic Disorder with Delusions, Generalized Anxiety Disorder, Major Depressive Disorder, Violent Behavior, and Drug Induced Secondary Parkinsonism. R1's Level II PASRR (Preadmission Screening and Resident Review) dated 02/26/2024 documents: He enjoys sports, soccer, food, and eating. -Soccer is his favorite. -He is good at playing sports, school, and running. -A good day is Waking up, eating breakfast, getting sun light, running (partaking in sports), being able to have some peace without people bothering you. -A Career, education, and sports is important to him. -To provide the best care for you, others need to be one-on-one, talking about sports. He will need to be provided the following services and/or supports: Socialization and recreation activities to decrease isolation, improve mood, and increase peer-interaction. Some things he enjoys includes sports, soccer, food, and eating. R1's current activities care plans initiated 06/06/2024 and 07/21/2024 documents he has poor use of leisure time and demonstrates significant problems with leisure and time planning related to lack of interest and initiative, R1 states he enjoys arts & crafts, exercise group, however, declines invitations to the groups, and does not include his interest in soccer or sports identified in his Level II PASRR from 02/26/2024. On 09/24/2024 3:32 PM V8 (Activities Director) stated R1 had a lack of interest of doing anything, he would come to socials or activities involving snacks and sit on the patio but other than that would never participate in activities. V8 stated R1 informed he likes arts and crafts but would never participate. V8 stated she asks the residents what their interest are and only includes information they provide directly. V8 stated if she was aware of R1's interest in soccer and sports she would have gotten a soccer ball and had him go outside, turned sports on television, and possibly taken him to a game. On 09/24/2024 at 3:58 PM V1 (Administrator) stated information regarding activity interests from past medical records should be included in the care planning process because at times residents may not divulge all available information due to discomfort or communication challenges. R4 is a [AGE] year-old female with a diagnosis's history of Bipolar Type Schizoaffective Disorder, Schizophrenia, Epilepsy, and Dementia who was admitted to the facility 07/01/2024. R4's Level II PASRR (Preadmission Screening and Resident Review) dated 06/30/2024 documents: Her mental health symptoms in the past have included: -Being easily upset. -Rapid emotional changes throughout the day. -She is currently easy to annoy. -She is currently able to easily upset when you are unable to make your needs known. -She yells and screams at others when she is unable to communicate her thoughts. R4's current care plan does not include a care plan or interventions for her behaviors identified in her Level II PASRR screening from 06/30/2024. On 09/24/2024 at 3:29 PM V7 (Psychosocial Services Rehabilitation Director) stated the behaviors listed in R4's Level II PASRR from June 2024 should be included in her care planning. V7 stated he is behind in updating care plans. The facility's Care Planning Policy received 09/24/2024 states: Purpose of the Policy is: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's mental and/or psychological needs is developed for each resident. Each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas. Incorporate risk factors associated with identified problems. Reflect the residents needs and preferences.

Based on interviews and record reviews the facility failed to follow their policy and procedures for provision of social services by not ensuring there is a sufficient number of social services staff to serve the needs of their residents. This failure applies to one of six residents (R1) reviewed for behavioral health services. Findings include: R1 is a [AGE] year-old male who was admitted to the facility 02/26/2024 with a diagnosis's history of Schizoaffective Disorder, Schizophrenia, Psychotic Disorder with Delusions, Generalized Anxiety Disorder, Major Depressive Disorder, Violent Behavior, and Drug Induced Secondary Parkinsonism. R1's current care plan documents he has violent behavior related to Schizoaffective disorder, Bipolar type and has a history of aggressive behavior, and has little interest or pleasure in doing things. R1's Level II PASRR (Preadmission Screening and Resident Review) dated 02/26/2024 documents: He has a history of physically acting out towards peers. He has Level II PASRR conditions of: -Schizophrenia; -Schizoaffective disorder; -Schizoaffective disorder, bipolar type; -Bipolar disorder; -Depression. Which likely need routine follow up with a mental health professional. R1's progress notes from June - September 2024 document he exhibited multiple instances of mood instability and was hospitalized five times within two months due to depressive, agitated, and aggressive behaviors. R1's Psychiatric Progress note dated 06/17/2024 documents his mood as irritable and anxious. R1's progress note dated 07/12/2024 documents he dialed 911 and reported to the paramedics I don't like my medication here, I can't survive here, I want to go and get some help; he voiced feeling of hopelessness and helplessness and was agitated, had already packed all his belongings prior to dialing 911, and was transported by the paramedics to the hospital. R1's progress note dated 07/29/2024 documents he called the Police/911 and when the police asked R1 what was wrong, he replied, I am getting crazier here, they are making me take pills that are very long, I want to go to the hospital The paramedics transported R1 to the hospital. R1's progress note dated 08/20/2024 documents R1 had manic episode in the front lobby with eyes rolling up in his head and hitting his head purposely on the floor. The ambulance was called to transfer him to the hospital for further psychological evaluation. R1's progress note dated 08/26/2024 documents he was observed with aggressive behavior, punching his TV, responding to internal stimuli, hallucinating, passing, and exhibiting irrational and impulsive behavior, the physician was notified, and an order was placed to send him to the hospital for medical evaluation. R1's progress note dated 09/17/2024 06:21 PM documents he was displaying physically aggressive behavior upon visit from family members, he attempted to strike his family member with his fist and also attempted to kick another family member and was not easily redirectable. R1 is also refusing medications and not compliant with plan of care. R1 contacted 911 to file a police report against his family member. After officers left, resident continued pacing hallways menacingly with auditory hallucinations. R1 was sent to the hospital. R1's progress notes from June - September 2024 document interaction from social services once on 06/03/2024, once on 07/23/2024, and once on 09/17/2024. R1's hospital report dated 08/24/2024 documents he continued to be easily agitated and threatening towards others. He was helped to develop better coping mechanisms to deal with his negative feelings. With medication, one to one, group and individual therapies, he was showing improvement in his mood and psychotic symptoms. On 09/24/2024 at 10:42 AM V2 (Director of Nursing/Registered Nurse) stated R1 has been in and out of the hospital frequently. V2 stated R1 is a newer resident to the facility and is very young. V2 stated R1 was recently sent out to the hospital due to becoming verbally aggressive and physically threatening towards his family members while they were visiting because he wanted to go home with them. V2 stated R1 had been exhibiting exit seeking behavior and was upset with his father and brother because they could not take him in. V2 stated R1 had also been experiencing hallucinations. On 09/24/2024 at 2:05 PM V7 (Psychosocial Services Rehabilitation Director) stated he believes R1's triggers for aggression are wanting to go home, family life and certain family members. V7 stated the difficulties he had with R1 was getting him to attend groups. V7 stated non-pharmacological interventions that were being implemented for R1's behavioral health were getting him set up with a mental health counselor approximately 3-4 months ago. V7 stated V6 (Mental Health Counselor) was attempting to see R1 at least once weekly, but he declined so she discontinued and then planned to attempt again in September. V7 stated additional nonpharmacological interventions included providing R1 with encouragement. V7 stated he would attempt to see or check in on R1 at least once weekly. V7 stated he believes family not coming or contacting him much may have contributed to his frequent hospitalization s. V7 agreed R1 could have benefited from more frequent check ins and interaction from social services but with only two social workers this would not be possible to do in conjunction with addressing all the needs of their current resident population. On 09/25/2024 at 11:11 AM V1 (Administrator) reported the facility has two social services staff including V7 (Psychosocial Services Rehabilitation Director) and V9 (Social Service Aide). The facility's Social Services Policy received 09/24/2024 states: The Purpose of the Policy is To provide medically related social services to assist residents in attaining and maintaining their highest practicable level of mental and psychosocial well-being based upon identified needs and the facilitation of the provision of services to meet those needs. Other Social Service staff will be employed, as needed, who are qualified by education and work experience in recognizing and initiating action towards solving social problems of the resident population. Social Service staff responsibilities include: Assisting residents in coping with illness, adjusting to the facility, promoting a therapeutic environment for the continuity of relationships with the family and community.

Based on interview and record review, the facility failed to follow their abuse policy by allowing a staff member to tease and laugh at a resident. This failure affected one of three residents (R2) reviewed for abuse. Findings Include: R2 is a [AGE] year old with the following diagnosis: bipolar disorder, schizophrenia, and drug induced parkinsonism. R3 is a [AGE] year old with the following diagnosis: bipolar disorder, anxiety, and spina bifida. The Final Incident Report dated 7/3/24 documents R2 reported to V1(Adminsitrator) on 6/27/24 that V5, V8, and V9 were verbally inappropriate to R2 on the overnight shift on 6/23 through 6/24/24. R2 reported staff were calling R2 names and talked about R2 ' s mom. R2 also stated staff laughed at R2. Upon interview, the three staff members denied the allegation. They stated R2 was very shaky and was being monitored in the dining room due to being a potential fall risk. R3 witnessed V5 and V8 in the dining room with R2. R3 stated a similar version that V5 and V8 were picking on R2 and laughing at R2. On 7/16/24 at 11:52AM, R2 stated there was an incident about 3-4 weeks ago where two CNAs (V5 and V8) were making rude comments about R2 and disrespectful comments about R2 ' s mother. R2 could not remember exactly what V5 or V8 were saying but felt they were making fun of R2 and laughing at R2. R2 stated this happened in the dining room. R2 reported asking V5 and V8 be put back to bed to go to sleep and they refused so R2 had to stay up all night in the dining room. R2 stated R2 was upset that night but now does not even think about what happened unless someone else talks about the incident. R2 then went to the hospital on 6/24/24 due to shaking and tremor movements. R2 stated telling V2 (Nurse) about the incident when R2 arrived back from the hospital. R2 reported being called into the office and told V1 what happened. On 7/16/24 at 12:04PM, when asked if there was an incident that occurred between R2 and staff members, R3 stated 2 female CNAs (V5 and V8) bullied and were being disrespectful and rude to R2 on a night shift in June of 2024. R3 could not remember the specific date. R3 reported R2 was sitting in a high back wheelchair in the small dining room diagonally across from the nurse ' s station. R3 confirmed R2 was being monitored by V5 and V8, but when R2 was calling out for help V5 and V8 would yell at R2 to stop moving and sit back down. R3 stated R2 asked to go lay back down in bed and one of the CNAs told R2 no because R2 was acting crazy. R3 reported one of the CNAs also told R2 that they do not care that R2 wants to go lay down in bed and R2 need to chill the f*ck out. R3 was unable to remember the exact wording but confirmed one of the CNAs made a comment about R2 ' s mom in a derogatory manner. R3 stated R3 was working on a laptop in the dining room so R3 could hear what V5 and V8 were saying. R3 stated both CNAs were making comments and R3 knew this because R3 is familiar with both of their voices. R3 reported V9 (Nurse) was sitting at the nurse ' s station and was able to hear what V5 and V8 were saying to R2 but at no point did V9 intervene. R3 confirmed hearing V9 say, This is going to show her how she needs to act. R3 stated witnessing this incident around 1-2AM but R3 left the dining room around 3AM to go to sleep and R2 was still sitting in the dining room with V5 and V8. R3 reported R2 seemed very nervous and kept shaking R2 ' s whole body but V5, V8, and V9 only told R2 to calm down and did not offer any other assistance. R3 stated about three or four days later R3 was pulled into the office for questioning by V1 and R3 told V1 what R3 witnessed that night. R3 confirmed V5 and V8 no longer work at the facility after hearing other staff talk about it. On 7/16/24 at 1:45PM, V2 (Nurse) stated when R2 got back from the hospital, R2 reported two staff members were mean to R2. V2 reported R2 was not able to remember their names but could describe the two CNAs (V5 and V8) perfectly. V2 stated R2 reported R2 needed help going to bed and V5, V8, or V9 (Nurse) would not help R2 back to bed that night. V2 reported V5, V8, and V9 were terminated due to this incident. V2 stated this incident would be considered verbal abuse for the staff saying mean things to R2 and for mental abuse for not putting R2 back to sleep when R2 requested. On 7/17/24 at 8:11AM, V5 (Former CNA) stated R2 was all over the place that night and the nurse (V9) said R2 was not allowed to go back to bed due to being a fall risk. V5 reported a couple days later V5 was called into the office and made aware of the allegation against V5. V5 denied bullying R2 but admitted to R2 asking to go to bed and V5 did not put R2 back to bed. V5 stated R3 was in the dining room during that shift. On 7/17/24 at 11:42AM, V8 (Former CNA) stated the nurse (V9) told V5 and V8 to keep R2 up in the dining room to be monitored during the night. V8 reported R2 kept shaking R2's entire body and the nurse told V8 it was just muscle spasms. V8 stated R2 then went out to the hospital for the spasms and upon return reported the allegation of abuse to management. V8 reported being told that R2 told V1 that V5 and V8 would not let R2 go to bed that night and they were bullying R2. V8 stated telling V1 that V9 told V5 and V8 to keep R2 up out of the bed. V8 confirmed R3 was also sitting in the dining room at some point during the night and gave V1 the same statement R2 gave V1. On 7/17/24 at 11:55AM, V9 (Former Nurse) stated V9 was terminated from the facility due to R2 accusing V9 of teasing R2. V9 reported R2 was hallucinating and saying things that weren't right that night. V9 denied calling a physician about this behavior or giving a PRN medication. V9 stated R2 was kept up in the wheelchair in the dining room all shift to be better monitored. V9 reported R2 did ask to go back to bed that night. V9 said, The resident felt humiliated I guess. On 7/17/24 at 1:33PM, V10 (Quality Assurance Nurse/ADON) stated V2 brought R2 to V10 due to R2 making allegations of abuse against staff. V10 reported that the way R2 was describing what happened R2 was acting like R2 was verbally abused. V10 stated R2 said the staff members being rude to R2 and mentioned R2's mother in a comment the staff made. V10 confirmed all three staff members were terminated. V10 stated V5 and V8 should not have been talking to R2 like that and V9 was terminated for not stopping them talking to R2 in that manner. On 7/17/24 at 3:15PM, V11 (Social Service Director) stated R2 is at risk for abuse due to R2 having a severe mental illness. V11 reported this would be considered abuse due to the manner in which the staff were speaking to R2. On 7/17/24 at 4:08PM, V1 stated V10 reported to V1 that R2 needed to tell V1 something concerning. V1 reported R2 told V1 that two night shift CNAs teased R2, laughed at R2, and made comments about R2's mom. V1 confirmed R2 also mentioned that R2 was not able to lie down to go to sleep that night. V1 said all three staff members were suspended and then terminated after the investigation was complete. V5 and V8 were terminated for mental abuse and V9 was terminated for not stopping V5 and V8 from abusing R2. A Nursing note dated 6/24/24 at 6:39 AM documents R2 was alert and up through the night at times verbally abusive to staff and combative trying to get up from the chair. There is no other documentation that V9 provided any other interventions to R2 to help R2 calm down or called the physician. A Nursing note dated 6/27/24 documents allegations were made. The physician and family were also notified as well as the Administrator and Director of Nursing. A Social Service note dated 6/27/24 documents social services met with R2 for wellness check. R2 reported feeling OK. Social services was made aware that R2 made verbal abuse allegation against staff. The Abuse Risk Review dated 6/6/24 documents R2 is at risk for abuse due to serious mental illness, reduced social interactions, and frailty/total dependence. An updated abuse risk review was completed on 6/27/24 and R2 is still at risk for abuse for the above reasons along with being exposed to trauma. The Care Plan dated 4/8/24 documents R2 has been identified to be vulnerable for abuse due to a history of sexual assault and a diagnosis of substance use. The Care Plan dated 4/12/24 documents R2 is at risk for abuse due to a diagnosis of severe mental illness, diagnosis of substance abuse, history of sexual assault, history of allegations of verbal abuse by staff, and residing at a mental health facility. One of the interventions on this care plan document to report all instances of alleged abuse to the abuse coordinator as soon as possible. The Brief Interview for Mental Status dated 6/6/24 for R2 documents a score of 13 indicating no cognitive impairment. The Brief Interview for Mental Status Review dated 5/21/24 for R3 documents a score of 15 (no cognitive impairment). The employee files for V5, V8, and V9 were reviewed. V5 and V8 completed abuse and sexual abuse training on 12/1/23. V9 completed the abuse and sexual abuse training on 1/21/24. The Termination Report dated 7/2/24 for V5 and V8 document the employees were notified of the termination via phone on this day. Termination is based on the investigation of the abuse allegation made by a resident on 6/27/24. The reason for termination documents physical or verbal abuse, neglect, or attempting to injure a resident or another person, including any other staff member, supervisor, or manager. The Termination Report dated 7/2/24 for V9 documents the employee is discharged after investigation of abuse. The investigation provided account of lack of supervision of the CNA ' s during the shift and failure to follow policy and procedure. The policy titled, Resident Rights, dated 12/2016 documents, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy interpretation and implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights might include the resident right to: a. a dignified existence; b. to be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation . The policy titled, Illinois Abuse Prevention Policy, dated 10/24/2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility, therefore, prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents . Definitions: Abuse means any physical or mental injury, or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .Mental abuse includes, but it ' s not limited to humiliation, harassment, threat of punishment or deprivation .Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur . Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property they observed, hear about, or suspect to the administrator immediately or to an immediate supervisor, who must then immediately report it to the administrator or to a compliance hotline or compliance officer .

Based on observations, interviews, and record reviews the facility failed follow their policy and procedures to ensure food was prepared under sanitary conditions by not ensuring the kitchen was maintained in a clean and sanitary manner, not performing hand hygiene when necessary, not ensuring the kitchen environment was maintained in a manner to prevent contamination, and not ensuring food preparation equipment was dried properly in between uses to prevent food-borne illnesses. This failure affects all 66 residents receiving food from the facility. Findings include: On 05/13/24 at 10:25 AM during kitchen tour surveyor observed the ice machine stained with residue on the inside wall, and rust along the border of the door, and frames of door, and buildup of a black substance on the upper corner of the interior of the ice machine between the lid and ice compartment. Observed V13 (Dietary Manager) remove all the residue and buildup on all these areas of the ice machine with a cloth. V13 stated, the ice machine is cleaned every six months, and all the kitchen staff are responsible for daily cleaning of the ice machine and kitchen appliances. Observed seven 3lb bags of yellow squash stored in the kitchen freezer with heavy buildup of ice on the packaged squash with no labeling. V13 stated the bags of squash should be labeled and will be thrown away because they are freezer burned and no good. V13 was unable to state for certain how long the yellow squash had been stored in the freezer. Observed dust and dirt particles on the kitchen knife holder with 3 knives stored in the holder. V13 stated the holder should not have dust or dirt particles on it. Observed a large bag of snicker doodle cookies stored in the freezer with heavy buildup of ice inside the bag and a hole in the bag. V13 stated, the bag of snicker doodle cookies was approximately 3lbs and he would be throwing it away because of the hole in the bag. Observed the creases inside the folds of the entire lid of the deep freezer where the cookies and meal shakes were stored with a heavy buildup of a black substance. V13 stated, he will clean the deep freezer lid today and he wouldn't want the buildup of the black substance to be present within the deep freezer lid because it could tear us apart. On 05/14/24 from 10:07 AM - 11:30 AM During the kitchen tour observed the floor tile underneath the three-compartment sink cracked and with heavy buildup. Observed the water temp booster next to three compartment sink underneath the handwashing sink with a heavy presence of rust, buildup, and residue, and with holes in walls around piping underneath both sinks. Observed a garbage bin for paper goods next to the stove covered with dust and residue. Observed the floor underneath a crate with a grease bucket sitting on top of it, with heavy buildup of oil, dust, food particles, and residue. Observed the floor underneath the steam table with cracked tiles, and heavy buildup. Observed the overflow drain near the steam table with heavy buildup inside the perimeter. Observed the spray hose attachment to dishwashing machine with a heavy presence of dust and rust. V13 (Dietary Manager) stated, the sprayer is used to prerinse dishes that go in the machine and should be clean. Observed buildup and two small holes along the wall directly next to the dishwashing machine scraping table. Observed spatter and dust on the walls and ceiling surrounding the dishwashing machine area. Observed the walls underneath the dish machine with cracked paint and heavy buildup. Observed the chlorine bottle tube connecting the chlorine to the dishwasher with a heavy presence of a dark and dusty substance. Observed several dish racks and eight utensil holders, some with clean utensils in them, heavily stained. V13 stated, the dish racks and utensil holders are old and need to be replaced. V13 and V15 (Cook) agreed that the staining of the dish racks and utensil holders makes it difficult to determine if they are clean. Observed the side of the ice machine with a heavy amount of dust, and the floor underneath the ice machine with cracked tile, and a heavy buildup of dust and residue. Observed the open window sill directly next to two dish racks with partially covered clean dishes with buildup and dust. Observed outlets directly next to and over the food prep table with heavy buildup. Observed V13 remove some of the buildup on the outlets with a cloth to confirm it can be removed. V13 stated, the outlets should be clean each time the food prep area is cleaned. Observed multiple slices of bread left on the floor underneath the food prep and storage table near the cooler. Observed a soap dispenser over the dishwashing machine area with heavy dust buildup. Observed multiple pipes on the ceiling and other areas of the kitchen with heavy presence of dust. Observed a hanging dish rack with multiple clean dishes hanging from it with dust on various parts of the rack. In response to surveyor asking if the kitchen should be kept clean, V13 stated, the building is old, and there is no ventilation in the kitchen and pointed out that there is only one vent in the kitchen over the stove. V13 stated, the kitchen needs a lot of attention. V13 stated, the lack of ventilation in the kitchen means the kitchen requires more attention with cleaning. V13 stated, if the kitchen is not kept clean the residents are at risk for salmonella and agreed they are also at risk for food contamination. V13 stated all dietary staff are responsible for maintaining the cleanliness of the kitchen and the daily cleaning requirements. Observed steam table with ready to serve food with heavy buildup of food particles along the crevice of the table. Observed V14 (Dietary Aide) drop the lid to a water pitcher, pick it up and place it in a rack to be run through the dishwasher, then continue to fill water pitchers without performing any hand hygiene. V14 stated, she didn't wash her hands because she did not touch the floor and only touched the top of the water pitcher lid. V14 stated, the water pitchers would be used to serve the residents during dining. Observed V15 (Cook) wash the industrial food processor base and lid in the dishwashing machine. Observed V15 then make peach puree in the food processor without allowing the food processor base and lid to completely air dry. V15 confirmed that the food processor equipment had not fully air dried when she used it to make the peach puree. On 05/16/24 at 10:06 AM V1 (Administrator) stated, per V13 (Dietary Manger) holes should be sealed for pest control to avoid any possible entry and the food processor has to be air dried in between uses after being sent through the dishwasher for infection control. V1 stated, per V13 paper towels or any sort of towel are prohibited for use to dry any equipment because of cross contamination. The facility's Dietary Infection Control Policy received/reviewed 05/15/2024 states: The purpose of the policy is To ensure that the dietary department practices and procedures ensure safe, sanitary food operation to prevent food borne illness. The policy states The dietary department will meet accepted standards of safety and sanitation of food, equipment, and cleaning supplies. The Dietary Department: Will be maintained in a clean and sanitary manner to prevent foodborne illness. Food is labeled and dated to allow for rotation of supplies. Food equipment: are thoroughly cleaned as required between food preparations. Food preparation procedures include: Discarding food that becomes contaminated. Dietary waste is kept away from food preparation area. Dietary department is cleaned on a regular schedule. The facility's Weekly Cleaning Assignments received/reviewed 05/15/2024 states: Clean bottom of walls; Clean ice machine; Clean windowsills in dietary; Wash steam table inside and out; Everything in Freezer should be labeled and in order. The facility's Handwashing Policy received/reviewed 05/15/2024 states: Food and nutrition service employees will practice safe food handling to prevent foodborne illness. Food and nutrition services employees will thoroughly wash their hands with soap and water at the following times: after touching anything unsanitary (dirty dishes).

Based on interviews and record reviews, the facility failed to designate an infection preventionist who had completed specialized training in infection prevention and control. Findings include: On 05/15/24 at 3:58 PM V3 (Assistant Director of Nursing/ IP - Infection Preventionist) stated, she has been the IP for the facility for approximately four years. The CDC (Centers for Disease Control) Nursing Home Infection Preventionist Training Course Certificate received/reviewed 05/15/2024 documents V3 (Assistant Director of Nursing/Infection Preventionist) was awarded certification on 05/15/2024. The facility did not provide a policy for infection preventionist qualifications requested on 05/16/2024.

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate and failed to ensure staff followed proper infection prevention practices during medication administration. There were four medication errors out of 27 medication opportunities, resulting in a 14.81% medication error rate and affected 2 residents (R27 and R39) observed for medication pass. Findings include: On 5/14/24 at 8:08 am, V10 (Licensed Practical Nurse/LPN) was observed passing medications with the medication cart for south hall. Surveyor observed V10 prepare 3 pills total for R39 (Cholecalciferol 125 mg - 1 tablet, Cyanocobalamin 100 mcg tablet, and Norco 5/325 mg - 1 tablet) that was to be administered to R39. Upon review of the medication card, surveyor observed that it belongs to another resident. V10 was handing the medication cup with the 3 pills and water to R39. Once V10 was going to administer pills to R39, surveyor stopped V10 from administering Norco 5/325 mg and asked nurse to verify medication and resident name on that medication card. V10 then realized that medication card belonged to R65 and was not the correct medication. V10 took the Norco 5/325 mg pill with her bare hands and popped it back in the card it came out of, without correctly discarding the pill or securing the pill to card. V10 then pulled out the correct medication card and popped the correct pill (lorazepam 1 mg) into the cup and administered all three medications to R39. After V10 administered the medication to the R39 surveyor pointed out the error for the cyanocobalamin and asked V10 if she had the correct medication/dose in her cart. V10 looked in medication cart and did not have the correct medication in the cart. The following medication errors were identified: 1.) Inaccurate dose error: Cyanocobalamin 100 mcg given instead of Cyanocobalamin ER 1000 mcg. 2.) Inaccurate medication/dose error: Norco 5/325 mg was about to be given instead of Lorazepam 1 mg before surveyor stopped nurse from giving wrong medication. R39's Medication Administration Report documents cyanocobalamin tablet extended release 1000 mcg - 1 tab was signed off by V10 as given on 05/14/2024 for 9:00 am dose. R39's Physician Order Report dated 4/15/2024 through 5/15/2024 shows order for cyanocobalamin tablet extended release; 1000 mcg; amt: 1; oral Once a Day; 09:00 AM DC date of 5/14/2024 (Awaiting DC Verification). This report also shows that R39 has an order for Lorazepam - Schedule IV tablet; 1 mg; amt: 1; oral Every 12 hours; 09:00 AM, 09:00 PM. R39 does not have an order for Norco 5/325 mg. R39's Brief Interview for Mental Status (BIMS) dated 04/11/2024 documents R39 with a score of 15 which indicates that R39 is cognitively intact. R39's face sheet documents, in part, R39's diagnoses including but not limited to: Anoxic brain damage, paranoid schizophrenia, schizoaffective disorder- bipolar type and anxiety. On 05/14/2024 at 8:31 am surveyor observed V10 (LPN) from the south hall medication cart start to prepare 6 pills total for R27 (Amlodipine 5 mg - 1 tablet, Atenolol 25 mg - 1 tablet, Cyanocobalamin 100 mcg tablet, Gemfibrozil 600 mg - 1 tablet, Glipizide 5 mg- 1 tablet and Metformin 850 mg - 1 tablet). V10 pulled 5 medication cards from the medication cart and one bottle from the top drawer of medication cart. The bottle was facility stock of cyanocobalamin 100 mcg. V10 pushed the tablet/pill from the 1st medication dispensing card plastic bubble which makes a pop sound audible to surveyor when the tablet exits out of the sealed lining at the back of the medication dispensing card. V10 then dispensed the pill from the 1st medication card with a pop sound audible to surveyor when the pill exits out of the medication card (bubble). V10 placed the medication card in a pile on top of the left side of the medication cart. V10 then picked up the Atenolol medication card and placed it over the pill cup, a popping sound was heard, but no pill observed dropping into the cup. Upon surveyor reconciling R27's medications that were ordered and scheduled for administration surveyor stopped V10 as she was handing medication cup to R27 and asked her to count the pills in the medication administration cup she was about to give to R27. V10 stated, she had 5 pills in the medication cup. V10 was asked by surveyor how many medications R27 should be getting she stated 6. Upon verification of what pills were in the medication cup and which one was missing it was discovered that there were supposed to be 2 small round pills. The one in the med cup was the one with markings U on one side and 5 on the other side which was the Amlodipine 5 mg. It was deducted that the atenolol 25 mg tablet with markings of 21 on one side and D on the other side was not in the medication cup. When V10 looked at that medication card she noticed that the pill was popped out but was stuck in the bubble pack and did not fall into the medication cup. After V10 administered medication to R27, the surveyor pointed out the dosage on the bottle of cyanocobalamin to V10. V10 looked at the order and asked surveyor if she should have given 5 tablets. Surveyor told V10 that she could not tell her what to do. V10 did not administer any other medication to R27. The following medication errors were identified: 3.) Inaccurate dose error: Cyanocobalamin 100 mcg given instead of Cyanocobalamin 500 mcg. 4.) Omission error: V10 would have omitted giving the Atenolol 25 mg pill if surveyor did not stop V10 from giving only the 5 pills in the medication cup. R27's Medication Administration Report documents cyanocobalamin tablet 500 mcg - 1 tab was signed off by V10 as given on 05/14/2024 for 9:00 am dose. R27's Physician Order Report dated 4/15/2024 through 5/15/2024 shows order for cyanocobalamin (vitamin B-12) tablet; 500 mcg; amt: 1 tablet; oral Once a Day; 09:00 AM. This report also shows that R27 has an order for atenolol tablet; 25 mg; amt: 1 tab; oral (DX: Essential (primary) hypertension) Every day; 09:00 AM R27's Brief Interview for Mental Status (BIMS) dated 03/21/2024 documents R27 with a score of 14 which indicates that R27 is cognitively intact. R27's face sheet documents, in part, R27's diagnoses including but not limited to: Type 2 diabetes mellitus, major depressive disorder, essential (primary) hypertension, and hyper lipidemia. On 05/14/2024 at 8:08 AM V10 was observed administering medications to 5 residents (R2, R17, R27, R39, R66). During this observation V10 did not wash hands or use alcohol-based hand rub one time between all 5 residents. On 05/15/24 at 2:12 PM Interview with V2 Director of Nursing (DON), V2 stated medication administration should go according to policy and procedure using 5 rights, infection control and all of them other things. A nurse should not walk away from the medication cart if it is unlocked. All nurses should wash hands or use alcohol-based hand rub between residents and use soap and water if hands become visibly soiled. When a med error does occur nurse should report immediately and call doctor and follow doctors' orders. Ongoing education is done twice yearly called a skills fair which includes med administration, hand hygiene, not leaving the cart unlocked when not present, and all other nursing and certified nursing assistant's competency skills. On 05/14/24 at 10:53 AM Phone interview with V12 Pharmacist consultant for facility pharmacy states the tablet(s) given to R39 should have been extended release not just the regular house stock bottle it was given from and the correct dosage that was ordered. On 05/15/2024 at 3:42 PM Interview with V2 DON. V10 did not report any med errors to me she reported giving R39 cyanocobalamin 100 mcg instead of cyanocobalamin extended release 1000 mcg to the front office. That is the only medication error she reported. Medication Administration Policy with an effective date of March 2014 and an Updated date of March 2022 states: 1. Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. 7. No medication may be returned to its original container once removed from that container. 8. Medications errors, drug side effects and adverse drug reactions, including overdoses or poisoning, will be immediately reported to the attending physician. Director of Nursing and pharmacist. The error or clinical symptoms will be documented in the clinical record and on the facility designated form. LPN Job description provided on 05/15/2024 by V1 at 2:12 pm states: Duties/Responsibilities/Function 6. Dispense medications as ordered by attending physician in accordance with facility policies. 23. Ensure compliance with infection control standards. Immediately correct/address identified instances of non-compliance.

Based on interview and record review, the facility failed to follow their abuse policy by not protecting /preventing a vulnerable resident from being sexually assaulted by another resident. This affected two of four residents (R1, R2) reviewed for sexual abuse. This failure resulted in R2 entering R1's room approximately 3 hours after being admitted to the facility and sexually assaulting R1 after R1 said no to sex. The Immediate Jeopardy began on 1/8/24 when R2 entered R1's room and sexually assaulted R1. V1 (Administrator) was notified on 1/18/24 at 2PM of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 1/18/24, but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R1 is a [AGE] year old with the following diagnosis: bipolar disorder, depression, and seizures. R2 is a [AGE] year old with the following diagnosis: bipolar disorder and schizophrenia. R3 is a [AGE] year old with the following diagnosis: major depressive disorder and schizoaffective disorder. A Social Service note dated 1/8/24 document social services was made aware the R1 reported another resident was being sexually inappropriate to R1. A Nursing note dated 1/8/24 documents R1 stated R1 was inappropriately touched by a peer. The Police Report dated 1/8/24 documents officers responded to the facility for a criminal sexual assault allegation at 3:38 PM. The police were met by V1 (Administrator) and advised R1 approached V1 and said R2 inappropriately touched R1. R1 was met in private and relayed the following information: R1 was sleeping in R1's room at approximately 2 PM. R1 noticed R2 enter R1's room, and R2 started talking with R1. R2 then proceeded to try to have sex with R1. R1 reported telling R2 to stop but R2 continued to take off R1's pants. R1 stated R2 placed R2's penis inside of R1's vagina without a condom. R1 advised R2 was trying to place R2's mouth on R1's nipples and was touching R1's buttocks saying, You are my girl. V1 was then interviewed. V1 advised R3 witnessed the event. R1 and R3 are roommates. Officers then spoke with R3 who stated that R3 was walking into R3's room and observed R1 lying on the bed with R1's pants completely off. R3 said R1 still had a shirt on. R3 observed R2 sitting on the edge of the bed and both residents were making out. R3 reported R2 saw R3 then yelled, Hey, as to get R3's attention to leave. R3 reported R1 and R2 exited the room shortly after and walked in opposite directions. R3 assisted the officers in identifying R2. R2 was taken to the police department for further investigation. R2 was interviewed at approximately 5:15 PM. R2 stated the following: R2 had just arrived at the facility for the first time on this day. R2 met R1 by walking into R1's room looking for a cigarette. R2 asked R1 if R2 could lay on the bed with R1 and R1 stated yes. R2 was laying with R1, and R2 put R1 on top of R2. R2 then asked R1 to be R2's girlfriend. R2 said they both stated they loved each other, and then R2 asked R1 to remove R1's shirt and R1 did. R2 reported then proceeding to lick R1's breast. R2 then asked R1 to take R1's pants off twice, and both times R1 said no. R2 then asked R1 a third time and R1 agreed. R2 stated they were kissing, and R2 was grabbing R1's butt so it was OK to take R1's pants off. R2 also described placing R2's fingers inside R1's vagina for 10 to 15 minutes. R2 reported that R2 didn't think R1 knew what was going on. R2 reported R1 told R2 that R2 could put it in, and R2 tried, but R2 could not get an erection. R2 said hey we're trying to have sex, but R2 was just rubbing R2's penis on R1's butt. R2 saw R3 then walked in the room and ended it all. The Ambulance Run Sheet dated 1/8/24 documents the fire department was called to the facility for a report of a sexual assault victim. R1 stated I was in my room sleeping when a male came in and did the sex to me. I asked him to stop, and he would not. R1 was transported to the hospital via request of the police department. The Hospital Records dated 1/8/24 documents R1 presented to the emergency department for a concern of an alleged sexual assault that happened at the extended care facility. A speculum exam was performed, and no evidence of injury was noted. The sexual assault kit was handed over to the police department. The Medical Forensic Documentation Forms document R1 was penetrated in the vagina and the anus by R2's penis as well as finger. On 1/10/24 at 8:50AM, V2 (Detective) said the police were called to the facility for a female resident (R1) that was sexually assaulted by a male resident (R2). V2 reported while interviewing R1, R1 said R2 came into R1's room and started talking to R1. V2 said R2 then attempted to have sex with R1 and R1 told R2 to stop, but R2 continued. V2 said R3 came into the room R1 and R3 share and R3 saw R1 on the bed without pants. V2 reported R3 was able to identify R2 and R2 was detained. V2 said R2 was interviewed at the police station. V2 said during R2's interview, R2 reported asking R1 to take R1's pants off twice and R1 said no. V2 said R2 admitted to asking R1 a third time and R1 agreed. V2 stated R2 reported R1 seemed like she did not know what was going on when they were about to have sex. On 1/10/24 at 12:05PM, R1 said there was an incident with a male resident that came into R1's room and raped R1 a couple days ago. R1's mental status was assessed and R1 was able to state R1's name and birth date, the location, and date. R1 said on the day of the incident, R1 was lying in R1's bed trying to take a nap when R2 entered R1's room. R1 said R2 began asking R1 questions such as R1's name, if R1 had a cigarette for R2, and if R2 could sit on R1's bed with R1. R1 stated R1 felt scared of R2 and didn't respond. R1 reported R2 then just sat on R1's bed and began pulling R1's pants and underwear off. R1 said R2 then placed two or three fingers inside R1's vagina and moved them around. R1 said R2 then laid on the bed and put R1 on top of R2. R1 said that is when R2 put R2's penis inside of R1. R1 reported R2 lifted R1's shirt and bra and began to suck on R1's breasts. R1 said at this point R1 told R2 to stop, but R2 replied You are my girl now. I will buy you stuff. R1 reported R2 did not stop penetrating R1 or kissing R1 when R1 said stop. R1 said R3 then walked in the room and R1 lied down in the bed. R1 said R2 left about five minutes after R3 came into the room. R1 reported then leaving R1's room and walking to the front office. R1 said R1 first saw V3 (Admissions) and began to tell V3 what happened. R1 said V3 brought R1 directly into V1's (Administrator) office, and R1 told V1 what happened with R2. R1 endorsed the police were called, and R1 spoke with the police before leaving for the hospital. R1 said R1 went to the hospital to be tested and so the hospital could do a rape kit. R1 said when R2 came in R1's room that was R1's first time meeting or speaking with R2. R1 denied R2 wearing a condom. R1 said R1 felt safe in the facility. R1 said R1 was raped about a year ago in this facility by another male resident that no longer resided here. R1 stated, I feel embarrassed this keeps happening to me. Why me? R1 denied having sexual relations with anyone else in the facility. When asked to define consent, R1 was not able and when asked what does it mean to give permission for something to happen, R1 again was unable to state what that meant. R1 reported R1 had a meeting with V8 (Social Service Director) yesterday and discussed what is sexual abuse, saying no when R1 does not want to do something, and to tell V1 about any abuse. R1 said R1 did not scream for staff help or tell R2 no again because R1 felt uncomfortable and was afraid to keeping saying no. R1 denied the facility starting any new plans to keep R1 safe from this happening again. On 1/10/24 at 12:33PM, R3 said R3 entered R3's room and walked to R3's bed (R3's bed is the bed furthest from the doorway) and saw R1 and a man in R1's bed. R3 denied knowing who the man was in R1's bed at the time but later found out the man was R2 and newly admitted . R3 reported the man's voice said Hey! and Yo! when R3 first walked into the room. R3 said R3 felt like R2 was warning R1 that someone else was in the room with them. R3 said R1 was completely naked from the waist down. R3 said R1 was lying on the bed and R2 was sitting on the bed. R3 reported lying down in R3's bed and tried to take a nap but heard R2 state, You like that? to R1. R3 denied R1 responding to R2's question. R3 said after about 15 minutes R3 heard R1 and R2 leave the room. R3 said the police then arrived to the facility and asked R3 to identify R2. R3 reported pointing out R2 to the police and R2 was taken out of the facility. R3 denied the facility having any special monitoring for newly admitted residents. On 1/10/24 at 1:20PM, V3 (Admissions) said V3 was exiting the front office when V3 saw R1. V3 said R1 whispered to V3 that R2 started kissing on R1 in R1's room and then R1 began to cry. V3 reported immediately bringing R1 into V1's office and heard R1 tell V1 that R2 began kissing R1 and sucking on R1's breasts. On 1/10/24 at 1:37PM, V4 (CNA) said R2 was a new resident admitted to the facility on [DATE]. V4 spoke of seeing R2 walking up and down the halls after being admitted . V4 reported R2 began talking to V4 while V4 was walking down the hall and tried to follow V4 into another resident's room. V4 said V4 had to tell R2 not to enter the other resident's room and R2 complied. V4 denied telling any other staff R2 attempted to enter another resident room. V4 said the facility monitors new admission residents every two hours just like all other residents. V4 said this incident would be considered sexual abuse because R1 did not want R2 touching R1. On 1/10/24 at 1:48PM, V5 (CNA) said V5 knew R2 was a new resident but wasn't aware of any special monitoring R2 needed. V5 denied the facility monitoring newly admitted residents unless the hospital says to watch for special behaviors. V5 reported hearing that R2 physically touched R1 but was not sure of the exact details. V5 said R1 did have a report of a similar episode of being sexually assaulted by another male resident in the past. V5 denied having any interventions in place for R1 to help prevent unwanted touching. V5 said the incident with R2 would be considered sexual abuse. On 1/10/24 at 2:06PM, V6 (Nurse) said R2 did not require any increased monitoring as a new admission. V6 said after the admission process is complete a resident is allowed to walk around the facility as they please. V6 admitted to seeing R2 walking up and down the halls but did not see R2 at all times. V6 said V6 was unaware of what happened between R1 and R2 until the police arrived. V6 admitted being aware R1 had another incident of reporting being raped in the past at the facility. V6 denied being aware of any interventions were put into place after the first allegation. V6 said this is sexually inappropriate behavior and would be considered abuse. On 1/10/24 at 2:32PM, V7 (CNA) said the admission process includes taking inventory of belongings and orienting the resident to the facility but after those are complete then the resident can walk freely in the facility. V7 denied newly admitted residents having increased monitoring. V7 reported being aware there was an allegation of R2 touching R1 inappropriately. V7 reported R2 was being monitored just like all other residents. V7 said this incident would be considered sexual abuse. V7 is unaware of any interventions that have been put into place for keeping R1 safe. On 1/10/24 at 2:58PM, V8 (Social Service Director) said R2 was admitted by the nursing staff and then social service went over policies of the facility. V8 reported abuse was discussed as part of the house rules. V8 said V1 told V8 around 3:15PM that R1 alleged R2 was sexually inappropriate with R1. V8 said V8 has been working at the facility about one month but did see R1's history of a sexual abuse allegation in the past. V8 stated, There might be some safety awareness issues and not fully understanding the scope of things, but she is alert and oriented. On 1/10/24 at 3:19PM, V9 (QA Nurse) said V9 was able to introduce V9's self to R2 but did not speak with R2 again after that. V9 said there was another situation with R1 that happened a while ago where R1 reported being touched inappropriately. V9 denied being aware of what interventions were put into place after the first incident to keep R1 safe. On 1/10/24 at 3:27PM, V1 said R1 reported the encounter with R2. V1 said R1 said R2 came into R1's room and asked to stay and R1 agreed. V1 said R1 then reported R2 began to kiss R1 and suck R1's breasts. V1 endorsed according to R1, R2 then penetrated R1 and R1 told R2 to stop. V1 reported interviewing R2 and R2 reported they made physical contact but R1 did not tell R2 to stop. V1 said R2 reported R3 came into the room and that is when R1 began saying no. V1 discussed interviewing R3 and R3 reported R3 saw R1 with no pants on while walking to R3's bed. V1 said R3 reported hearing a male voice ask, You like that? V1 said the police were called and took R2 to the station for questioning. V1 reported R1 did have an incident in the past where R1 reported a male resident had sex with R1 against R1's will. V1 said after the first incident R1 was educated on safe sex and setting boundaries and the facility will continue to reeducate R1 on safe sex and check in on R1 to make sure R1 feels ok. On 1/17/24 at 4:25PM, V10 (Medical Director) stated, The one thing I would have to say is that she (R1) is either manipulative and fooled the man into sleeping with her then said he raped her or she's not able to fully understand boundaries. V10 reported being aware R1 had another incident of reporting being raped about one year ago. V10 said for the facility to stop incidents like what happened between R1 and R2 then the staff need to be trained more and increasing monitoring of the residents. This surveyor told V10 that R1 was not able to define consent and asked how can a resident consent to sex if they cannot define consent? V10 stated, We cannot take away their right on what they want to do. A lot of the residents at the facility are not very educated and not smart people. They have the right to vote so I would say they have the right to consent to, what they want to do with their body. The following documentation is for R1: A Nursing note dated 12/6/22 documents R1 was inappropriately touched by a peer. R1 was sent to the hospital for an evaluation and treatment. A Social Service note dated 12/8/22 documents R1 returned from the hospital related to allegation of an unwanted sexual encounter with a male peer. Social services provided teaching/counseling related to the unwanted sexual encounter. R1 verbalized comprehension of the information presented. The Care Plan dated 12/8/22 documents R1 had a recent allegation of unwanted sexual encounter with a male peer. An intervention for this care plan documents staff will monitor and perform wellness checks on R1 to help determine if R1 is safe from unwanted sexual advances. There is no further documentation of any monitoring taking place for R1. The Sexuality assessment dated [DATE] documents R1 is currently sexually active. R1 can be ambivalent, and per R1's report when it comes to deciding if R1 wants to have sex, R1 describes R1's self as having difficulty saying no. R1 reportedly does not resist men's sexual approaches. R1 reported yes when asked if R1 has ever been hurt in a sexual way or forced to have sex when R1 did not want to. R1 reported having a hard time saying no, so R1 does not say anything, and reportedly doesn't resist. R1 stated, Sometimes I just want to kiss. During the assessment, R1 seemed embarrassed and was giggling. The Human Sexuality Questionnaire dated 8/1/23 documents R1 does not engage in sexual activity with others. R1 was asked what R1 would do if R1 were asked to have sex but didn't want to. R1 answered just say no. No safety issues were identified regarding R1's sexual history. There is no mention in this assessment of R1's previous history of being sexually abused or interventions that are in place to keep R1 safe. The Abuse Risk Review dated 1/8/24 documents R1 made an allegation against another resident for being sexually inappropriate. R1 is at risk for physical, sexual, verbal, and mental abuse. There is no other abuse risk review before this date. The Care Plan dated 1/8/24 documents R1 alleges that another resident was sexually inappropriate with R1. This care plan also documents R1 is at risk for abuse due to history of alleged sexual inappropriateness by other residents and diagnosis of severe mental illness. This care plan was not initiated until after the incident with R2. The following documentation is for R2: A Social Service note dated 1/8/24 at 2 PM documents social services met with R2 to go over admission paperwork and assessments. Social services explained the facility rules and policies. R2 expressed understanding and signed all appropriate paperwork. A Social Service note dated 1/8/24 at 4:08 PM documents it was reported to social services that R2 was being sexually inappropriate with R1. Both residents were separated, and the allegation was reported to the abuse coordinator. A Nursing note dated 1/8/24 at 4:15 PM documents the nurse practitioner and physician were notified of the alleged rape charges against R2. R2 was escorted out of the facility by the police. The Care Plan dated 1/8/24 documents R2 was accused of being sexually inappropriate with another resident. An intervention is documented as R2 will understand that unwanted sexual advances are not OK. The Facility House Rules were reviewed and document Physical or verbal abuse of another resident or a staff member is prohibited. This includes abusive or threatening behavior towards resident or staff. Residents who are found to be in or assist in violation of the house rules may be subject to progressive consequences, including immediate discharge from the facility for abusive or unsafe behavior directed against another resident or staff member. R2 signed a copy of the house rules on 1/8/24. The Facility Final Incident Report Form dated 1/16/24 documents R1 reported to V1 that R2 was sexually inappropriate on 1/8/24. Both residents were separated and assessed. R1 stated that R2 came into R1's room approximately at 2 PM and begin asking sexually inappropriate questions. R1 reported that R2 then proceeded to have sex with R1 even after R1 told R2 no. Upon interview, R2 denied the allegation. R2 stated R2 entered R1's room looking for money. R2 stated, asking for permission to sit on R1's bed, and R1 allowed. R2 denied having sex with R1 because R2 was not able to get an erection. R2 further stated that R3 entered the room, and that is when R1 told R2 to stop. R2 reported stopping at this time and exiting the room. R3 was interviewed and reported hearing a man's voice when entering the room. R3 stated seeing a man sitting on the edge of R1's bed. R3 stated, I think he had clothes on. R2 was initially transported to the police department for an interview. The policy titled, Abuse Policy, dated 10/2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents . This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members, legal guardians, friends, or any other individuals . Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse, is the willful infliction of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident . The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault, including nonconsensual, or non-competent to consent sexual activity. The Immediate Jeopardy that began on 1/8/24 was removed on 1/18/24 when the facility took the following actions to remove the immediacy. Abatement Plan The facility abatement plan includes the following: 1) The male resident identified as R2 remained in police custody until 1/9/2024. Then on 1/9/2024 he was sent to (Local) Hospital for evaluation. The resident has not returned to the facility. The facility provided an emergency involuntary discharge notice to the resident. 2) R1 was sent to the Hospital for medical treatment and agreed to an evaluation on 1/8/24. Follow-up care such as wellness checks were completed and no changes in mood or behavior was noted. Wellness checks will be completed weekly x8 week for R1 starting 1/19/2024 and ending on 3/15/2024. Documentation will be noted in the EMR. Emotional Support was offered to R1 via facility's psychologist on 1/10/24, 1/15/24, and 1/17/24. Facility psychologist concluded R1 has no signs of distress. Facility psychologist will offer services to R1 as needed. Documentation is noted in the EMR. 3) The police were contacted on 1/8/24 and are ongoing with their investigation. 4) The facility reported the incident per policy and applicable regulation. 5) Facility has conducted a full investigation and analysis into the occurrence involving R1 and R2 to ensure all further risks or potential abuse to residents have been eliminated. 6) As of 1/8/24, all interviewable residents have been interviewed by the Administrator, Nurse Consultant, and Medical Records Director to determine if any other residents have been subject to unwanted physical contact or abuse. Administrator also asked all if they feel safe in the facility. All residents that were interviewed expressed feeling safe. No further issues of abuse identified. Facility will continue to monitor. 7) The facility's policies and procedures on abuse, including sexual abuse, were reviewed and confirmed to be accurate, complete, and up to date by the Administrator on 1/18/24. 8) On 1/18/24, the facility has initiated abuse vulnerability screens on R1 and all residents to identify any residents at risk and/or vulnerable to sexual assault. The screening was completed by DON, ADON, and PRSD. Any identified risks or vulnerabilities will be addressed with person-centered interventions in an updated care plan based on the assessed need. i) Abuse vulnerability screens will be completed on admission, annually, and as needed. This is to be completed by the DON, ADON, or PRSD. ii) Facility staff including staff on vacation or on leave were in-service on facility abuse policy. Start date 1-16-2024. Completion date 1-19-2024. In-services will be completed upon hire, quarterly or as needed. Abuse posttest will be completed after each new hire, quarterly, or as needed. Additional education will be given if needed. 9) Residents who have cognitive deficits and score at risk on the Abuse Vulnerability Screen are roomed near the North end of the facility, which is noted to have the nursing station and noted to be a higher traffic area. 10) On 1/9/24, Administrator provided education to R1 and to all other residents on their rights, safe sexual conduct, how to decline unwanted conduct or activity and how to report any uncomfortable or unwanted contact for themselves or others. On 1/18/24, DON and PRSD provided additional education to R1 to reinforce previous education on rights, safe sexual conduct, how to decline unwanted conduct or activity and how to report any uncomfortable or unwanted contact for R1. a) Post-test will be given to residents who are interviewable to gauge their knowledge. Additional education will be given if needed. Post-test were started on 1/19/2024. Completed on 1/20/2024. 11) New facility policy titled New Admission Monitoring effective as of 1/18/24. a) Direct care staff will perform checks on all newly admitted residents at least hourly during the first 24 hours of admission. The DON or PRSD may instruct more frequent checks as needed and appropriate if resident's background check, referral information, prior records behavior/demeanor/presentation on admission demonstrate aggressive or abusive behavior. b) Inservice on New Admission Monitoring will be completed for all staff including staff on vacation or on leave to gauge their knowledge. Started on 1/19/2024. Completed on 1-19-2024. c) New Admission Monitoring Post Test will be completed for all staff including staff on vacation or on leave to gauge their knowledge. Additional education will be given a needed. Started on 1/19/2024. Completed on 1/20/2024. 12) Facility DON or Administrator will conduct in-services and posttest prior to new agency staff starting the shift. The in-services include facility's abuse policy and new admission monitoring. Abuse Post test and new admission monitoring posttest will be completed prior to new agency staff starting the shift. Additional education will be given if needed. a) Agency staff were trained on the Abuse Policy and completed Abuse Post test on 1/8/24, 1/12/24, 1/13/24, and 1/14/24. b) Agency staff were trained on the Abuse Policy and new admission monitoring on 1/19/24. Agency staff completed posttests for Abuse Policy and new admission monitoring on 1/19/24. 13) Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent: a) A QA audit tool will be completed by the Administrator/designee on a sample of 5 residents twice a week for 3 months to ensure staff knowledge on new admission monitoring. b) A QA audit tool will be completed by the Administrator/designee on a sample of 5 residents twice a week for 3 months to ensure resident knowledge on sexual conduct. c) QA audits will be presented and reviewed at the facility monthly QA meetings for 3 months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. 14) Facility Medical Director made aware of IJ on 1/18/2024. 15) Facility conducted emergency QA meeting on 1/19/2024. Person Responsible for IJ Removal Actions: Administrator

Based on interviews and record reviews the facility failed to prevent an incident of staff to resident inappropriate sexual behavior, failed to prevent an incident of resident to resident sexual assault, and failed to prevent an incident of staff to resident verbal abuse. This affected four of four residents (R1, R9, R10 and R5) reviewed for sexual and verbal abuse. This failure resulted in V4 taking advantage of R1 with a diagnosis of major depression and traumatic brain injury by engaging in sexual intercourse with R1. This failure also resulted in R10 being touched and kissed inappropriately by R9. This was identified as an Immediate Jeopardy which began on 9/06/2023 when R1 was observed having sexual intercourse with V4. V3 (Administrator) was informed of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 10/24//2023 at 10:25 am. The facility provided an acceptable removal plan on 10/26/23; the deficiency remains at the second level. On 10/27/23 the surveyor was onsite to confirm the removal plan was implemented. Findings include: 1. R1 face sheet denotes diagnosis of bipolar disorder, major depressive disorder, single episode, personal history of traumatic brain injury. Facility final report to the department dated 9.13.23 denotes in-part incident date 9.6.23, description of occurrence: in part an allegation was made by staff that a housekeeper was sexually inappropriate with R1. E1 was immediately sent home pending investigation. Physician notified of allegation. Police notified. Nurse completed body assessment with no injury noted to R1. Investigation complete. Administrator was notified by nurse on 9/6/23, that she (E2) witnessed E1 and R1 engaged in sexual activity inside R1's room. E2 was instructed to send E1 home immediately. E1 left premises without incident. Administrator presented to facility and initiated investigation. R1 was interviewed and stated E1 was in my (R1) room, and I asked him (E1) to put on a condom. E1 was standing behind me when E2 entered the room and she (E2) saw us. R1 stated that E1 and her (R1) sexual relationship was consensual. Upon interview, E1 denied the allegation, stating I (E1) was grabbing the garbage in the room. I (E1) was standing behind R1, who was bent over, when E2 entered the room. Nothing was happening. R1 was transported to the hospital for evaluation. R1 declined rape kit and was returned to the facility. Police IR #xx-xxx44. All residents interviewed indicated feeling safe in the facility with no reports of any issues with staff. Occurrence resolution: R1 still resides in the facility. Resident was assessed by her psychologist, MD, and psychiatrist with no concerns. Based on R1's psychologist, R1 has the mental and emotional capacity to grant consent. R1 states she never felt threatened by E1. Wellness checks completed with no changes in mood or behavior, R1 states she feels safe in facility. E1 was terminated for breaking union work rules. Facility staff were in-serviced on following abuse policy and work rules including but not limited to maintaining or attempting to maintain a relationship with a resident that is sexual or romantic in nature is not acceptable. Care plan reviewed. On 10.7.23 at 10:40am R1 observed alert, oriented to person, place, time, situation, R1 agreed to speak to surveyor in private setting, R1 said she solicited V4 (housekeeper/ laundry staff) by asking V4 if he had a girlfriend, V4 replied no, R1 said she asked V4 when was the last time he had sex? V4 replied it's been a long time, R1 said she asked V4 if he wanted to try it, and V4 said yes. R1 said her and V4 had been having intercourse since July 2023. R1 said when she would see V4 in the facility she would ask V4 if he wanted to have sex, and V4 would say he will be down there (to her room), and sometimes if V4 is in her room for housekeeping reason she would ask and V4 would say he will be back. R1 said her and V4 got caught on 9.6.23. R1 said she put the condom on V4, she stood up and bent over her wheelchair, R1 said she raised her skirt up so that her lower half of her body was exposed so they could have sex. R1 said someone came in the room, and that prompted her to look around her privacy curtain and sit in the wheelchair, and she saw V5 (laundry staff), V5 was dropping off clothes to her roommate. R1 said she said what to V5, and V5 said I didn't say anything, and V5 left out the room. R1 said shortly after that the V2 (nurse) came in the room and observed her and V4 in a sexual position. R1 said when V2 came in the room V4 was about to penetrate her. R1 said she was bent over her wheelchair, V4 was standing behind her, her skirt was up over her lower body, and V4 pants was down. R1 said she feels safe in the facility. On 10.7.23 at 2:54pm V5 (laundry/ housekeeping staff) said he was delivering clothing to bed 2 on 9.6.23 and when he entered the room, the privacy curtain was making a waving motion, V5 said he did hear whispering sound, but he could not make out the voice. V5 said R1 peaked her head from around the curtain and simultaneously sitting herself in the wheelchair and pulling down her skirt. V5 said R1 said what and he replied, I didn't say anything, V5 said he left the room and immediately informed V6 that they might want to check on R1. V5 said he saw V4 exit R1's room with a garbage bag. V5 said V4 asked him what did V5 say to him. V5 said he blew V4 off because he doesn't want to get involved. V5 said he was on his break around 6:00pm, sitting in his car when V4 approached him again, and V4 said V2 pulled the curtain back and assumed we was doing something, but I was just cleaning the room. V5 said he did not engage V4 in any conversation regarding the incident. V5 said he did not see a housekeeper cart in front or near R1's room when V4 came out of R1's room. V5 said the resident rooms are cleaned on the morning shift not the evening shift. On 10.7.23 at 10:57am V2 (Nurse) said she was informed that R1 was in the room having sex and that she might want to check on R1. V2 said when she went to R1's room, she observed R1 bent over on her wheelchair, V4 was standing behind R1, V4 was having intercourse with R1. V2 said R1's lower body was exposed and V4's lower body was exposed. V2 said V4's pants were down below his knees and above his ankles. V2 said she saw V4 in the physical action of having intercourse with R1. V2 said what she saw total caught her off guard and she gasped and said STOP and left the room. V2 said she was in disbelief, distraught, V2 said she was not thinking straight. V2 said she should have made V4 leave R1's room right away, V2 said they can't explain her actions, but she did call the Administrator and DON and informed them of her observation. V2 said the Administrator informed her to tell V4 to leave the facility pending an abuse allegation. V2 said she couldn't interact with V4, so she asked V6 to inform V4 that he had to leave the facility pending an abuse allegation. On 10.7.23 at 4:09pm V6 (nurse) said she was informed by V5 (housekeeping) to check on R1. V6 said she immediately informed V2 to check on R1. V6 said V2 did go and check on R1 immediately. V6 said when V2 returned to the nurse station she asked V2 what was wrong and V2 said it was V4 in R1's room having sex with R1. V6 said she does remember V2 calling V3 (Administrator) and V1 (DON) regarding the matter. V6 said V3 told V2 to send V4 home pending an abuse allegation. V6 said V2 asked her to tell V4 to leave because she was distraught and could not do it. V6 said V4 was outside, coming from the garbage and she informed V4 that he had to go home, and that he must punch out and leave the premises because there is abuse allegation against him. V6 said V4 got his bag and left. V6 said V4 was gone before the police arrived and before the Administrator arrived. V6 said she doesn't know what color garbage bag V4 had dumped. V6 said she only said to V4 that he had to leave the facility, he had to punch out and leave the premises because there was an abuse allegation against him. V6 said she did not say who the resident was, she did not say who witnessed the incident, she did not say who reported the incident of allegation. On 10.7.23 at 12:33pm V4 (housekeeper/laundry staff) said when V2 (nurse) saw him in R4's room he was dumping the garbage in the room, V4 said when V2 saw him in R1's room R1 was getting in the wheelchair, and R1 had bent over, and he was standing right there. V4 said when R1 bent over her lower body was exposed. V4 said the garbage bag was on the floor when V2 came in the room because he had dropped the garbage. V4 was asked why he didn't remove himself when R1 allegedly bent over and exposed her lower body, V4 said R1 is wide when she bent over, and he didn't think about it. V4 said R1 don't wear underwear, that's why she was exposed when she bent over. V4 was asked how he knew R1 don't wear underwear, V4 said the CNA told him, when asked who the CNA are, V4 said the CNAs be talking, he don't know who said it. V4 was asked why his pants was down if he was emptying garbage from R1's room? V4 denied that his pants were down. On 10.7.23 at 11:04am V3 (Administrator) said she was notified of the incident and she immediate returned to the facility. V3 said she called the police while she was in route to the facility. V3 said she interviewed R1, and R1's statement has been consistent that her and V4 have been in a sexual relationship since July 2023. R1 said V4 was about to penetrate her when V2 came in the room. V3 said V4 has been terminated per the union contract for having sexual relations with a resident. V3 said she substantiated the allegation; she just did not document the language substantiated. V3 said staff cannot have sexual relations with any residents. V3 said if a resident has the capacity to consent to sexual relationship, they cannot consent to a sexual relationship with a staff member. On 10.8.23 at 1:58pm V1 (Director of Nursing) said V2 called her on 9.6.23, and V2 informed her that she thinks she saw R1 and V4 having sex. V1 said V2 informed her that she saw R1 and V4's lower body exposed. V1 said she informed V2 to go and get V3. V1 said staff and residents cannot have a sexual relationship, it is not ethical, and it is abuse. R1's progress note dated 9.6.23 denotes in-part report of inappropriate behavior was made involving resident and staff member. Resident reports no injuries. Resident reports feelings safe at this time. ADM/DON/NP (Administrator/ Director of Nursing/ Nurse Practitioner) made aware. DON informed resident's emergency contact. Police notified of allegation IR #xx-xxx44. Writer unable to complete skin/body assessment due to resident being sent to hospital for rape kit. Resident transported to Local Hospital for evaluation. V4 employee report dated 9.6.23 denotes in-part employee was notified by charge nurse on 9.6.23 that an allegation of abuse was made against him, and he needed to clock out and leave the building. Message left by Administrator at 734pm to return call. Return call received at 8:09pm. Administrator informed employee via telephone that he was suspended for duration of investigation. Employee denied the allegation of sexual abuse stating he was taking out garbage and was positioned behind resident in an awkward position. Employee report dated 9.12.23 denotes in-part discharged , other misconduct: abuse, maintaining sexual relationship with a resident. Abuse allegation was investigated R/T (related to) sexual abuse of a resident by this employee. Abuse was witnessed by a staff member and resident admitted to having a sexual relationship with this employee (V4 initials noted). Employee was notified via telephone on 9.12.23 by Administrator and with supervisor present that he is terminated. Facility policy titled abuse prevention dated 2/2020 denotes in-part the facility affirms the resident right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property or mistreatment of the residents. In order to do so, the facility has established a resident sensitive and resident secure environment. The purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property or mistreatment of the residents. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family member or legal guardian, friends, or any other individual. Abuse means any physical or mental injury, sexual assault inflicted upon a resident other than by accidental means. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident's property will be removed from the residents contact immediately. During this survey the facility video surveillance was not available. The Immediate Jeopardy began on 09/06/2023. The immediacy was removed on 10/26/23, the deficiency remains at the second level. The facility took the following actions to remove the immediacy. 1. On 9/6/23 at approximately 6pm, an allegation was made by staff that V4 was observed having sex with R1. - E1 was immediately sent home. - Police were notified. - Physician notified of the allegation and orders were received to send R1 to the hospital for evaluation. - Administrator interviewed R1 prior to her transport to hospital. - R1 stated the sexual relationship between her and V4 was consensual. - Administrator contacted V4 via telephone and V4's statement was received. - V4 was notified of suspension pending investigation. - R1 returned from hospital, refused rape kit. - Administrator began interviews with staff members on 9/6/23. - Interviews were conducted with residents on 9/7/23. - All interviews with staff were completed by 9/11/23. - Investigation completed. - E1 was terminated on 9/12/23. 2. The facility is following its Abuse Policy. 3. Any allegations of abuse will be reported immediately in accordance with Facility Abuse Policy including sexual abuse. 4. All witnesses to the alleged abuse will be identified as soon as possible and interviewed with accordance with Facility Abuse Policy. 5. In-services were held with All facility staff including staff on vacation or leave of absence on the facility Abuse Prevention Policy and Procedures. In-services included: a. A review of the requirement that all residents are to be free from abuse or neglect including sexual abuse and how to prevent inappropriate staff sexual behavior/acts or prevention of staff manipulation of residents of sexual gratification. b. A review of the facility's polices on abuse investigation and each staff members role as followed: i. All staff must report all allegations of Abuse to the Abuse Coordinator ii. In the event the Abuse Coordinator is not available, the Director of Nursing be must informed of any allegations of Abuse. iii. Allegations of Abuse that occur on 3-11 or 11-7 shift, the charge nurse must send the staff who is accused of perpetrating abuse home immediately and inform abuse coordinator and/or DON. iv. In-Service completed on 9/7/23. Education was provided by Administrator and DON. 6. In-services were held with All facility staff including staff on vacation or leave of absence, with no agency staff on duty to include, on how to respond to a request from a resident engaging in sexually inappropriate behavior. The facility will gauge the knowledge and understanding of the training by completing a post test. Answering all questions correctly will note that the training was effective. Education provided by Administrator and completed on 10/26/2023. 7. Facility conducted background checks on all current facility staff members. Completed on 9/12/2023. 8. Administrator reviewed V4's file and noted background check was completed prior to start date on 5/14/2021. 9. Newly hired facility staff members will complete finger printing and background checks prior to starting. 10. Facility will continue to train newly hired facility staff members about sexual abuse. This training includes how to respond to a request from a resident to engage in sexually inappropriate behavior. The facility will gauge the knowledge and understanding of the training by completing a post test. Answering all questions correctly will note that the training was effective. 11. Abuse training including sexual abuse training will also be conducted on the quarterly and as needed basis. 12. Agency staff will be included in the sexual abuse training. As of 10/26/2023, no agency staff is scheduled. 13. R1 was educated on not to have sex or to coerce sex with facility staff members. R1 was re-educated on 10/24/23 and R1's Care Plan was updated on 10/24/23. 14. R1 received psychological services by facility's psychologist after the incident on 9/11/2023. 15. Resident counsel was held on 9/13/2023 and discussed facility's abuse prevention policy including sexual abuse. Education was provided by the Social Service Director. 16. The majority of residents were interviewed on 9/7/2023 about sexual relationships with facility staff members. Interviews on 9/7/2023 were completed by ADON and Social Service Director. The remaining resident interviews were completed on 10/8/23 about sexual relationships with facility staff members. Interviews on 10/8/2023 were completed by the Social Service Director. No past or current sexual relationships were identified. These interviews were repeated on 10/24/23 and no past or current sexual relationships between residents and staff were identified. Interviews on 10/24/2023 were completed by Social Services Director, Medical Records Director, ADON, Activities Director, MDS Coordinator, and Dietary Manager. 17. An emergency QAPI was conducted on 9/14/2023. The Medical Director for facility was included in the emergency QAPI on 9/14/2023. 18. All allegations of abuse including sexual abuse will be investigated in accordance with the Facility Abuse Policy. 19. Any allegations of abuse will be reported immediately in accordance with Facility Abuse Policy including sexual abuse. 20. All witnesses to the alleged abuse will be identified as soon as possible and interviewed with accordance with Facility Abuse Policy. 21. The facility is following its Abuse Policy. 22. Any allegations of abuse will be reported immediately in accordance with Facility Abuse Policy including sexual abuse. 23. All witnesses to the alleged abuse will be identified as soon as possible and interviewed with accordance with Facility Abuse Policy. 24. Abuse Coordinator and DON's numbers are posted by the nursing station and around facility. 25. Abuse coordinator or designee will conduct QA studies: a. Will perform random twice weekly audits to ensure staff knowledge of abuse prevention. QA will include 5 staff members twice weekly for 3 months. Will follow up with if staff member requires any additional training. b. A QA study will be conducted after each allegation of Abuse. The QA committee will meet weekly for the next 3 months to review Abuse Coordinator's action with respect to such allegation and/or reports. 2. Facility final report to the department dated 9.15.23 denotes in-part reportable incident occurred 9.8.23 at 10:05 a.m., individual allegedly involved: resident to another resident. Residents involved R9, and R10 name is noted. Description of occurrence R10 notified Administrator that R9 was inappropriate with her (R10) in the hallway around 10:00a.m., on 9/8/23. R9 and R10 remain separated by staff. Family and Physicians of R10 and R9 notified of allegation. Police notified. Nurse completed body assessment with no injury noted to R10. Investigation complete. Upon interview, R10 stated that R9 kissed my hand and grabbed my breast in the hallway. Upon interview, R9 stated I don't know why, I (R9) am bipolar. R9 did not deny the allegation. Police arrived to facility, IR#23-xxxxx. Care plan and assessments reviewed and updated for R10. Staff has continued to monitor R10 for changes in mood or behavior. Staff will continue to conduct well-being checks on R10 to ensure she continues to feel safe in the facility. R9 was monitored by staff 1:1 until he was transported to the hospital for psych evaluation. Residents were provided education on the Abuse Prevention Policy and encouraged to report any instances of abuse to the Abuse Coordinator. On 10.24.23 at 12:11pm R10 said a male kissed her hand and them grabbed her breast. R10 said she can't remember the date, but she did report this to the staff. R10 face sheet shows diagnosis of schizoaffective disorder bipolar type, bipolar disorder, major depressive disorder single episode, anxiety disorder due to known physiological condition. R9 witness statement for abuse allegation dated 9.8.23 at 12:23pm conducted by V3 (Administrator) denotes in-part I was in the hallway by the activity room and the new guy in the wheelchair (R9) kissed my hand, grabbed my breast and told me he wanted to see my pxxxx. R10 progress notes dated 9.8.23 denotes in-part, writer was informed by social services that resident reported inappropriate sexual behavior with co-peer. ADM/DON/NP (Administrator/Director of Nursing/ Nurse Practitioner) and Mother made aware. R9 PASSR dated 9.5.23 denotes in-part diagnosis of schizophrenia, bipolar disorder, inappropriate sexual behavior, aggression. R9 is not available for observation or interview. R9 witness statement for abuse allegation dated 9.8.23 at 12:23pm conducted by V3 (Administrator) denotes in-part I don't know, I'm bipolar- that causes me to be inappropriate sometimes. The residents' rights for people in the nursing home denotes in-part you must not be abused, neglected, or exploited by anyone, financially, physically, verbally, mentally, or sexually. 40066 3. R5's diagnosis include but are not limited to Type 2 Diabetes, Major Depressive Disorder, Substance Abuse, Homicidal Ideations, Post traumatic Stress Disorder, and Insomnia. On 10/24/23 at 11:48AM R12 said in the early morning hours he heard V7, Certified Nursing Assistant (CNA), dropping the F bomb towards R5. R12 said it occurred in the hallway. R12 said V7 has been mildly aggressive with residents in the past. On 10/24/23 at 1:31PM V8, Registered Nurse, said V7 told me at 4:00AM that she asked R5 to remove like 12 towels from his room. V8 said V7 reported to her that R5 cursed at her. V8 said V7 told me she said to R5 same to you. V8 said I did not see any of this I was down the hall passing medications. On 10/24/23 at 1:59PM V3, Administrator, said R5 reported to me that in the early morning hours of the weekend V7 came into his room. V3 said R5 said V7 began to take towels out of the room and he told her to get out. V3 said R5 said as V7 got to the door, f--- you to R5. V3 said I interviewed R5, R12, and R13. R13, R5's wife/roommate, said she heard V7 curse at R5 and V7 had a bad attitude since she entered the room. V3 said while interviewing residents in the hall way R12 said he heard an exchange between R5 and V7. V3 said she is not aware of R5 cursing at staff in the past. V3 said she terminated V7 following the investigation. On 10/25/23 at 10:08AM R5 said V7 came in all mad, she didn't want to work and she had to come in and help my wife. R5 said I am independent but R13 needs help. R5 said V7 started saying you have too many towels, I'm taking them. R5 said he tried to tell V7 that they need the towels, but she kept taking them. R5 said he told V7 to leave and as she was walking out of the room she said f--- you. R5 said I got up and she kept walking, I said what? And she kept walking away towards the nurses station. R5 said R12 saw this, I was telling her she can't talk to us that way, I'm reporting you and I'll have your job. R5 said I followed V7 all the way to the nurses' station and the nurse V8 (R5 said V8's name) was there. The nurse was telling me to calm down, but she didn't say nothing to V7. R5 said I've heard V7 be rude and curse at other residents before. R5's care plan does not indicate a behavior of cursing at staff. R5's progress notes 9/22/23 - 9/27/23 do not include any notes related to R5 having verbal outbursts or cursing at residents. The facility final abuse investigation dated 10/3/23 states R5 reported to Administrator that V7 was verbally inappropriate with R5 on 9/24/23. R5 reported that V7 said f--- you when he asked her to leave his room. The facility abuse prevention policy dated 2/2020 reads the purpose of this policy is to assure that the facility is doing sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.

Based on observation, and interview the facility failed to ensure that one of two shower rooms were in good repair, and without dark black substance on the walls and ceiling and without a foul smell. This has the potential to affect all residents utilizing the north shower room. Findings include: Facility census dated denotes 10.24.23 there are 64 residents residing in the facility. On 10.24.23 at 12:00pm R11 said the shower head in the bathroom does not have a hook to hold the showerhead, and the showerhead hangs and touches the floor. R11 said it's the shower room on the other side of the facility (north side of building). On 10.25.23 at 11:32am during a tour of shower room on the north side of the building, the shower head was observed to hang down. V10 (Maintenance Supervisor) said the showerhead arm is broken. V10 said he was not aware that the showerhead arm was broken. There was a black dark substance observed on the ceiling and walls in the shower room, there was a foul smell in the shower room, the smell was noticeable although a face mask was worn. V10 said the black dark substance is from condensation, and maybe they don't leave the vent on. V3 (Administrator) was summoned for the observation, V3 said she does smell the odor and she will shut the bathroom down and have someone come out for testing. On 10.27.23 at 11:08am V21 (CNA-Certified Nursing Aide) said, the facility usually has two shower rooms for the residents, and now there's one shower room because one shower room is shutdown. V21 said she doesn't know why the shower room is shut down. V21 said all the residents use both shower rooms. V21 said there may be a few residents that refuse showers. V21 doesn't know the names of the residents that usually refuse showers. On 10.27.23 at 2:06pm R6 (president of resident council) said in the north shower room, the showerhead is broken and there's stains on the walls. R6 said she has mentioned this in the resident's council minutes. Resident council minutes dated 10.25.23 denotes the shower head holder broken in north side shower. On 10.27.23 at 11:04am there was a sign noted on the north shower room door denoting out of order.

Based on interviews and records reviewed the facility failed to report an allegation of abuse. This affected one of three (R5) reviewed for reporting incident of abuse. The findings include: On 10/24/23 at 1:31PM V8, Registered Nurse, said V7 told me that R5 cursed at her. V8 said V7 told me she said to R5 same to you. V8 said I did not see any of this I was down the hall passing medications. On 10/24/23 at 1:59PM V3, Administrator, said R5 reported to me that in the early morning hours of the weekend V7 came into his room. V3 said R5 said as V7 got to the door, f--- you to R5. On 10/25/23 at 10:08AM R5 said he told V7 to leave his room and as she was walking out of the room she said f--- you. R5 said I got up and she kept walking, I said what? And she kept walking away towards the nurses' station. R5 said I followed V7 all the way to the nurses' station and the nurse V8 (R5 said V8's name) was there. The nurse was telling me to calm down, but she didn't say nothing to V7. On 10/25/23 at 10:32AM V3, said staff shouldn't engage in arguments with the residents. V3 said it is inappropriate to argue with the residents. V3 was asked what should happen if a resident cursed at a staff and the staff responded, same to you. V3 said the staff witnessing should report this to me and staff saying that should be removed. V3 said no one told me that V7 said same to you to R5. The facility investigation report states R5 notified V3 on 9/27/23 that V7 was verbally inappropriate with him. The facility Abuse Prevention Policy states employees are required to report any incident, allegation of suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately.

Based on interviews and records reviewed the facility failed to follow hospital instruction and ensure a resident has a follow up Gastroenterology appointment. This failure affected one of three residents (R13) reviewed for follow up appointments. Findings include: R4's diagnosis include but are not limited to Alcoholic Cirrhosis of Liver with Ascites, Chronic Systolic and Diastolic Heart Failure, Hepatic Encephalopathy, Anemia, and Alcohol Abuse. R4 was admitted to the facility on [DATE]. On 10/25/23 at 2:28PM V11, Licensed Practical Nurse (LPN), said on resident admissions the orders are processed and the physician is notified of the orders. V11 said the physician will direct to keep or discontinue any orders. V11 said the same process is done when referrals come at the time of admission. V11 said I will put the order in the records and notify the person who handles the appointments and transfers. On 10/25/23 at 2:52PM V12, Medical Records, said if I had known R4 needed an appointment I would have called and made it. V12 said when new admissions come in the nurse will review the admission record packet and let me know if I need to schedule an appointment. V12 said I will also look while I scan the records into the electronic medical record. While reviewing the April and May 2023 schedules V12 said R4 has no appointment recorded. The surveyor showed V12 the hospital discharge instructions for R4 and asked if this required an appointment, V12 said yes, that looks like one. R4's Hospital Discharge Instructions, provided by the facility include: follow up appointment V13, Gastroenterology, in two to three weeks call for appointment, [phone number listed]. Progress Notes from 4/18/23 until 5/7/23 reviewed. There is no documentation of pending appointments. Physician Order Report for R4 does not list follow up appointment information. The facility provided calendar of appointments for April and May 2023, R4 is not on the calendar.

Based on observation, interview and record review, the facility failed to monitor and keep residents free of accidental hazards for 1 of 3 residents(R36) at risk for falls and with history of falls in the sample of 15. This failure caused R36 to sustain 3 unobserved falls, with the 3rd fall causing emergent transfer to the hospital emergency room for treatment of head contusion, eye lacerations and nasal fractures. Findings include: R36 is a [AGE] year-old with diagnoses listed in part with [CONDITION(S)], [CONDITION(S)], cognitive communication deficit, [CONDITION(S)] and diabetes. Two facility fall assessments dated 11/4/21 and 11/24/21 were conducted by V5 (RN) with both assessments showing R36 to be at high risk for falls. A facility accident/incident form dated 11/3/21 written by V2 (Director of nurses) read, Resident had a fall in the bathroom. The nurses went to the bathroom and resident was on the floor leaning up against the wall. Resident stated that he was trying to transfer himself, but he fell over his footrest. R36's MDS (Minimum Data Set) dated 1/15/22 showed R36 needing maximum assistance with a minimum 1-person physical assistance for bathing, toileting, dressing, and personal hygiene. A facility accident/incident form dated 11/24/21 written by V2 showed, Writer observed resident on left, side-lying position, on floor in the small dining room. Writer assessed resident, bruising and swelling noted to the left upper eyebrow area. Resident stated, I was leaning forward in the wheelchair and my foot slipped off the footrest, then I fell out of my wheelchair. Orders received to send to hospital ER for evaluation. On 3/14/21 at 10:55 AM, R36 was observed awake in bed with bilateral side rails up. R36 appeared alert and oriented and was conversive. R36 had a visible redness and swelling to his left eyebrow and was asked what had happened to him. R36 responded, I fell while I was trying to get something from the refrigerator (pointing to the refrigerator placed atop a dresser drawer). That fell down when I reached for something in it, and I fell forward, and I broke my nose. Surveyor asked if the refrigerator fell on him, R36 stated, I don't know, I just know it fell and I fell forward out of my wheelchair and then I went to the hospital and I got stitches and a broken nose, and it really hurt. On 2/24/22, R36 sustained another unsupervised fall. Hospital Emergency Department records showed: 02/24/2022 11:39. Patient presents after fall at his nursing home. Says he was reaching into his refrigerator, and he fell forward when his wheelchair moved, hitting the left forehead right above his left eyebrow. Visit diagnoses: 1. Forehead contusion, 2. Eyebrow laceration, 3. Fracture of nasal bones, 4. Maxillary sinus fracture, 5. Dizziness. On 3/14/21 at 11:15 AM interview with R36's nurse V5 (RN) stated, (R36) is a fall risk. He is a left side hemi ([CONDITION(S)]) due to [CONDITION(S)]. Surveyor asked about R36's recent fall involving the refrigerator, V5 stated, He (R36) was reaching for something inside his refrigerator, and he fell forward from his wheelchair. We put his fridge up higher on the dresser, so he doesn't have to bend down and fall over again. Surveyor asked if the refrigerator was secured to the dresser to prevent it from falling over, V5 stated, The maintenance man is the one that placed it on top of there. Surveyor and another fell ow surveyor inspected the refrigerator and showed it to be unsecured to a waist high dresser drawer. The refrigerator showed to easily tip over upon opening the refrigerator door and was not secured with any bolts or other mechanical device keep the refrigerator from tipping over. On 3/16/22 at 11:25 AM V7 (maintenance director) was asked about the refrigerator in R36's room. V7 stated upon interview, I set up all the refrigerators in the room. They are normally provided by the family but there are some that the facility provides, I think. I generally place them on the ground, and I put thermometers in them, so we (facility) are responsible for their maintenance and upkeep. Surveyor asked if refrigerators should be placed atop dresser drawers, V7 stated, I normally would not put them on top of a dresser drawer due to safety because it could fall over and fall on someone. Surveyor asked if there were refrigerators on top of dressers, what precautions the facility would take, V7 stated, I would probably ensure that it is secured to the dresser with something but otherwise I would not put it on top of a dresser. Surveyor asked if he placed R36's refrigerator on top of a dresser, V7 stated, More likely I did because I install all of them, but I will have to see if it is secured. Calls to R36's physician made on 3/16 at 2:30 PM and 3/17 at 9:30 AM were left unanswered and with no return calls made to the surveyor. Facility policy undated policy titled Facility Policy Regarding Resident Falls reads in part, This facility is committed to minimizing resident falls so as to maximize each resident's physical, mental, and psychosocial well-being. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies, and facilitate as safe of an environment as possible. All resident falls will be assessed and the resident's existing plan of care will be evaluated for needed changes.

Based on interview and record review, the facility failed to provide monitoring and supervision per facility policy for a resident with a known history of suicidal ideation and self-harm by not having effective interventions in place to monitor the resident and by failing to intervene promptly to maintain resident safety. This failure applied to one (R1) of five residents reviewed for supervision and resulted in R1 being able to leave the facility unsupervised and having two separate instances of swallowing batteries, which resulted in R1 having to be sent to local hospital to undergo procedures to have batteries removed from R1's stomach. Findings Include: R1 is [AGE] year female with medical [DIAGNOSES REDACTED]. R1 is not currently residing in the facility and was reviewed as a closed record. Review of R1's medical record included (but was not limited to) the following information: 11/28/19 at 3:45pm, R1 approached and told staff that she swallowed (10) AA batteries a few minutes ago while she was in her room and that she intended to report it right away. Resident was sent out to the hospital, 4 batteries were removed and 6 digested as documented in nurse's progress note and ER record. R1 was readmitted to the facility on [DATE] with no new orders or any change in her care plan or supervision level. R1 was assessed for and had a pass to leave the facility independently until 1/07/2020; at this time it was revoked as documented in the physician order [REDACTED]. Per nurse's note, resident was found with slurred speech and smelled of alcohol on 1/9/2020; per R1's smoking care plan, R1 was able to smoke unsupervised. 01/27/2020, R1 was observed by staff outside of the facility walking toward the facility, upon entering the facility resident noted to have a cup of coffee. She was re-educated that she does not have independent pass privileges at this time and that she's not to go out of the facility without permission or a staff escort. She states, I know that I am not supposed to go out, but I needed some air. DON (Director of Nursing), administrator, nurse practitioner (V8) aware, will refer to social services to f/u. no apparent s/s of distress noted. 2/09/2020, R1 came to the nurse station and told staff that she swallowed 20 batteries and that she was suicidal. MD was made aware order to send resident to hospital for medical/psych with petition. Resident placed on 1:1 monitor while waiting for ambulance to transport to hospital. Resident was admitted with [DIAGNOSES REDACTED]. Per hospital record, resident stated that she swallowed the batteries because facility staff did not believe her when she told them that she was suicidal. CT scan of the abdomen conducted at the hospital showed multiple foreign bodies identified at the gastric lumen consistent with batteries. resident underwent [REDACTED]. 10/28/2020 at 11:06AM, V5 (RN) stated that the facility is aware that R1 is suicidal, including about 6 other residents, everyone gets the same level of supervision unless one expresses thoughts of suicide, then they will be placed on a 1:1 monitoring pending transportation to the hospital. V5 also added that the facility does not have alarms on the doors but have monitors located at the front office and the nursing station. V5 was asked if there is a designated staff for monitoring the cameras and he said no, if someone is not at the nursing station or around the camera at a particular time, it is possible for a resident to walk out without being seen. Behavior care plan for R1, dated 10/22/2019, states (R1) experiences auditory hallucinations AEB (as evidenced by) hearing voices telling her to eat batteries. Goals state that resident will show a decrease in episodes of auditory hallucinations by staff redirecting conversation. Interventions include to document in the progress notes the intensity, duration or frequency of behavior. Provide redirection or distraction to minimize frequency or duration of behavior. R1 has an SMI (Serious Mental Illness) care plan dated 12/18/2019 and Suicidal Ideation care plan dated 12/05/2019, state that resident has a history of SELF-HARMFUL behavior AEB resident digesting batteries, Evidence of severe mental illness (i.e., active [MEDICAL CONDITIONS], lack of sound judgment, poor contact with reality), Poor impulse control, Attention seeking Problems/needs are manifested by, Voicing threats of self-harm. Additional risk factors include previous self-harmful behavior, Substance abuse history, etc. During the course of this survey, there were no care plans provided that documented any changes to R1's plan of care or required level of supervision. 10/27/2020 at 10:30AM, V4 (Social Worker/PRSC) said that she was the assigned social worker for R1; per V4, (R1) was pleasant, provides a lot of insight to her past and had a good relationship with co-peers. V4 added that R1 had a history of [REDACTED]. When she returns from the hospital, the social worker will do a one to one counseling, and do a room sweep for 72 hours. Then they will do a random room check on a daily basis and document it in resident's medical record. She added that she is aware that R1 is a high risk for suicide. R1 was not placed on a one to one supervision with an assigned staff because the facility does not provide that level of monitoring. Per V4, if a resident requires that level of care, they are usually sent to the hospital. V4 added that R1's room was searched the day that she swallowed 20 AAA batteries. During the course of this survey, surveyor asked for documentation that R1's plan of care was followed by searching R1's room but it was not provided. 10/28/2020 at 11:20AM, interviewed V6 (Psychiatrist) stated that he does not recall the resident but was reminded of resident's documented behavior and suicidal attempts by the surveyor. V6 stated that it is very difficult to manage residents with self-injurious behavior but that someone with this type of history could have been monitored better, she should not be able to go out and get a cup of coffee. V6 continued to state that he does not decide where people go; he only manage their health and medications, it is up to the social worker at the hospital and the facility to determine appropriate placement for the resident; sometimes the facility will state that they don't have the capability to handle a particular resident and placement arrangement will be made. 10/27/2020 at 3:08PM, V8 (Nurse Practitioner) stated that she is very familiar with resident, she is aware that she is suicidal but said that she also has a history of swallowing batteries. She added that R1 is not considered a high risk once they come back from a psych hospital because they have completed their psychotherapy. V8 was not sure how the resident got the batteries she swallowed but said that R1 told her that she paid another resident to purchase the batteries for her. 10/28/2020 at 11:49AM, V2 (DON) stated that the suicidal residents in the facility are monitored by a daily checks conducted by social services and that they all have individualized care plans. V2 was asked if R1 was supposed to be an independent smoker with her history of suicidal ideation and ingestion of foreign bodies. When asked, V2 stated that it is possible for a suicidal resident to pick up anything while smoking independently and that no one knows where R1 got the batteries she swallowed. Facility policy titled, Resident Behavior Watch (undated), reads: Objective; It is the facility policy to assess, evaluate and investigate statements voiced or otherwise communicated by residents that may be threatening to themselves or others. The facility will provide appropriate follow-up intervention based upon the individual's need. The document goes further to identify persons who are considered at greater risk including persons with a history of previous suicide attempt, history of psychiatric problems and / or a personality disorder diagnosis, etc. Under procedure, the document states that follow-up intervention and evaluation will be provided based upon each individual's need. Item 5 of the procedure states that care plan approaches and interventions may include suicide warning signs. Staff should look for warning signs and promptly report any change in behavior, and intervene accordingly to promote resident's safety.

Based on observations, interviews and record reviews, the facility failed to prevent a resident (R1) from being injured by another resident with a history of battery and assault. This failure resulted in one (R1) of three residents reviewed for abuse receiving four sutures on her upper lip and multiple bruises to her face. Findings include: R1 is a [AGE] year old. [DIAGNOSES REDACTED]. Per MDS(Minimum Data Sheet) dated 11/27/19, R1's cognitive assessment score was 10, indicating she is mildly cognitively impaired. On 12/24/19 at 9:40AM V1, Administrator, said she investigated the incident on 12/9/19 and watched the facility surveillance footage. V1 said no one had entered or left R1's room except for R2. V1 said after investigating there was no other conclusion except that R1 and R2 had an altercation. V1 said R1 verbalized once that R2 attacked her but would not say more and neither resident would say what happened. V1 said the incident happened in the morning. R1 and R2 were roommates on 12/9/19. On 12/24/19 at 10:18AM R1 observed by surveyor with a light purple crescent shaped bruise under left eye along her cheek bone. On the right side of her nose, maxillary region, is a light purple discoloration. R1 has a dry scab over her left upper lip. R1 said someone hit me, I don't know who. R1 changed the subject and would not discuss the bruises or altercation further. On 12/24/19 at 10:36AM V3, Nurse, said she was assigned to R1 and R2 on 12/9/19. V3 said she was alerted by the Certified Nursing Assistant (CNA) that something had happened to R1. V3 stated she did not know the CNA's name. CNA later identified as V4. When she(V3) entered the room, R1 was sitting on her bed holding her face. R1 had a nose bleed and was getting anxious. V3 said no one saw what happened. V3 said she provided first aid and applied ice to R1's nose and the back of her neck. On 12/24/19 at 10:42AM, R4(friend of R1) said she saw R1 after the incident on 12/9/19 occurred and her face was all black and blue. On 12/24/19 at 11:00AM V4, CNA, said on 12/9/19 she saw R2 walking nervously in the hall and she kept looking back at her room and rubbing her hands. V4 then saw R1 wobbling out of her room and holding her face. V4 said R1's face was covered in blood. On 12/24/19 at 11:10AM V5, Quality Assurance Nurse, said R1 and R2 were both seen in their room and in their beds unharmed around 7:30 or 8:00AM on 12/09/19. V5 said she didn't see any altercation between R1 and R2, but V4 called for her to assist R1. V5 said when she entered R1's room V3 was providing care to R1 who was bleeding. V5 said R1 is forgetful and has memory problems. R2 had a history of [REDACTED]. On 12/24/19 at 11:39AM V7, Psychiatric Rehabilitation Services Coordinator, said R2 was brought into her office on 12/9/19 and was reminded of the facility rules and she remained with her until the ambulance arrived for her. V7 said she saw R2's hands and the right hand was a different color than the left and she had a dry scratch above the fourth finger knuckle. V7 said that R2's right hand was discolored. It was an absolutely different shade of pink compared to the left hand and as time passed the color returned to her usual color. V7 said R2 did not say what happened to R1 but said no one else had entered the room. On 12/24/19 at 12:00PM V8, Former Psychiatric Rehabilitation Services Director, said she didn't see the altercation but spoke with R1 and R2. R1 denied falling. On 12/26/19 at 9:00AM V10, CNA, said on 12/9/19 she was in the break-room when V4 notified her that R2 attacked R1. V10 said after she was notified she assisted R1 by cleaning the blood off her face and changing the bloody bed sheets. On 12/26/19 at 10:15AM V1 said R2 was alert and oriented and able to make her own decisions. On 12/26/19 at 12:00PM V13, Nurse Practitioner, said she saw R1 after the incident occurred. V13 said R1 would not say what happened, despite multiple times asked, with and without family and or staff present. R1 had multiple purple bruises including on her chin, jaw line, right eye area, and on her neck. V13 said R1 denied falling. V13 said she has seen bruising on people who have fallen out of bed and this did not look like that. V13 said an occurrence occurred but we don't know what may have caused R1's bruising. On 12/26/19 at 12:35PM V14, Police Officer, said he was called to the facility for a report of a bloody nose. V14 said when he saw R1 she looked like she had been attacked. She had said her roommate attacked her but she could not identify who that was, and then said she could not remember anything. V14 said R2 had no blood on her hands but her hands were swollen. V14 said R2 had done something to cause R1's injury. V14 said R2 had an extensive criminal history, but he was unable to arrest her because R1 was unable to identify who hit her. R1's After Visit Summary from the hospital dated 12/9/19 denotes reason for visit: assault victim; [DIAGNOSES REDACTED]. Accident Report written by V3 dated 12/9/19 denote writer was called to R1's room and observed R1 sitting on the bed with swelling and bruising on her face. Contributing factors denoted aggression of co peer / roommate. R1's Care Plan includes a focus dated 12/10/19 for bruising to the entire facial area, secondary to injuries. Four sutures in inner upper lip. On the same page of the Care Plan a focus dated 12/11/19 denotes resident has been a victim of suspected abuse. On 12/10/19 a Progress Note written by V5 denotes R1 is still observed with swelling and bruising to right and left side of face. A Progress Note written by V3 on 12/10/19 denotes R1 has many facial bruises. R2 is [AGE] years old and [DIAGNOSES REDACTED]. R2's Criminal History Record issued by the State Police dated 8/7/19 denotes charges including Battery and Assault in (YEAR), Battery in 2014, 2013, and 2003. On 9/6/19 the facility received a Criminal History Analysis Report for R2. The report denotes R2 as a moderate risk. The resident requires closer supervision and more frequent observations than standard or routine for more residents in an open facility. The specific considerations important in the recommendations include threatened her roommate. On 9/19/19 R2's cognitive assessment score was 15, indicating she is cognitively intact. The facility's Final Incident Investigation Report dated 12/13/19 denoted R2 had displayed socially inappropriate aggressive behavior towards R1 in their bedroom at approximately 9:45AM. First aid was applied and 911 was called. R1 was taken to the hospital for treatment to her injuries. The facility policy for Abuse Prevention dated 12/2019 denotes Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. .

Based on interview and record review, the facility failed to follow the facility policy on identifying the right resident, administering medications as ordered by the physician, and safeguarding resident from receiving another resident's medications. These failures resulted in R23 complaining of dizziness, weakness, heart pounding, and trouble breathing. R23 was sent emergently to the local hospital and diagnosed with [REDACTED]. Findings Include: R23 is [AGE] years old with [DIAGNOSES REDACTED]. Minimum Data Set Section C, Cognitive Patterns (dated 9/12/19) indicate R23 has intact condition. On 12/9/19 at 10:59 am, R23 was asked if she had ever been given wrong medication. R23 answered, Yes. The person who gave me the wrong medicine was V20 a new person. I was asleep and V20 woke me up. When V20 gave me the patch, I thought the doctor changed my medications. I don't think she asked me my name, because I would have said I am not that person. I was really scared when I got sick. I got sick because I only take Tylenol for pain. I got really dizzy, throwing up, pretty bad, and my body started tingling. I couldn't stand up right. My legs were weak. I was totally dizzy. Almost [MEDICAL CONDITION]. [MEDICATION NAME] was so strong. Everything was going numb, I almost passed out. I couldn't catch my breath and my heart was pounding. I was sleeping and V20 woke me up. I trusted the staff to give me the right medication. V20 told me here's your meds, put the patch on and gave me pills. I woke up sick and went to the nursing station and I asked, what is this on my arm and they were shocked. It was probably around 8-9am. They gave me a pill, they called the ambulance and I went to the hospital. Progress Notes dated 10/4/19 03:00pm authored by V2 (Director of Nursing) documented that R23 was trembling and needing assistance by 2 staff members to sit. Skin was warm, face, chest and arms were flushed. [MEDICATION NAME] Patch was in place on the resident left upper arm. Record was reviewed and R23 had no order for [MEDICATION NAME] Patch. Facility called Nurse Practitioner and ordered [MEDICATION NAME] with no immediate relief. R23 showed increased mental confusion and restlessness. Vital signs were: Blood pressure: 86/54 mmHg, Pulse rate: 100 bpm, Respiratory rate: 22 shallow. 911 was called, they arrived 2 minutes after call was placed to take resident to nearest hospital. R23's last set of vital signs prior to incident taken 9/10/2019 documented as: Blood pressure: 130/70 mmHg, Pulse: 70 bpm, Respiration: 20 rpm, Temperature: 98.6F, Weight: 209 lbs. Vital signs taken on 10/6/19 (two days post incident) were: Blood pressure: 124/82 mmHg, R: 18, P: 81 bpm, T97.9 On 12/9/19 at 12:01 pm, V20 (Licensed Practical Nurse) stated, I was orienting with another nurse. I looked at the MAR (medication administration record) at the nurses' station, and then I went to the room, I asked Are you (R265's first name), she said yes. V20 said I will give you your meds and she said yes. She was lying on the bed, when I knocked on the door, and said (R265's first name), the lady in the first bed, sat up, and she answered to (R265's first name). I asked her 3x if she was (R265's first name) and she said yeah. When she sat up from the bed, she said yes, I told her who I was, I said I will give you your meds. I walked out from the room and went to the MAR and prepared the medications. I went back to the room, and said I got your meds, she said ok, I gave oral medication and put the patch on. When I gave her the patch, I asked her where you wanted me to put your patch, she said, That's new, I never had that before so I said I will put it on you. I went to nursing station and told V24 (LPN) that (mentioned R265's first name) said she never gets a patch, and V24 in the nursing station said, She has been getting that for years. V20 was asked when she learned that there was a medication error, she stated When the DON (Director of Nursing) called me. She asked me if I put a patch on somebody. I shouldn't have been passing medication because I was on orientation. I really didn't know the people. Only one nurse was working with me. I was giving medication by myself. That was my first time to pass medication in that building (Facility). V20 was asked if she asked R23's last name, V20 answered, No; and if she asked R23's birthday, V20 answered No. On 12/11/19 at 3:30pm, V2 said V24 was the preceptor, and V24 was at the nursing station passing medications. V2 also said, V20 was by herself when she administered the medications, and it was V20's first time to pass medication in the facility but, V20 has been a nurse for ten years. On 12/9/19 at 11:53am, V2 said, on (MONTH) 4, 2019 R23 received 6:00 am medications ordered for R263. R263's (MONTH) 4, 2019 Medication Administration Record documented, [MEDICATION NAME] 7.5mg tablet, [MEDICATION NAME] 0.5mg tablet, [MEDICATION NAME] 88mcg tablet, [MEDICATION NAME] 25mcg/hr [MEDICATION NAME], was signed out by V20. R23's Physician order [REDACTED]. No orders for [MEDICATION NAME] or [MEDICATION NAME]. R265's Physician order, documented [MEDICATION NAME] 25mcg/hr [MEDICATION NAME] apply 1 patch by [MEDICATION NAME] route every 3 days at 6:00am, [MEDICATION NAME] 7.5mg-325mg 1 tablet by oral route every 8 hours, [MEDICATION NAME] 0.5 mg by oral route, and [MEDICATION NAME] 88mcg tablet by oral route once daily. Progress Notes dated 10/4/19 6:03pm, authored by V22 Nurse Practitioner documented, R23 was administered a [MEDICATION NAME] Patch 25mg (referring to mcg), [MEDICATION NAME] 7.5/325mg and [MEDICATION NAME] 0.5mg. Assessment and Plan Opioid overdose: patient incorrectly given wrong medication. Patient rushed to ED, and received [MEDICATION NAME]. On 12/10/19 at 10:07am, interview with V22, was asked the question, Do you think the administration of these medication may have contributed to R23's symptoms? V22 stated, The patch was strong for a person who only takes Tylenol. The mixture of the 3 medications together was strong and I was concerned of respiratory distress, and they don't have [MEDICATION NAME], and I want it available as needed, so I wanted her to go the hospital to be able to better manage the resident. On 12/10/19 at 3:09pm V22 (Nurse Practitioner) was asked to clarify if an opiate overdose is a life threatening situation? V22 answered Yes it is. V22 was also asked what the potential harm was to R23, and what would be the concern? V22 answered Respiratory distress, that's why she was sent out to be able to manage appropriately in a timely fashion. Emergency Medical Services Narrative: In summary crew arrived to find pt. AO (Alert Oriented) x2 complaining of nausea. Staff related to crew that pt was given the wrong drugs. [MEDICATION NAME]. Pt was taken to ambulance for continued ALS (Advance Life Support) care. Crew administered 4 mg [MEDICATION NAME]. R23 AO x3 upon arrival at local hospital. Pt care transferred over at nurse's station. Local Fire Department (Paramedics) Vital Signs on 10/4/19 at 09:01 am: 130 (bpm) Pulse rhythm, Respiratory rate 18, Blood Pressure 142/70 mmHg emergency room 's Final Diagnosis: [REDACTED]. On 12/9/19, V7 Registered Nurse (RN) (at 11:37) and V10 RN (at 2:17pm) were interviewed regarding medication pass. Per the facility medication policy, both nurses stated the correct way to administer medication to residents. Facility's Incident/Accident Final Report Dated (MONTH) 7, 2019, Documented, Resident was accidentally given her roommate's medication. She was taken to Local Hospital via EMS for evaluation and treatment. She received [MEDICATION NAME] in route to Hospital (D/T (due to) Ingestion of Narcotic [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) and antianxiety medication ([MEDICATION NAME]). Facility's Policy titled; Specific Medication and Administration Procedures dated (MONTH) (YEAR) states in part; to administer medications in a safe and effective manner. Identify resident using two identification methods before administering medication (e. g photo plus verbal confirmation of last name, photo and confirmation by family member, etc.) Facility's Medication Errors policy states in part; a medication error is defined as a dose of medication that deviates from the physician's orders [REDACTED]. Unauthorized drug- Administration to the resident of medication not authorized/ordered.

Based on observation, interview and record review the facility failed to provide a safe physical transfer for a resident according to the care plan and policies governing resident transfers. This applies to two of three residents (R1, R2) reviewed for injury, in a sample of three. This failure resulted in R1 sustaining a fracture to the upper left arm. Findings include: 1.) R1's Physician order [REDACTED]." On 2/11/15 at 11:45am, R1 was observed sitting in a wheelchair with a cast on her left arm. The surveyor asked R1 what happened to her arm and R1 stated "I don't know." R1's primary language is Japanese. R1's left side of the body was paralyzed. R1 had the use of one leg due to an amputation of the leg. R1's care plan dated 9/4/14 reads "R1 has impaired ability to make self understood, and requires a one person assist for transferring." R1's Minimum Data Set (MDS) dated 12/4/14 under section G reads Transfer "Two person physical assist." Transfer is described as how resident moves between surfaces including to or from: bed, chair, wheelchair." On 2/11/15 at 11:30am, E3 (Licensed Practical Nurse) stated that around 10:30pm on 2/5/15, E4 came out of R1's room and stated "I need you to look at R1's left arm." E3 stated R1's left paralyzed arm was red, swollen and there was a bone protruding. E3 stated she called Z1 (Physician). Z1 gave the order to send R1 to the hospital. On 2/11/5 at 1pm, E4 (Certified Nursing Assistant) stated that he was taking care of R1 on 3-11 shift on 2/5/15. E4 stated he usually does not take care of R1. E4 stated he transferred R1 from wheelchair to bed by himself around 6:30pm. E4 grabbed underneath R1's right arm and around R1's waist to transfer R1 from wheelchair to bed. E4 stated that on his final rounds at approximately 10:30pm on 2/5/15, he noticed R1's left paralyzed arm was swollen and red. He saw a little bone popping out of her skin on R1's upper arm. E4 went to get the nurse and reported how R1's arm was reddened and swollen. E4 stated there was a bone protruding underneath the skin R1's left arm. On 2/11/15 at 4:30pm, the surveyor asked E4 if he was aware that R1 is supposed to have 2 persons transfer her from wheelchair to bed. E4 stated he did not know that R1 was a 2 person transfer. On 2/11/15 at 1:45pm, E6 (Nurse) stated that R1's arm was fine on day shift on 2/5/15. E6 stated that she saw R1's arm on 2/5/15 during the day shift and R1's arm did not have any redness, swelling or bone protruding underneath her skin. R1's x-ray report from the hospital dated 2/6/15 reads "Spiral fracture of the distal humerus with posterior displacement and angulation of the distal fragment." R1 returned to the facility with a cast on her left arm. On 2/11/15 at 4pm, Z1 stated that R1's spiral fracture of her left humerus could be the result of a transfer. The facility's accident report sent to the state agency dated 2/6/15 reads "Upon investigation possibly happened when CNA (Certified Nursing Assistant) was transferring R1 from wheelchair to bed." 2.) During the survey staff members were observed for techniques for transferring residents as follows: -On 2/13/15 at 9am, E10 (CNA) was observed transferring R1 from the wheelchair to bed. E10 placed a gait belt around R1. The gait belt was not placed around R1's waist. The gait belt was placed around R1's upper Chest. E10 grabbed underneath R1's right arm while transferring R1 from the wheelchair to the bed. E1 (Director of Nursing) was in R1's room at the time of the transfer. E1 stated this is not correct transfer procedure. E1 stated , E10 should have placed her hands on the gait belt to transfer R1. -On 2/13/15 at 9am, E10 (CNA) and E9 (Restorative CNA) transferred R2 from the wheelchair to the bed. E10 placed a gait belt around R2's waist. E10 and E9 grabbed underneath R2's arms and transferred R2 from the wheelchair to the bed. On 2/13/15 at 9:30am, E9 stated you should not grab underneath a resident's arm during a transfer. The facility's Lifting and Transferring Residents policy date 1/14 reads "Residents are lifted and transferred safely in all instances. Residents are assessed and determinations are made for lifting and transferring requirements and the procedure for each resident." The facility failed to follow R1's assessment for transferring noted in R1's 12/4/14 MDS (Minimum Data Set). The facility's Gait Belts for Transfer policy dated 2008 reads "Apply belt around resident waist. To transfer: Assist resident into a standing position by grasping belt at the waist from underneath. Pivot resident into chair or bed." The facility failed to follow its own policy for gait belt transfer for R1 and R2 on 2/13/15.