Every finding on record at La Bella of Rochelle

Based on interview and record review the facility failed to protect a resident (R2) from abuse. This applies to one of two residents (R1 & R2) reviewed for abuse in the sample of nine.This past compliance occurred between 7/28/2026 to 8/4/2026.The findings include: The facility serious injury incident report dated 7/28/26 shows that at 6:41 PM an altercation between R1 and R2 occurred. The report shows the residents were separated and an investigation was started after reporting to Physician, Power of Attorney and the police. The facility investigation showed R2 spit on R1 and R1 hit R2 with a coloring book on the head.The facility face sheet for R1 shows diagnoses to include but not limited to paranoid schizophrenia, dementia, mood disturbance and anxiety. The facility assessment dated [DATE] shows R1 is cognitively intact and requires supervision for her activities of daily living.The facility face sheet for R2 shows he was admitted to the facility with diagnoses to include but not limited to adult failure to thrive, anemia, irritability and anger. The facility assessment dated [DATE] shows R2 to have severe cognitive impairment and is dependent on staff for his activities of daily living.On 8/7/26 at 9:20 AM, R1 said she hit R2 on his head after he spit on her. R1 said she used the coloring book she was coloring with to hit R2. R1 said he asked her for help, and she told him she couldn't, and then he spit on her.On 8/7/26 at 9:26 AM, V3 said she saw what happened between R1 and R2 in the activity room. V3 said she saw R2 spit on R1 and then R1 hit R2 on the head with a coloring book.On 8/7/26 at 9:43 AM, V3 Activity Aide said she was in the activity room with the residents on 7/28/26 and at around 6:45 PM, she heard what sounded like someone hitting someone else with a book and then she heard her co-worker (V4) say did you just hit him. V3 said she did not see what happened, but R1 said she hit R2 because he spit on her. V3 said prior to this happening, R2 was repeatedly asking for someone to put him to bed.On 8/7/26 at 9:55 AM, V4 Activity Aide said she was also working the night of the incident. V4 said she did not witness the altercation. V4 said R1 and R2 were sitting at the same table and R2 was asking to be put to bed numerous times. V4 said she then heard what sounded like someone being hit with a book. V4 said she turned towards the noise and saw R1 with a coloring book in her hand. V4 said she asked R1 if she hit R2 and she said yes because he spit on her.On 8/7/26 at 11:07 AM, V1 Administrator said during the investigation she discovered R2 was asking for help to go to bed and R1 said she couldn't help him and R2 spit on R1 and then R1 hit R2 over the head with the coloring book she was using. V1 said R2 doesn't understand who can and who can't help him. A nursing progress note for R1 dated 7/28/26 at 11:37 PM, shows R1 was involved in a resident to resident altercation with R2. The note shows R1 hit R2 after R2 spit on her.A nursing progress note for R2 dated 7/28/26 at 10:51 PM, shows R2 spit on R1 and R1 responded by hitting R2 on the head with a coloring book.The facility abuse policy with a revision date of 5/8/26 shows it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Prior to the survey date of 8/7/26 the facility had taken the following action to correct the noncompliance:The staff members have been educated to the expectations for immediate increased supervision of any resident having escalating behaviors completed 8/4/26.The staff members have been educated to the expectations set forth in the abuse prevention policy completed 8/4/26.IDT will be implementing a manager on duty program from 1PM to 9PM to enhance the evening time supervision 7 days a week completed 8/4/26.The Administrator will perform observation audits tool 3 times a week for 4 weeks to ensure quarterly risk assessments are completed.The Administrator will perform observation audit tool 3 times a week for 4 weeks to ensure that escalating behaviors are monitored with increased supervision.Any concerns identified from the audits will be addressed immediately and will be reviewed by QAPI committee until no longer necessary.

Based on interview and record review the facility failed to prevent a resident to resident abuse for two residents (R4 & R5) reviewed for abuse on the sample list of 11. This facility failure resulted in R4 sustaining a thoracic fracture and being sent to the hospital. Findings include: The facility face sheet for R4 shows he has the following diagnoses to include schizoaffective disorder bipolar type, chronic obstructive pulmonary disease and epilepsy. The facility assessment dated [DATE] for R4 shows him to have severe cognitive impairment and requires supervision for ambulation with a walker.The facility face sheet for R5 shows he was admitted to the facility with a diagnosis of schizoaffective disorder bipolar type. The facility assessment dated [DATE] shows R5 to be cognitively intact and requires supervision for his activities of daily living.A nursing note dated 7/16/26 at 1:39 PM shows R5 was shining a flash light into R4's face. R4 got up and attempted to throw his walker at R5 causing them both to fall to the ground at the same time. The note goes on to show the staff attempted to stop the residents from kicking at each other as they lay on the ground. The note shows the residents were separated and assessments were completed on both residents. R4 was found to have 3 scratches to his left cheek and a skin tear to his right hand.The nursing note dated 7/15/26 at 4:34 PM, shows a physical resident to resident altercation. The note shows the staff intervened immediately and 911 had been called. R4 refused treatment at the local hospital and from EMS (Emergency Medical Services). Abrasions were identified to R4's left side of his face and the area was cleansed.The nursing note dated 7/15/26 at 7:45 PM, shows follow-up assessments to R4 showed complaints of significant pain to his low to middle back that became worse upon movement. R4 was sent to the local emergency room.The local hospital records shows R4 was seen in the emergency room for evaluation of injuries suffered in an assault with another resident. A CT scan (Computed Axial Tomography) was completed on 7/15/26 and showed significant calcification on the ligaments with a disruption at the T 9-10 level. (Thoracic spine) If patient is symptomatic an MRI (Magnetic Resonance Imaging) is recommended. The hospital records also show on 7/16/26 a MRI scan was completed and showed an acute fracture of the calcified anterior ligament at the T9-10 level. The records then show R4 was transferred to a larger hospital for a neurology consultation for possible surgical repair.The discharge summary from the larger hospital R4 was sent to dated 7/21/26 shows fracture involving the calcified anterior longitudinal ligament at the T9-10 level.On 7/22/26 at 10:00AM, R7 said she was sitting in the activity room when R4 and R5 had there fight. R7 said R5 shined a light into R4's face and R4 stood up and went to raise his walker at R5 when they both fell into each other and fell to the ground. R7 said she screamed for the staff to come help.On 7/22/26 at 10:13 AM, R6 said she was also sitting in the activity room when R4 and R5 had a fight. R6 said she saw a flash of light out of the corner of her eye and then she turned towards R4 and R5 and saw R4 standing up and going towards R5 with his walker, but they both fell to the ground.On 7/22/26 at 10:19 AM, R11 said she saw R5 shine a light into R4's face and then she saw R4 get up and go towards R5 to try and hit him with the walker, but they both fell to the ground.On 7/22/26 at 9:40 AM, V11 and V20 both CNA's (Certified Nursing Assistant) said they were both headed down a hall to help a resident when they heard yelling and screaming. They both turned and ran to the noise in the activity room and saw R4 and R5 on the floor with staff trying to separate them.On 7/22/26 at 9:37 AM, V19 RN (Registered Nurse) said she was the nurse for R4 the day of the altercation between R4 and R5. V19 said she did not see what happened prior to the yelling by the other residents in the activity room. V19 said when she got there, she saw R4 and R5 both on the floor wiggling around. V19 said V4 and V17 were on the floor trying to separate the two residents.On 7/22/26 at 10:04 AM, V4 Maintenance Director said he responded to the activity room after hearing the resident yelling. V4 said when he got there both R4 and R5 were on the ground. V4 said he pulled R4 and R5 apart to stop them from fighting.On 7/22/26 at 10:06 AM, V17 Housekeeper said he was in the janitor closet next to the activity room and heard the residents yelling loudly, so he went out to the activity room right away. V17 said both residents were already on the floor and he pulled them apart to stop the fight.On 7/22/26 at 9:45 AM, V2 DON (Director of Nursing) and V5 ADON (Assistant Director of Nursing) said they were in a meeting with other management staff in the office across from the activity room when they heard residents yelling and screaming. They said R4 and R5 were already on the ground and V4 and V17 were separating them when they opened the door. V2 said she called 911 and went to assess both residents. V2 said R4 had some cuts to his hand and the left side of his face but refused to go to the emergency room when the paramedics arrived. V2 said R5 had no apparent injuries. V2 said later that same day R4 began to complain of pain to his back and agreed to get it checked out at the hospital.On 7/22/26 at 12:15 PM, V1 Administrator said she expects the staff to be supervising the residents when they are in the activity room to prevent any incidents and to de-escalate any problems the residents may be having with each other.The undated abuse policy for the facility shows that this facility is to provide protections for the health, welfare and rights of each resident. The prevention of abuse shows identifying, correcting and intervening in situations in which abuse is more likely to occur.The facility final investigation summary of the incident shows the conclusion of the report shows that a resident to resident conflict escalated into a physical altercation involving both residents.

Based on observation, interview, and record review the facility failed to thoroughly investigate a resident-to-resident sexual abuse allegation involving a resident (R1) with impaired cognitive abilities. This applies to two of five residents (R1 & R2) reviewed for abuse in the sample of 11.The findings include: The facility face sheet for R1 shows her to have diagnoses to include but not limited to dementia, Pick's Disease (a rare irreversible neurodegenerative condition, a type of dementia), mild intellectual disability and schizoaffective disorder bipolar type. The facility assessment dated [DATE] shows her to have moderate cognitive impairment and requires moderate assistance with her activities of daily living.The facility face sheet for R2 shows he was admitted to the facility with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease, hypertension and anemia. The facility assessment dated [DATE] shows R2 to be cognitively intact and uses a wheelchair for his ambulation.A nursing progress note dated 7/16/26 shows the nurse (V9 Registered Nurse) receiving report at the start of her shift. V9 wrote she was told that R1 had a [NAME] to her neck that she received on the night shift of 7/15/26 from male resident (R2). V9 wrote she reviewed R1's record and saw no documentation the incident had been reported, so she notified the abuse coordinator (V1 Administrator) and was told she would call her back. V9 then called the Physician for R1 (V3) and was told to follow the protocol regarding abuse. V9 then called the local police and the POA (Power of Attorney) for R1.On 7/21/26 R1 was observed self-propelling herself in her wheelchair all over the facility. R1 was observed at times talking to herself and moving quickly throughout the facility. A small faint red discoloration was observed in R1's left neck. At 10:19 AM when asked about the [NAME] to her neck, she stated, Nothing happened, I don't want to talk about it. R1 repeated this statement numerous times.On 7/21/26 at 12:03 PM, V9 (Agency Registered Nurse) said she came into work on 7/16/26 and was told in report that R1 had a [NAME] to her neck and it had happened on the overnight shift by R2. V9 said she was told to keep an eye on R1 as she was not able to give consent for this. V9 said she reviewed R1's record and saw no documentation of the incident and called the abuse coordinator to report what she had heard. V9 said V1 told her she was on vacation and would call me back, but she never did. V9 said she then called V3 (R1's Physician) to report what she had heard and was told by V3 to follow the abuse protocol. V9 said she then called the local police and left a message for R1's POA. V9 said when she tried to talk to R1 about it, R1 was not able to answer any questions and was rambling with her speech.On 7/21/26 at 12:11 PM, V10 RN said she came on her shift at 6 AM on 7/16/26 and was asked by V12 (Housekeeper) to come look at R1's neck stating it looked like she had a [NAME] on her neck. V10 said she texted the ADON (Assistant Director of Nursing) and told her what was found. V10 said the ADON and the DON (Director or Nursing) arrived at the facility and took over the situation.On 7/21/26 at 12:55PM, V12 Housekeeper said she was cleaning the lobby and she R1 wheel past her and she noticed a bruise to her neck that looked like a [NAME]. V12 said she went and told the nurse right away.On 7/21/26 at 12:25 PM, V4 Maintenance Director said when he came to work on 7/16/26 he was told that R1 had a [NAME] on her neck. V4 said he went and reviewed the video footage of the night before and saw R1 and R2 kissing and hugging in a dark activity room. R2 then wheeled himself towards his room and R1 followed him.On 7/21/26 at 2:00 PM, V2 ADON said she had watched the video, and the time stamp was for 7/16/26 at 12:06AM. On 7/21/26 at 11:56AM, V3 (R1's Physician) said he has cared for R1 for a very long time and feels it's a gray area trying to determine if she is able to give consent for this type of interaction with a peer. R1 would be receptive to any attention someone would try to give her.On 7/21/26 at 1:50 PM, V15 (R1's sister) and POA said she was called about the incident and said she wishes she wasn't involved in the situation. R1 was abused sexually by her husband and has always liked the boys. V15 said she thinks R1 is still capable of giving consent but is not 100% sure.On 7/21/26 at 7:34 PM, V16 (Police Officer) said he came to the facility on 7/16/26 around 8PM. V16 said he was told a resident had a [NAME] on her neck and she is not capable of giving consent. V16 said he met with the woman, and she was not able to even complete a full sentence and was not making any sense. V16 said he then spoke with the man involved and he admitted to kissing and hugging the woman and giving her a [NAME] on her neck. V16 said some of the staff reported to him that the woman is able to give consent, and she knew what she was doing. V16 said he was not completely sure about that, and the case was handed over to a detective.On 7/21/26 at 10:40 AM, V2 DON said R1 and R2 are just friends and will hold hands and hang out. V2 said R1's POA is aware and has no concerns. V2 said she told R1's Physician that R1 and R2 are just friends and the family is fine with it. V2 said the police officer said R1 is allowed that friendship.On 7/22/26 at 12:15 PM, V1 Administrator said when the situation is a Grey area it should be investigated.The social services quarterly assessment dated [DATE] for the section trauma factors including abuse/neglect it asks for factors that increase the resident vulnerability e.g. dementia, poor insight, poor communication skills. The question was answered yes.The abuse/neglect screening dated 5/2/26 shows R1 is at high risk for abuse.The Psychiatry note dated 7/1/26 for R1 shows the resident demonstrates expected neurocognitive decline but is able to engage in somewhat meaningful conversation. The mental status exam showed limited insight and judgement, fair memory and fair attention span.The undated abuse policy from the facility shows an immediate investigation is warranted when suspicion of abuse occurs.

Based on observation, interview, and record review the facility failed to have interventions in place to protect a cognitively impaired resident from potential abuse. This applies to one of five residents (R1) reviewed for abuse in the sample of 11.The findings include: The facility face sheet for R1 shows her to have diagnoses to include but not limited to dementia, Pick's Disease (a rare irreversible neurodegenerative condition, a type of dementia), mild intellectual disability and schizoaffective disorder bipolar type. The facility assessment dated [DATE] shows her to have moderate cognitive impairment and requires moderate assistance with her activities of daily living.A nursing progress note dated 7/16/26 shows the nurse (V9 Registered Nurse) receiving report at the start of her shift. V9 wrote she was told that R1 had a [NAME] to her neck that she received on the night shift of 7/15/26 from male resident (R2).On 7/21/26 R1 was observed self-propelling herself in her wheelchair all over the facility. R1 was observed at times talking to herself and moving quickly throughout the facility. A small faint red discoloration was observed in R1's left neck. At 10:19 AM when asked about the [NAME] to her neck, she stated, Nothing happened, I don't want to talk about it. R1 repeated this statement numerous times.On 7/21/26 at 12:03 PM, V9 (Agency Registered Nurse) said she came into work on 7/16/26 and was told in report that R1 had a [NAME] to her neck and it had happened on the overnight shift by R2. V9 said she was told to keep an eye on R1 as she was not able to give consent for this. V9 said she reviewed R1's record and saw no documentation of the incident and called the abuse coordinator to report what she had heard. V9 said when she tried to talk to R1 about it, R1 was not able to answer any questions and was rambling with her speech.On 7/21/26 at 12:25 PM, V4 Maintenance Director said when he came to work on 7/16/26 he was told that R1 had a [NAME] on her neck. V4 said he went and reviewed the video footage of the night before and saw R1 and R2 kissing and hugging in a dark activity room. R2 then wheeled himself towards his room and R1 followed him.On 7/22/26 at 9:45 AM, V5 ADON said R1 likes to seek out male attention and wanders around the facility on her own. R1 can be talking normal one minute and then the next minute she will be in own little world and not be making any sense.On 7/22/26 at 10:00AM V2 DON (Director of Nursing) said R1 seeks out other residents for attention. She will wander around the facility and will go into other resident rooms seeking attention. R1 likes the male residents. V2 said the staff try to keep her busy and redirect her as needed.On 7/22/26 at 10:24 AM, V18 Social Service Director said R1 likes to wander around the facility in her wheelchair. V18 said R1 likes to seek out attention from the male residents. V18 said the staff try and redirect her away from this type of behavior.On 7/21/26 at 11:56AM, V3 R1's Physician said he has cared for R1 for a very long time and feels it's a gray area trying to determine if she is able to give consent for this type of interaction with a peer. R1 would be receptive to any attention someone would try to give her. V3 said the facility staff should be closely monitoring R1.On 7/21/26 at 1:50 PM, V15 R1's sister and POA said she was called about the incident and said she wishes she wasn't involved in the situation. R1 was abused sexually by her husband and has always liked the boys. V15 said she thinks R1 is still capable of giving consent but is not 100% sure.On 7/21/26 at 7:34 PM, V16 (Police Officer) said he came to the facility on 7/16/26 around 8PM. V16 said he was told a resident had a [NAME] on her neck and she is not capable of giving consent. V16 said he met with the woman, and she was not able to even complete a full sentence and was not making any sense. The social services quarterly assessment dated [DATE] for the section trauma factors including abuse/neglect it asks for factors that increase the resident vulnerability e.g. dementia, poor insight, poor communication skills. The question was answered yes.The abuse/neglect screening dated 5/2/26 shows R1 is at high risk for abuse.The Psychiatry note dated 7/1/26 for R1 shows the resident demonstrates expected neurocognitive decline but is able to engage in somewhat meaningful conversation. The mental status exam showed limited insight and judgement, fair memory and fair attention span.The care plan for R1 shows no interventions for wandering into other resident rooms or seeking out the attention of male peers. An updated intervention was added to the impaired cognition on 7/17/26 (The day after the kissing and [NAME] incident) that states the resident is capable of consenting to having a friendship with a male resident.

Based on interview and record review the facility failed to notify a resident's power of attorney - POA of the residents fall for 1 of 3 residents (R1) reviewed for notification in the sample of 7.The findings include:The Incident Report dated 6/8/26 for R1 showed the certified nursing assistant notified the nurse that R1 was on the floor in her room during rounds. The description showed that the resident fell and landed on her knees in her room. The form showed the physician was notified; there was no documentation of the POA being notified.On 6/30/26 at 9:35 AM, R1 stated she has had two falls and each time they didn't ask if she needed to go to the hospital. R1 said she went to the hospital recently and her power of attorney was notified by the hospital; not by the staff there (at facility).On 6/30/26 at 9:43 AM, V4 Nurse Practitioner stated after a resident falls the provider, director of nursing, and power of attorney should be notified.On 6/30/26 at 10:35 AM, V6 registered Nurse - RN stated that she did not notify V7 (R1's POA) after R1 fell on 6/8/26. V6 stated since it was early in the morning she did not call V7. Normally they call the POA but she was going to wait until waking hours to do it and then didn't call. V6 stated when R1 came back from the hospital on 6/20/26, not related to the fall, V7 was called and that was when V7 stated she was not getting calls like she should.On 6/30/26 at 1:00 PM, V3 Assistant Director of Nursing - ADON stated after a resident falls the POA is notified; they will call immediately if an injury occurs otherwise they wait until waking hours. V3 stated she would have called the POA at around 8:00 AM.The face Sheet dated 6/30/26 for R1 showed diagnoses including malignant neoplasm of upper lobe bronchus or ling, cellulitis, bipolar disorder with mixed severe psychotic features, borderline personality disorder, post-traumatic stress disorder, suicidal ideation, iron deficiency, depression, aneurysm, anxiety disorder, GERD, chronic pain, nausea, malignant neoplasm of upper lobe left bronchus, insomnia, toxic liver disease, chronic viral hepatitis, epilepsy, and acute interstitial pneumonitis.The facility's Fall Prevention Program policy (2025) showed, when any resident experiences a fall, the facility will: notify the physician and family.

Based on observation, interview, and record review the facility failed to ensure a complete assessment was done and documented after a residents fall for 1 of 3 residents (R1) reviewed for falls and assessments in the sample of 7.The findings include:The Incident Report dated 6/8/26 for R1 showed the certified nursing assistant notified the nurse that R1 was on the floor in her room during rounds. The description showed that the resident fell and landed on her knees in her room. The fall was unwitnessed. The Incident report was not completely filled out in the areas of level of pain, level or consciousness, mobility, or mental status. There was no documentation of R1's vitals signs.The Progress Notes for R1 showed on 6/9/26 at 5:39 AM, Certified Nursing Assistant - CNA heard yelling, entered the room and the resident was on the floor. No vital signs were documented or a complete assessment of what the nurse evaluated for the resident post fall.The Progress Notes for R1 for 72 hours after her fall were reviewed and showed a post fall evaluation completed on 6/11/26 and a fall risk evaluation on 6/11/26. The facility did not have ongoing post-fall documentation including any assessments, vital signs or neurological evaluation during the 72 hours after her fall.On 6/30/26 at 9:35 AM, R1 was lying on top of her bed, completely dressed with regular grey socks on; no grips to the socks were noted. R1's wheelchair was next to her bed. R1 did not have any shoes out in the open in her room. R1 stated she had two falls and each time they didn't ask if she needed to go to hospital. R1 stated she told them the second time she fell that she wanted to go to the hospital, and she was told that she did not need to go. R1 stated she told them that she had pain in her left side. R1 stated she was in her wheelchair, her foot got caught under her chair and she fell out of her chair onto the floor. R1 stated the staff came in, picked her up, and put her in her bed. R1 stated the nurse did not come and check her. R1 stated she was given some pills and put in bed and that was all that was done. On 6/30/26 at 9:43 AM, V4 Nurse Practitioner stated after a resident falls the nurse should assess the resident, check vital signs and start neurological checks if it is an unwitnessed fall. V4 stated the assessment should be documented after the residents' fall.On 6/30/26 at 1:00 PM, V1 Administrator and V3 Assistant Director of Nursing were present and interviewed. V3 stated the expectation for nursing after a resident has a fall is to immediately assess the resident, ask them what they were doing, why they fell and try to figure out the situation. V3 stated an assessment is done, vital signs are checked, range of motion is checked and then a decision is made if they need to be sent out or can be treated in the facility. If the fall was unwitnessed then neurological checks are done. The assessment and vital signs are entered into the charting. The post fall charting is initiated. V3 reviewed R1's medical record and stated it did not show a complete assessment for R1 after her fall on 6/8/26. V3 stated she did not see the 72 hour post fall charting or neurological assessments in R1's medical record. V3 stated the documentation did not reflect the facility's policy.The face Sheet dated 6/30/26 for R1 showed diagnoses including malignant neoplasm of upper lobe bronchus or ling, cellulitis, bipolar disorder with mixed severe psychotic features, borderline personality disorder, post-traumatic stress disorder, suicidal ideation, iron deficiency, depression, aneurysm, anxiety disorder, GERD, chronic pain, nausea, malignant neoplasm of upper lobe left bronchus, insomnia, toxic liver disease, chronic viral hepatitis, epilepsy, and acute interstitial pneumonitis.The facility's Fall Prevention Program policy (2025) showed, when any resident experiences a fall, the facility will: assess the resident, complete a post-fall assessment, complete an incident report, and document all assessments and actions.

Based on interview and record review, the facility failed to ensure resident to resident abuse did not occur for one of 5 residents (R1) reviewed for abuse in the sample of five. This failure contributed to R1 experiencing a fracture and increased pain in his right foot. The findings include:R1's admission Record dated June 16, 2026 shows he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, morbid obesity, sleep disorder, depression, anxiety disorder, low back pain, and difficulty in walking. R1's Care Plan initiated May 26, 2026, shows, The resident is/has potential to be verbally aggressive (cursing at staff and other residents) related to ineffective coping skills, poor impulse control. When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact. R1 did not have any behavioral symptoms. R2's admission Record dated June 16, 2026 shows he was admitted to the facility on [DATE] with diagnoses including schizophrenia. R2's Care Plan revised on November 15, 2025 shows R2 has a conviction history-criminal damage to property. Needs additional monitoring to ensure respect of other resident's rights. Resident requires closer supervision and more frequent observation than standard or routine. Care Plan revised on November 21, 2025 shows R2 has potential to be physically and verbally aggressive related to history of harm to others and poor impulse control. R2's Care Plan revised on February 19, 2025 shows R2 has conviction history-physical assault related-battery with bodily harm. R2's Minimum Data Set, dated [DATE] shows he is cognitively intact. R2 did reject evaluation or care. On June 16, 2026 at 9:22 AM, R2 said him and R1 were talking to each other and R1 hit R2 in his head. It hurt. He kept on. He was being nasty. R2 said he told the nurse that R1 was not acting right that day. At 9:36 AM, R1 was interviewed in regards to the incident with R2. R1 said, He kind of whooped my a*s. I asked him to be quiet, he was talking in the middle of the night. I was trying to sleep. I told him to shut the f**k up. I was standing up, he pushed me into the door, he punched me in my head multiple times. he put his knee on my foot and broke my toe. I had a bruise to my left eye. I couldn't walk right for about a week and a half. The pain to my foot was bad. R1 said the incident happened in their room with the door closed. I didn't say anything until a few days later, cause I didn't know what was going to happen. He acted like nothing happened. I eventually told staff and they moved him out of my room. Aren't they supposed to protect us? R1 said he attempted to hit R2 back, but was not able to make any contact. R1 said that R2 told R1 that R1 was drunk. The facility's Investigation shows that R2 was interviewed on June 3, 2026. R2 said R1 came back to the facility drunk, R2 thought. R2 said R1 asked R1 how he got into the facility and R2 was telling R1 about R1's wife and R1's [NAME] car. R2 said that R1 yelled at R2 to shut up and then came over and punched R2 in the head. R2 stomped R2's foot onto R1's foot, and the altercation stopped. R1 was interviewed by the facility on June 3, 2026 and said he came back to the facility after being out on pass. R1 said R2 was talking, and R1 asked R2 to stop. R1 told R2 to shut the hell up.' R2 came over and punched R1 in the head. R1 said he did not know what R2 did to R1's toe, but it hurts and showed the interviewer his foot. R1 said he did not report it because R1 is not a sore loser, he just wanted R2 out of his room. A signed statement obtained by the facility on June 4, 2026 from V10 (Registered Nurse) RN shows R2 told V10 that he reported the incident to a nurse after it happened. R1's Progress Note dated June 4, 2026 at 11:43 AM shows, Resident finally told the RN (Registered Nurse) how he thinks he got the toe fracture. Resident states that he and his roommate got into a verbal altercation Saturday night (May 30, 2026) and that while this resident and his roommate (R2) were arguing, residents roommate got into his face and fell into his body and onto his toe. The roommate admitted to 'stomping on [R1's] foot.' This RN asked resident why he didn't tell any staff until he told administration yesterday and this RN today and the resident states he was a little embarrassed and 'didn't want to admit he got bullied.' Resident told this RN that the only reason why he told administration yesterday is because he wanted the roommate out of his room .The (Director of Nursing/DON) reached out to the doctor and got an order for an X-Ray because the resident complained of toe pain. R1's Skin Check dated June 3, 2026 shows, Right dorsum foot. 2-4th dorsal proximal toes issue: bruising. Evaluate for occurrence of trauma as a cause. R1's Radiology Results Report dated June 3, 2026 shows, Recent fracture of the proximal phalanx right 2nd toe. Subacute/old fracture right 5th metatarsal bone. Soft tissue swelling. On June 16, 2026, V1 Administrator was interviewed in regards to the incident. V1 said that R1 told her that R1 returned to the facility from his outside pass and R2 was conversing with R1. R2 asked R1 to stop and R2 did not stop. R1 to V1 that R2 got up and punched R1. R2 admitted to stomping on R1's foot. V1 said that no staff heard the altercation. V1 said she did not substantiate abuse during her investigation, V1 considered the incident a disagreement. They did not want to pursue charges. I considered it an argument. At 2:59 PM, V2 (Director of Nursing/DON) said she saw bruising to R1's top of right foot from his 2nd toe to his 4th toe. V2 said R1 complained of pain when he stood up. At 8:33 AM, V6 Social Services Director said the incident happened over the weekend. V6 said herself and V1 talked with R2. V6 said R2 told her that R1 returned to the facility from a pass and was acting weird, but R2 was not specific. The facility's Abuse, Neglect, and Exploitation policy dated 2025 shows, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on interview and document review, the facility failed to ensure medications were documented as administered on the Medication Administration Record (MAR) after administration for 1 of 5 residents (R4) reviewed for medication administration in the sample of 5.The findings include:On 6/16/26, R4's Medication Administration Record (6/1/26-6/16/26) showed that R4 did not receive the following medications on 6/9/26 at 9:00AM as ordered: ferrous sulfate 325mg (milligram), folic acid 1mg, gabapentin 300mg, pyridoxine 25mg, carvedilol 3.125mg, Keppra 500mg, and amoxicillin 500mg.On 6/16/26, R4's Medication Admin (Administration) Audit Report for 6/9/26 showed that R4 did not receive the medications as ordered.On 6/16/26 at 1:00PM, R4 stated he did not receive morning medications on 6/9/26. R4 stated that this can occur when there is an agency nurse as they are not always familiar with the residents and at times the residents will have to go looking for the nurse to receive their medications.On 6/16/26 at 3:00PM, V2 (Director of Nursing) stated that medications are to be documented within the MAR upon administration to the residents. At this time, V2 reviewed R4's MAR (medication administration record) and Medication Audit Report and confirmed the documents indicated that the medications were not administered.On 6/17/26, the facility emailed signed attestations by V2 (Director of Nursing), V9 (Licensed Practical Nurse), and R4 documenting that physician orders for medications were administered but not documented at the time of administration due to oversight. The attestations do not include the date, time, or medications that were administered.The facility's Medication Administration policy (reviewed/revised: 6/26) documented that medications are administered as ordered by the physician and in accordance with professional standards of practice that include signing of MAR after medications are administered.

Based on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter and gallbladder drain for 1 of 3 residents (R1) reviewed for infection control in the sample of 4.The findings include:On 2/2/26 at 9:55 AM, R1 was lying in bed, V3 (Licensed Practical Nurse) was in her room at her bedside. There was no sign posted on R1's door and no PPE (Personal Protective Equipment) cart outside of her room to identify R1 was on any type of isolation or precaution. After V3 was finished she exited R1's room and told this surveyor that R1 has a urinary catheter and both a gallbladder drain and a Jackson Pratt drain to the same area of her surgical site. On 2/2/26 at 9:57 AM, R1 said she came to the facility with two drains and a urinary catheter. R1 said she had a bad infection in the hospital and a tube was put in to help her breath and she is lucky to be alive. R1 said she cannot recall staff wearing gowns when they handle her catheter or drain. On 2/2/26 at 10:25 AM, V3 said that R1 should have Enhanced Barrier Precautions (EBP) in place since she has a catheter and drains and staff should wear PPE including gowns and gloves when providing direct care to R1 or when handling her drains or catheter. V3 said she is not sure why R1 no longer has a PPE cart outside her room because she used to. On 2/2/26 at 10:30 AM, V2 (Director of Nursing) walked down to R1's room and verified with this surveyor that there were no Enhanced Barrier Precautions in place for R1. V2 said she was also unsure why the sign was no longer on her door and the PPE cart was not there. R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including septic shock. R1's Physicians Order Summary fails to have an order for Enhanced Barrier Precautions however there is an order for dressing changes three times a week for her gallbladder drain. The facility provided Enhanced Barrier Precaution policy dated 10/13/25 shows if residents have indwelling urinary catheters or a drain they should have EBP precautions in place and staff should wear gowns and gloves when providing direct cares. The policy also shows that a PPE cart should be outside or close to the residents room to identify the need for EBP precautions.

Based on interview and record review the facility failed to ensure post fall assessments, to include vital signs, head to toe assessment and fall follow up, were completed for 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3.The findings include:1. R1s admission record shows he was admitted on [DATE] with multiple diagnoses including adult failure to thrive, unspecified lack of coordination and weakness. The 11/11/25 annual resident assessment and care screening documents R1 to have severe cognitive impairment.R1s nursing progress notes of 10/8/25 show at 8:28 PM, he experienced a witnessed fall at the bedside. The roommate alerted staff R1 had rolled out of bed onto the floor. R1 reported he fell out of bed. R1 had no further assessments documented related to his fall.The 11/3/25 risk management report shows R1 was found lying on his right side on the ground at bedside. Fall mat in place. R1 reported he rolled over while in bed. The progress notes show no follow up assessments for 11/4/25. The post fall assessment for 11/5/25 includes the vital signs taken on 11/3/25.R1s nursing progress notes for 1/2/26 document he was sitting in bed and fell forward striking his face on the nightstand next to the bed. R1 was sent out to the emergency room and returned at 10:00 AM with sutures to the bridge of his nose. R1 had no further assessments documented for 1/2/26. On 1/3/26 at 2:39 PM, a follow up assessment was documented for the laceration to R1s nose. The progress notes show no further assessments or vital signs related to his fall. On 1/8/26 at 10:00 AM, V6 Registered Nurse (RN) said for resident falls, basically we do neuro checks for everyone. The incident should be documented in the progress notes it should say if the fall was witnessed or unwitnessed, skin assessment, physical assessment, pain assessment, it is all included in the forms we fill out. All falls are followed up every shift for 72 hours. A post fall evaluation form should be completed and that will generate a progress note. She said for the fall on 1/2/26, R1 should have charting for 1/3, 1/4, and 1/5. For the assessment, nursing should be getting a fresh set of vitals. She said it would be the same for 11/3/25, there should be documentation every shift for 3 days.On 1/8/26 at 12:34 PM, V2 Director of Nursing (DON) said the nurses are to follow the post fall tool. This tool includes monitoring every shift for 72 hours. The nurses should be assessing for any new pain or injury, or changes to their mobility. All this information would be charted in the notes.2. R2s admission record shows she was initially admitted to the facility on [DATE] with a history of falling. She had multiple diagnoses including dementia and bipolar disorder. Her 12/9/25 quarterly resident assessment and care screening documents her to have severe cognitive impairment.R2s nursing progress note dated 12/18/25 documents she had an unwitnessed fall in her room on 12/17/25 at 8:45 PM. She stated she fell and hit her face/head on the floor. The notes show she was sent out to the emergency room for evaluation. She returned to the facility and was placed back into bed. The progress notes were reviewed and show no follow up assessment related to this fall during the 72 hours following the incident.On 1/8/26, at 12:34 PM, V2 stated the nurses should have used the post fall too. And it is the DONs responsibility to review the documentation for compliance.The facility's undated Fall risk tool documents change of condition charting to be done every shift for 72 hours and includes a full set of vial signs and if skilled, head to toe assessment and fall follow up in notes.

Based on observation, interview and record review the facility failed to ensure fall interventions were in place for 1 of 3 residents (R1) reviewed for safety in the sample of 3.The findings include:R1s admission record shows he was admitted on [DATE] with multiple diagnoses including adult failure to thrive, unspecified lack of coordination and weakness. The 11/11/25 annual resident assessment and care screening documents R1 to have severe cognitive impairment.R1s nursing progress notes of 10/8/25 show at 8:28 PM, he experienced a witnessed fall at the bedside. The roommate alerted staff R1 had rolled out of bed onto the floor. R1 reported he fell out of bed. The 11/3/25 risk management report shows R1 was found lying on his right side on the ground at bedside. Fall mat in place. R1 reported he rolled over while in bed.R1s care plan of 11/11/24 documents he is a high risk for falls related to history of falling and poor safety awareness. The interventions include on 10/9/25, a floor mat at bedside while in bed. The intervention was revised on 11/3/25 following the second fall.On 1/8/26 at 9:44 AM, R1 was observed lying in bed on his left side facing the wall. He declined any questions from this surveyor. There was no fall mat located next to his bed, or in the room. On 1/8/26 at 9:50 AM, V5 Certified Nursing Assistant (CNA) said R1 transfers with 2 staff with a stand and pivot. She was not aware R1 had previous falls out of bed, and did not know he was supposed to have any fall mat next to the bed.On 1/8/26 at 10:00 AM, V6 Registered Nurse (RN) said (R1) should have a floor mat next to the bed. Most of the time during the day we keep him at the nurse's station, but If he is in bed he should have a fall mat next to his bed. V6 observed the room and no fall mat in place. She stated one should be placed.On 1/8/26 at 12:34 PM, V2 Director of Nursing stated it is the responsibility of nursing and management to ensure fall interventions are in place.The facility's 10/13/25 policy for accidents and supervision documents: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 3. Implementing interventions to reduce hazards and risk. 4. Monitoring for effectiveness and modifying interventions when necessary.

Based on interview and record review the facility failed to prevent the misappropriation of resident medications by staff. This applies to 1 of 3 residents (R5) reviewed for misappropriation in the sample of 8. The findings include: R5's EMR (Electronic Medical Record) shows that R5 was last admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Chronic Obstructive Pulmonary Disease and Drug Induced Subacute Dyskinesia. The EMR shows that R5 had an order for Cyclobenzaprine (Muscle Relaxant) 10mg three times a day for muscle spasms. The EMR also shows that R5 discharged from the facility AMA (Against Medical Advice) on 8/20/25. On 12/12/25 at 10:55 AM V2 (Director of Nursing) stated, (V11-Registered Nurse) was a unicorn! She was wonderful! She worked nights, full time. She really knew what she was doing. That day I was with the (V10-Business Office Manager) she returned a call from the significant other of (V11) and he said that (V11) had been arrested for a domestic charge and during that arrest they found 2 cards of medication of a former resident (R5). We immediately contacted (V14) our VP of clinical operations, and we were told we had to terminate (V11) right away. (V11) was the night nurse so she had access to medications. When a resident is discharged , we usually return the medications to the pharmacy. Except for narcotics- those we destroy. As far as I know (V14) contacted IDPH regarding this issue. It broke my heart to lose (V11) as a nurse. On 12/12/25 at 11:05AM V10 stated, I took a phone call (On November 12, 2025) from a gentleman who identified himself as the significant other of (V11). He said (V11) was just arrested for domestic violence and they also found a resident's medication cards in her possession. His lawyer had advised him to contact us. He had taken pictures of the cards as proof and wanted to send them to my email- which he did. We called (V14) and she told us we needed to terminate (V11) right away.On 12/12/25 at 12:00PM, V14 stated, I contacted IDPFR (State Department of Professional Regulation) and IDPFR is investigating it. The resident was discharged so there was no harm. There was no proof that the meds came from the facility. The (Neighboring town) Police Department is investigating the domestic violence, not the medications found in the house.On 12/12/25 V10 provided copies of the emails sent to her by V11's significant other. The pictures show 2 medication cards filled with Cyclobenzaprine 10mg with R5's name on them. One of the cards appears full (30 tabs) and the other looks to contain about 17 pills. The facility Abuse Policy Revised on 10/13/25 states, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.

Based on interview and record review the facility failed to ensure the safety of residents by allowing a nurse with witnessed behavior changes outside her norm to provide cares to residents. This failure had the potential to affect all 25 residents (R1-R25) V12 Licensed Practical Nurse (LPN) cared for on 12/2/25. The findings include:The facility's December 2025 nursing schedule showed V12 LPN worked in the facility from 6AM-6PM on 12/2/25. The schedule showed V3 Certified Nursing Assistant (CNA), V4 CNA, V9 Housekeeping, V10 Dietary Manager, and V11 CNA worked with V12 LPN on 12/2/25. A facility resident roster printed 12/4/25 showed V12 LPN was assigned to and provided cares to R1-R25 on 12/2/25.On 12/5/25 at 7:51 AM, V3 CNA stated on 12/2/25, V3 observed V12 LPN falling asleep standing up. She would sit down and nod off. Just bizarre and scary behavior. V3 stated she also observed V12 LPN drawing up a medication in a syringe but her eyes kept closing and she would nod off. V3 CNA stated she reported V12 LPN behaviors to V1 Administrator and V2 Director of Nursing (DON) the morning of 12/2/25. V3 stated, (V1 Administrator) kept telling me to keep an eye on her. I don't know what happened after that but (V12 LPN) did work her full shift that day.On 12/5/25 at 8:20 AM, V4 CNA stated on 12/2/25, V4 observed V12 LPN falling asleep while working. V4 stated, (V12) was falling asleep standing up at the med cart. She would lean forward on the cart with her eyes closed. At some point, I saw her drawing up a medication with her eyes closing off and on. I also saw her testing (R2's) blood sugar. (R2) was sitting down and (V12) was bent over, with her eyes closed, next to (R2), while waiting for the blood sugar results. V4 CNA stated she reported V12 LPN's behaviors to V1 Administrator on the morning of 12/2/25. V4 stated V1 Administrator told V4 to keep an eye on V12. V4 stated, I don't know what happened with (V12) but she was a huge safety issue. She was still working the floor when I left that day. On 12/5/25 at 9:58 AM, V9 Housekeeping stated on 12/2/25, she observed V12 LPN standing at her med cart, trying to punch out pills in a cup but she would nod off, her head would jerk back, and she would wake up. V9 stated she reported V12's behaviors to V1 Administrator on 12/2/25.On 12/5/25 at 10:10 AM, V10 Dietary Manager stated on 12/5/25, V10 observed V12 LPN standing at her med cart and she would start to fall asleep. She tried to put her key in the med cart to open it up but kept missing the keyhole because her eyes would shut. V10 stated she reported V12's behaviors to V1 Administrator on the morning of 12/2/25. V10 stated, I was told to keep an eye on her. I don't know what happened. (V12) was still working the floor when I left at 4PM that day.On 12/5/25 at 10:24 AM, V11 CNA stated on 12/2/5, she observed V12 LPN trying to put medication in a syringe but she was swaying back and forth while she was standing by the med cart. Her eyes kept closing and her head would [NAME] back and forth. Her behavior was unsafe. I wouldn't want her taking care of my loved one. V11 stated she reported V12's behaviors to V1 Administrator on 12/2/25. V11 stated, I was told to watch her by (V1). When I left at 1 PM that day, (V12) was still working the floor.On 12/5/25 at 10:32 AM, a telephone interview with V12 LPN was conducted. V12 denied being under the influence of drugs or alcohol but admitted she'd had a previous addiction to opioids and benzos (benzodiazepines) of which she was treated for in 2019. V12 stated on 12/2/25, she should have requested to go home that day because I was so tired. V12 stated she did at some point on 12/2/25 start to doze off if I sat down and her head may have bobbed or jerked because she was so tired. V12 stated she took a urine drug test on 12/2/25 that was given to her by V2 Director of Nursing (DON). V12 stated, My urine test was negative, so I went back to work and finished my shift. I was so tired I should have requested to go home after my test came back negative.On 12/5/25 at 11:03 AM, V1 Administrator stated he did receive concerns from V3 CNA, V4 CNA, V9 Housekeeping, V10 Dietary Manager, and V11 CNA about V12 LPN falling asleep at work on 12/2/25 around 10 AM. V1 stated around 11 AM that morning, V1 and V2 DON pulled (V12) in to talk to her. V1 stated, (V12's) eyes were open. We asked her if she needed any help. (V12) said she was just tired. We gave her a cup of coffee. We let her go back to work. She denied she had taken any drugs or alcohol. I kept watching her. Around lunchtime, I saw (V12) nod off and close her eyes. That's when we called our human resources, and they told us to drug test her. V1 stated V2 DON went to a local pharmacy to get a an over the counter (OTC) urine drug test because the facility did not have a contract with a local laboratory to have employees drug tested. V1 Administrator stated V12's OTC urine drug test was negative however V1 could not state exactly what drugs V12's urine was tested for and did not have any written results of V12's urine screen. V1 pulled out his cell phone and showed this surveyor a black and white pictures of an unlabeled and undated specimen cup. The cup showed no written results that identified exactly what was measured or identified from the liquid specimen noted in the cup. When V1 was asked what the facility policy was on what to do if a staff member appears impaired or too tired at work, V1 stated, We would send the staff member home because their productivity would be compromised if they can't stay awake. They wouldn't be able to chart or give medications. When V1 was asked how he could ensure that V12 was able to provide safe cares to residents on 12/2/25 after multiple complaints from staff members, V1 stated, We kept an eye on her. Her drug test was negative. I guess I can't answer that. I should have sent her home, but I left that up to (V2 DON). On 12/5/25 at 12:07 PM, V2 DON stated she received multiple complaints from staff, on 12/2/25, stating V12 LPN was falling asleep at work. V2 DON stated on 12/2/25 around late morning, V2 and V1 Administrator pulled V12 LPN aside to speak with her. V2 stated she found V12 to be awake and alert at that time. V2 stated V12 reported that she was tired. V2 and V1 sent V12 LPN back to work. V2 stated around lunch time she again was notified by staff that V12 continued to fall asleep at work. V2 DON stated she went to a local pharmacy to pick up an OTC urine drug test. V2 returned to the facility and watched V12 LPN take the drug test. When asked exactly what drugs were tested for in V12 LPN's urine drug test, V2 stated, I don't exactly know all of them. I would have to look at the box. I just know the urine test was negative. V2 DON was unable to provide any written test results from V12's urine drug screen completed on 12/2/25. V2 DON stated she sent V12 LPN back to work after her drug screen was negative because I never saw her sleeping or saw her with any behaviors I was concerned about. I would have sent her home if I myself had seen her sleeping. On 12/5/25 at 12:44, V14 Medical Director was asked what he would do if his saw a staff member falling asleep in a facility or the staff member seemed impaired in any way, V14 stated, I would report it immediately to the administrator or DON. When V14 was asked if he would allow a nurse to take care of his residents if he or she appeared impaired for any reason, V14 stated, Absolutely not.The facility's Conduct and Behavior policy (undated) showed, All employees must adhere to accepted professional standards. This includes displaying business conduct and behavior, and exhibiting a high degree of integrity at all times. Conduct that interferes with the safe operation of the facility, brings discredit to the company, residents or staff, or that is offensive to a resident, family member, visitor, or employee, will not be tolerated and can be grounds for disciplinary action.

Based on interviews and record review, the facility failed to ensure that a resident (R1) received a physical therapy evaluation per physician's order. This failure affects 1 of 2 residents (R1) reviewed for physical therapy in the sample of 3.The findings include:On 12/02/2025 at 9:46 AM, R1 indicated he had not received physical therapy services since admission. R1's face sheet documented admission date of 11/11/2025 with a past medical history not limited to: type 2 diabetes mellitus, hypertensive heart disease with heart failure, congestive heart failure, atrial fibrillation, congestive heart failure and personal history of transient ischemic attack.Review of R1's active orders as of 12/02/2025 showed physical therapy (PT) occupational therapy (OT) eval and treat dated 11/21/2025; and OT clarification order: OT to treat 3-5 times/week for 30 days dated 11/23/2025.Restorative Progress Note dated 12/2/2025 9:40 AM indicated that R1 completed six days of facility sponsored therapy yesterday. Will follow up with therapy for restorative recommendations.Review of R1's progress notes showed no physical therapy evaluation or screening was completed as of 12/02/2025.On 12/02/2025 at 2:54 PM, V9 (Physical Therapy Assistant) said R1 was evaluated by OT but not by PT. V9 added that R1 is on Medicaid so the facility would have to cover therapy services.On 12/02/2025 at 2:59 PM, called V10 (Regional Director of Therapy) said the facility approved six visits of OT for R1 that were met as of 12/01/2025. V10 added that she was unaware of the order for a PT evaluation, she only knew of OT eval.On 12/02/2025 at 3:25 PM, V11 (MDS Coordinator) indicated it is facility protocol that all new admits are screened by therapy to see if they are candidates for any type of skilled therapy services that includes physical, occupational or speech therapy.On 12/03/2025, email correspondence between V10 and V11, provided by V1 (Administrator), showed in part, we are going to move forward with a PT eval if [V1] approves the facility pay eval and [six] visits to treat. [R1] is Medicaid so [V10] have to have approval (email sent!) before we schedule the PT eval. [Staff] did mention the patient is doing OK in OT but could use PT.Undated Provision of Physician Ordered Services policy reads in part: the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity.

Based on interview and record review the facility failed to prevent abuse between two residents when R1 hit R2, This failure applies to two of four residents (R1/R2) reviewed for abuse in the sample of six.The findings include:The written Statement from Administrator dated 10/20/25 in an investigation file for R1 & R2 showed, On October 20th, during a conference call around noon, the writer was informed of a confrontation between two residents, R2 and R1 both with a BIMS (Brief Interview of Mental Status) of 15 (no cognitive impairment). R2 reported that she entered R1's room without a clear reason, which R1 found objectionable. Following this, R1 confronted R2 in her own room. R1 claimed that R2 was going through her personal belongings, which she did not appreciate. At the time of these interviews, there was no evidence or confirmation of physical contact or altercation between the two. The Medical Doctor was notified, and the Power of Attorney (POA) was contacted. A preliminary investigation was initiated, although initially, there was no founded evidence of an altercation, and thus, it was not reported externally. The facility did not have an Initial Report for the resident-to-resident altercation between R1 and R2.On 10/23/25 at 8:34 AM, V3 Registered Nurse (RN) stated on Monday (10/20/25) she was working and R1 and R2 had an altercation. V3 stated she wasn't the nurse for R1 and R2; V4 RN was working in that area. V3 stated she was told R2 was caught in R1's room going through R1's things. Someone told R1 that R2 went into R1's room. R1 and R2' share a bathroom in between their room. R1 went to her room, went through the bathroom to R2's room and punched her in the face. This has not happened before; neither resident have been physical before with each other. V3 stated when something like this happens the nurse will assess the residents, let management know what happened, and they do the investigation and reporting. In the past the police would be called when something like this happens, but she did not see the police come in this time. V3 stated the Administrator, Director of Nursing (DON), and Social Services were here when this happened.On 10/23/24 at 8:40 AM, V5 Certified Nursing Assistant (CNA) stated he was working at the time of the incident between R1 and R2. V5 stated he was in the hall going to get a dressing for V4 RN who was in a room doing a dressing change. V5 stated when he came back with the dressing, V4 told him to get V2 DON because R1 had punched R2. V5 stated he went and got V2 and V2 got V1 Administrator. R2 did not go to the hospital. V5 stated he did not see any injury to R2's face. V5 stated the police did not come in for the incident. V5 stated he has never had a problem between R1 and R2 before. V5 stated R1 doesn't have any behaviors and has never hit any residents before. V5 stated R2 has behaviors of going into other residents' rooms and taking things that are not hers. V5 stated they try to monitor R2 as much as they can, so this doesn't happen. V5 stated when R2 goes into someone else's room V2 will talk to her about having personal boundaries and tell her she can't take other residents things. V5 stated this gets documented, grievances are filled out, and V1 is notified.On 10/23/24 at 8:45 AM, R1 was sitting in a wheelchair by the door in the common area waiting to go outside to smoke. R1 declined going anywhere to talk in private and stated it could be done right there. R1 stated on Monday R2 was in her room stealing. R1 stated R2 was bent over a box container that had snacks in it under her bed. R1 stated R2 ran from R1's room through the bathroom and jumped onto R2's bed. R1 stated she followed R2 into her room and she punched R2 in the face. R1 stated R2 has stolen stuff from her room before and no one is doing anything about it, R1 stated she took things into her own hands and hit R2 in the nose. R1 stated R2 stays away from her now. R1 stated they offered to give her a different room and she doesn't want to change rooms. R1 stated she keeps the bathroom door to her room closed at all times now. R1 stated if they (facility) would do something about R2 stealing then this would not have happened. R1 stated if the facility would have handled R2 stealing before this then she would not have had to. R1 stated she was told she can't hit people yet staff were glad that she did it because R2 steals from them and other residents. R1 stated she does not go around hitting people and knows not to do that.On 10/23/25 at 8:56 AM, R2 was in her room, awake, laying on her bed. R2 stated she got in a fight because R1 was mad at her. R2 stated she went into R1's room and was going through her stuff to find something to drink. R2 stated snack time was 4 hours away and she wanted something now. R2 stated R1 did not tell her she could go in her room or through her stuff. R2 stated she knows it was wrong. R2 stated she was in R1's room and the janitor saw her. R2 stated when R1 came back to her room she came over to R2's room and punched her in the face. R2 stated she did not get hurt, and she was not upset over being hit. R2 denied any injury. R2 stated she is not afraid of R1 and did not want to change rooms. R2 stated after it happened V1 Administrator, and V2 DON came and talked to her, and she told them what happened. V1 and V2 told her not to do it again. R2 stated the police did not come in and talk to her. R2 stated she doesn't go into other people's room all the time. R2 stated she just so hungry that she wasn't thinking straight and was trying to find something to eat and drink.On 10/23/25 at 9:03 AM, R6 was in her room that she shares with R2 and stated she was in the room when the incident happened. R6 stated R1 came into R2's room and she tried to tell R1 to get out. R1 said she did not care and that she was going to knock R2 out. R6 stated the curtain between her and R2's bed was partially closed so she got up and saw R1 hit R2 in the nose. R6 stated R1 followed R2 through the bathroom and hit R2. R6 stated she heard R2 took something from R1's room. R6 stated other residents have complained about R2 taking things from their rooms but they don't bother her about it because they know she does it. It is a disease that R2 has, and she doesn't know what she is doing. R2 just thinks she is hungry and thirsty and does it. R2 doesn't think to go to the nurse or put her light on and ask for water. R6 stated she tries to help R2 and watch over her because R2 is her friend. R6 stated V1 and V2 came and talked to R2 and then talked to R6 about it later. R6 denied R1 ever coming into their room before or R1 and R2 ever being in a fight before. R6 stated she was not afraid of R1 and was not worried about her coming into their room. R6 stated R2 knows she shouldn't steal, and the staff have talked to her about it before.On 10/23/25 at 9:51 AM, V1 Administrator stated he was on a conference call when the incident happened, and he wanted to make sure it happened. V1 stated he wanted to make sure it wasn't he said she said situation. V2 did not find any injury on either resident. V1 stated he should have reported this and is aware that abuse will be cited for the facility. V1 stated staff should have documented the incident in the chart, that he was not aware that it wasn't documented, and did not know why it wasn't documented. V1 stated they were not saying the incident did not happen.On 10/23/25 at 10:32 AM, V2 Director of Nursing (DON) stated R2 has behaviors and a history of stealing. R2 goes into other resident's rooms all the time. Staff keep redirecting her. When R2 does this it is reported, and we continue to educate her. R2 has had her room moved in the past and occasional room searches are done. R2 is focused on stealing food and soda. V2 stated she hasn't been at the facility very long and was not sure what all has done in the past. V2 stated she was made aware of the incident and talked to R1 and R2. V2 stated R1 told her that she confronted R2 about being in her room. V2 stated R2 did not tell her that R1 hit her, V2 stated R2 admitted going into R1's room but did not recall everything R2 told her. V2 stated she told R2 that it was inappropriate to go in anyone room and touch things. V2 stated the residents were kept away from each other. V2 stated R1 was offered a room change and refused. R1 and R2 have been monitored and stay away from each other. V2 stated she looked into R1 and R2's medical records today and saw that there wasn't any documentation about the incident. V2 stated she put a note in risk management today about the incident. V2 stated the nurse should have documented in the resident's medical records what happened. V2 stated V1 is the abuse coordinator, and he does the reporting and investigation of any allegations of abuse. V2 stated her part is to enter the incident in risk management. V2 stated the police were not notified of the incident and the families were contacted by the administrator.The Minimum Data Set (MDS) dated [DATE] for R1 showed no cognitive impairment. The MDS dated [DATE] for R2 showed no cognitive impairment.The facility's Abuse, Neglect, and exploitation policy (2025) showed, abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on interview and record review the facility failed to report an allegation of abuse between two residents to the state agency when R1 hit R2. This failure affects two of four residents (R1/R2)reviewed for abuse in the sample of six.The findings include:The written Statement from Administrator dated 10/20/25 in an investigation file for R1 & R2 showed, On October 20th, during a conference call around noon, the writer was informed of a confrontation between two residents, R2 and R1 both with a BIMS (Brief Interview of Mental Status) of 15 (no cognitive impairment). R2 reported that she entered R1's room without a clear reason, which R1 found objectionable. Following this, R1 confronted R2 in her own room. R1 claimed that R2 was going through her personal belongings, which did she did not appreciate. At the time of these interviews, there was no evidence or confirmation of physical contact or altercation between the two. The Medical Doctor was notified, and the Power of Attorney (POA) was contacted. A preliminary investigation was initiated, although initially, there was no founded evidence of an altercation, and thus, it was not reported externally. The facility did not have an Initial Report for the resident-to-resident altercation between R1 and R2.On 10/23/25 at 8:34 AM, V3 Registered Nurse (RN) stated on Monday (10/20/25) she was working and R1 and R2 had an altercation. V3 stated she wasn't the nurse for R1 and R2; V4 RN was working in that area. V3 stated she was told R2 was caught in R1's room going through R1's things. Someone told R1 that R2 went into R1's room. R1 and R2' share a bathroom in between their room. R1 went to her room, went through the bathroom to R2's room and punched her in the face. R2 did not go to the hospital. R1 and R2 were separated for the day and monitored. V3 stated when something like this happens the nurse will assess the residents, let management know what happened, and they do the investigation and reporting. In the past the police would be called when something like this happens, but she did not see the police come in this time. On 10/23/24 at 8:40 AM, V5 Certified Nursing Assistant (CNA) stated he was working at the time of the incident between R1 and R2. V5 stated he was in the hall going to get a dressing for V4 RN who was in a room doing a dressing change. V5 stated when he came back with the dressing, V4 told him to get V2 DON because R1 had punched R2. V5 stated the police did not come in for the incident. V5 stated he has never had a problem between R1 and R2 before. V5 stated R1 doesn't have any behaviors and has never hit any residents before. V5 stated R2 has behaviors of going into other residents' rooms and taking things that are not hers. On 10/23/24 at 8:45 AM, R1 was sitting in a wheelchair by the door in the common area waiting to go outside to smoke. R1 declined going anywhere to talk in private and stated it could be done right there. R1 stated on Monday R1 was in her room stealing. R1 stated R2 was bent over a box container that had snacks in it that had been under her bed. R1 stated R1 ran from R2's room through the bathroom and jumped onto R2's bed. R1 stated she followed R2 into her room and she punched R2 in the face. R1 stated R2 has stolen stuff from her room before and no one is doing anything about it, R1 stated she took things into her own hands and hit R2 in the nose. R1 stated R2 stays away from her now. R1 stated they offered to give her a different room and she doesn't want to change rooms. R1 stated she keeps the bathroom door to her room closed at all times now. R1 stated if they (facility) would do something about R2 stealing then this would not have happened. R1 stated if the facility would have handled R2 stealing before this then she would not have had to. R1 stated she was told she can't hit people yet staff were glad that she did it because R2 steals from them and other residents. R1 stated she does not go around hitting people and knows not to do that.On 10/23/25 at 8:56 AM, R2 was in her room, awake, laying on her bed. R2 stated she got in a fight because R1 was mad at her. R2 stated she went into R1's room and was going through her stuff to find something to drink. R2 stated snack time was 4 hours away and she wanted something now. R2 stated R1 did not tell her she could go in her room or through her stuff. R2 stated she knows it was wrong. R2 stated she was in R1's room and the janitor saw her. R2 stated when R1 came back to her room she came over to R2's room and punched her in the face. R2 stated she did not get hurt, and she was not upset over being hit. R2 denied any injury. R2 stated she is not afraid of R1 and did not want to change rooms. R2 stated after it happened V1 Administrator, and V2 DON came and talked to her, and she told them what happened. V1 and V2 told her not to do it again. R2 stated the police did not come in and talk to her. R2 stated she doesn't go into other people's room all the time. R2 stated she just so hungry that she wasn't thinking straight and was trying to find something to eat and drink.On 10/23/25 at 9:51 AM, V1 Administrator stated they did not report the incident between R1 and R2 to Illinois Department of Public Health (IDPH) because we wanted to do a soft investigation to see what happened. V1 stated he was on a conference call when the incident happened and he wanted to make sure it happened. V1 stated he wanted to make sure it wasn't a he said she said situation. V2 did not find any injury on either resident. V1 stated we did not report this and we are supposed to report it within 2 hours but did start an investigation. V1 stated he should have reported this and is aware that abuse will be cited for the facility. The Minimum Data Set (MDS) dated [DATE] for R1 showed no cognitive impairment. The MDS dated [DATE] for R2 showed no cognitive impairment.The facility's Abuse, Neglect, and exploitation policy (2025) showed, abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Reporting/Response: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review the facility failed to ensure a resident with a fractured leg received scheduled pain control medication for 1 of 1 residents (R1) reviewed for pain in the sample of 3. This failure resulted in R1 experiencing pain rated at a 10 out of 10. The findings include: R1's facesheet showed she was admitted to the facility 9/18/19 with diagnoses to include transient cerebral ischemic attack, pseudobulbar affect, disorders of bone density and structure, major depressive disorder, spastic hemiplegia, insomnia, bipolar disorder, hyperlipidemia, mood disorder, and anxiety disorder. R1's facility assessment dated [DATE] showed she has moderate cognitive impairment. R1's care plan initiated 7/18/23 showed, [R1] is at risk for alteration in comfort for pain related to her diagnoses of an old stroke with left side weakness. Has orders for scheduled and PRN (as needed) pain medications for potential breakthrough pain . Interventions: Administer pain medication as ordered. R1's care plan initiated 11/14/23 showed, [R1] has acute/chronic pain related to depression, Diabetic neuropathy, disease process, and impaired mobility; Goal: [R1] will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date . Interventions: Administer analgesia as per orders . Anticipate resident's need for pain relief and respond immediately to any complaint of pain . Staff to offer non-pharmacological interventions for pain management such as ice, repositioning, guided imagery , relaxation techniques, deep breathing, stretching, ROM (range of motion) exercises, warm packs, etc . R1's care plan initiated 6/16/25 showed, [R1] has a pathological bone fracture of the proximal tibial metaphysis related to severe osteopenia. Goal: [R1] will express/exhibit relief of pain after administration of ordered medications, alternative comfort measures . Interventions: Give pain, anti-inflammatory medications as ordered . R1's 6/14/25 portable X-ray results showed, . Generalized soft tissue swelling of the leg without lacerations or radiodense foreign bodies or fascial emphsema. Advanced degenerative disease of the knee and the ankle. severe osteopenia. Nondisplaced acute fracture of the proximal tibial metaphysis . Impression: Profound osteopenia of the skeleton of the left leg and nondisplaced acute fracture of the proximal tibial metaphysis . R1's June and July 2025 Physician Order sheet showed an order for hydrocodone-acetaminophen (narcotic pain control medication), give 1 tablet orally three times a day for pain, an order for acetaminophen 325 mg, give 1 tablet orally every 6 hours as needed for pain/fever, and an order for oxycodone-acetaminophen 10-325 (narcotic pain control medication), give 1 tablet by mouth every 4 hours as needed for pain. R1's June 2025 eMAR (electronic Medication Administration Record) showed on 6/30/25, R1 received a dose of hydrocodone-acetaminophen at 5:00 PM and subsequently received a dose of her PRN (as needed) oxycodone-acetaminophen at 6:57 PM when she reported her pain level at a 5. (This pain medication was administered within 2 hours of the previous pain medication.) R1's next dose of pain medication documented was on 7/1/25 at 4:36 AM when she received a dose of her PRN pain medication oxycodone-acetaminophen. On 7/1/25 at 10:30 AM, R1 was lying in her bed with a long hinged brace to her left leg. R1 was rubbing and holding her upper leg and wincing in pain. R1 said she rated her pain at a 10 out of 10. R1 said she has breaks in her leg and she is not doing good . I'm hurting so bad. I need to get out. I need something. On 7/1/25 at 10:36 AM, V4 RN (Registered Nurse) said she has been really busy this morning with a resident who is one on one at the nursing station. V4 said she was taking R1's scheduled hydrocodone-acetaminophen scheduled to be administered at 7:00 AM into R1 right now (3.5 hours after the scheduled administration time). V4 said a CNA (Certified Nursing Assistant) came up to her and told her R1 needed something for pain. V4 said she just got the word now regarding R1's pain so she headed down to see her. On 7/1/25 at 2:30 PM, V2 DON (Director of Nursing) said after reviewing R1's medication administration record, [R1] should not have been given the 6:57 PM dose of oxycodone with a pain level of 5. I would have expected them to give her Tylenol, reposition her, use distraction, or see what else we can do to make it better at that point. It was too soon to give another narcotic pain medication. That is probably why she slept through until the morning after that and didn't need another dose until the morning. This morning with the delayed medication pass she should have pulled an aide to sit with the resident at the nurses station and passed her medications instead of being so far behind. The facility's policy and procedure implemented 3/2025 showed, Pain Management . Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences . The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated . c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: . c. Fidgeting, increased or recurring restlessness d. facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw) e. Behaviors such as: resisting care . irritability, depressed mood . Pain Management and Treatment: 1. Based upon evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individuals resident's pain beginning at admission . 7. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain . h. Opioid treatment for acute pain, subacute pain, and chronic pain will be prescribed and dosed in accordance with current professional standards of practice and manufacturers guidelines to optimize their effectiveness and minimize their adverse consequences .

Based on observation, interview, and record review the facility failed to ensure medications were administered within their scheduled timeframe for 1 of 1 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's facesheet showed she was admitted to the facility 9/18/19 with diagnoses to include transient cerebral ischemic attack, pseudobulbar affect, disorders of bone density and structure, major depressive disorder, spastic hemiplegia, insomnia, bipolar disorder, hyperlipidemia, mood disorder, and anxiety disorder. On 7/1/25 at 10:36 AM, V4 RN (Registered Nurse) was administering medications to R1. V4 said, These are [R1's] scheduled morning medications. V4 said she has been really busy this morning with a resident who is 1 on 1 at the nursing station. R1's July 2025 eMAR (electronic Medication Administration Record) showed medications scheduled to be administered at 7:00 AM to include dicyclomine 10 mg (milligrams) TID (three times a day), gabapentin 600 mg TID, Hydrocodone-Acetaminaphen 10-325 mg TID, and Metformin HCL 1000 MG BID (two times a day). These medications were administered at 10:36 AM (2.5 hours outside of the allowable medication administration time). The next dose of dicyclomine, gabapentin, and Hydrocodone-Acetaminophen were scheduled to be administered at 12:00 PM (only 1.5 hours after the morning medications were administered.) On 7/1/25 at 2:30 PM, V2 DON (Director of Nursing) said after reviewing R1's medication administration record,This morning with the delayed medication pass [V4] should have pulled an aide to sit with the resident at the nurses station and passed her medications instead of being so far behind. Medications can be passed 1 hour before and 1 hour after the scheduled administration time. It would be too soon to give these medications again at the next scheduled administration time. The facility's policy and procedure revised 11/2024 showed, Medication Administration . Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .

Based on interview and record review the facility failed to ensure residents were allowed to smoke for 17 of 19 residents (R1 and R3-R18) reviewed for resident rights in the sample of 19. The findings include: On 6/17/25 the facility provided list of residents that smoke which included R1 and R3-R18. On 6/17/25 at 9:15 AM, R15 stated she was told by facility staff on Friday (6/13/25) that the 5:30 PM smoke break was going to be discontinued starting the following Monday (6/16/25). R15 said all the smokers were told on Friday but they would still have the weekend to get a 5:30 PM smoke break. R15 said none of the smokers got to go outside at 5:30 PM on Saturday because there was no one to take them outside. On 6/17/25 at 9:28 AM, R3 said over the weekend the 5:30 PM smoke break was taken away. R3 said she was seated outside on the patio on Saturday. It was after dinner and she was not allowed to smoke. R3 said she heard two male residents yelling just inside the door. It was something about not being able to smoke. R3 said she was told the 5:30 PM smoke break would continue over the weekend, but it did not. On 6/17/25 at 9:35 AM, R1 said he was arguing with staff over the weekend about a smoke break not happening. R1 said they were told the day before, the 5:30 PM break was going away but that they would still be allowed outside over the weekend. R1 said it wasn't supposed to happen for a few more days. On 6/17/25 at 3:39 PM, R8 stated he goes out to smoke at almost every break. R8 said he was told the 5:30 PM break was going to stop on a Monday. R8 said it stopped on the Saturday before then. R8 said the staff told them they still had the weekend to go outside to smoke at 5:30 PM, but that didn't happen. On 6/17/25 at 3:42 PM, R7 said the facility took away the 5:30 PM smoke break over the weekend. R7 said it wasn't supposed to happen until Monday, but they did it anyway. On 6/17/25 at 8:52 AM, V10 (Certified Nurse Aide) stated she heard there was an incident on Saturday (6/14/25). It was around 5:30 PM. The residents were upset because they weren't getting their 5:30 PM smoke break. They had been told on Thursday and Friday that the 5:30 PM smoke break was going to be stopped. The activity aide who was the person who had been supervising that smoke break was not available on Saturday. V10 said she thought it was supposed to start on Saturday but found out later it was not supposed to start until Monday. On 6/17/25 at 2:16 PM, V4 (Registered Nurse) stated R1 was yelling and screaming on Saturday because he wasn't allowed to go outside for the after-dinner smoke break. V4 said none of the smokers were allowed to smoke that evening. On 6/17/25 at 2:59 PM, V8 (Activity Director) said residents were given a one week notice that the 5:30 PM smoke break was going to be discontinued. It was supposed to start yesterday (6/16/25) due to lack of staff to supervise. Residents got verbal alerts and they had to sign a paper showing they knew of the upcoming change. V8 said there wasn't enough staff to supervise them over the weekend so the 5:30 PM smoke break did not happen. On 6/17/25 at 3:04 PM, V2 (Director of Nurses) said the 5:30 PM smoke break was discontinued due to lack of staff supervision. The activity department usually supervises and they are leaving the building at an earlier time now. V2 said the administrator had meetings with each smoker and they signed forms on Friday (6/13/25). The change should not have taken effect until Monday (6/16/25). On 6/17/25 the facility provided a list of the residents that smoke. The list included R1 and R3-R18. The document showed the smoking times of 9 AM, 11 AM, 1 PM, 4 PM and 530 PM. The 530 PM time was crossed off with a black pen. The facility supplied documentation of the residents' in-services regarding smoke breaks. The in-service showed new smoking times (without the 530 PM time) and a start date of Monday, 6/16/25. The facility's Resident Smoking Privileges policy revision dated 11/2024 states: 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting) at designated times, and in accordance with his/her care plan. The facility's Residents' Rights policy (undated) states under the rights to dignity and respect section: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of like.

Based on observation, interview, and record review, the facility failed to ensure a residents (R1 & R2) were free from physical abuse for two residents reviewed for abuse in the sample of 19. The findings include: On 6/17/2025 at 9:17 AM, R2 was sitting in the activity/sitting area watching television. R2 did not understand this surveyor's questions due to R2 mostly speaking Spanish. V11 (Certified Nursing Assistant-CNA) translated for this surveyor and R2. R2 was asked about the incident with another male resident a few days prior. R2 said R1 was walking from the back hall. R2 said he (R2) got up to go over to the table across the room. R1 pointed to him to go over there, (like get moving), then R1 hit him (R2) in the shoulder and made him hit his head on the wall. R2 said they sent him to the hospital to check him out. He does not think he had any injuries. R2 said R1 hit him at least 3 times. R2 pointed to each area his left lower arm, upper left arm, and his right shoulder. R2 said he swung back at R1, but R1 was the one that started it. R2 said he feels safe in the facility; but if R1 does try to hit him again, he will fight back. R2 was asked if he had any problems with R1 prior to that incident. R2 said sometimes when he (R1) is sitting in the TV room, R1 would come and talk to him. R2 said it triggers him (R2), because R1 will call him (A wrong name). R2 said when that happens, he (R2) would just get up and go to his room. R2 said he has not had any problems with R1 after the incident. No visible signs of injury were observed on R2. On 6/17/2025 at 9:35 AM, R1 was in his room exiting the bathroom. R1 was asked about the physical altercation with another resident a few days prior. R1 stated, the guy was taunting me, I was like what does he want. R1 said he (R2) was grunting, so I asked if he wanted to fight or what. R1 said he (R2) got up and threw his walker towards me, I stood up and hit him. I was protecting myself. R1 said the nurse, or a CNA stepped in, and he accidentally hit her because he blanked out. R1 said before it happened, I was arguing with staff about the smoke break. I said we should get a smoke break because we were just told about the change in smoke break times, and it was not supposed to happen until a few days later. R1 said he has not gotten into any arguments or physical altercations with R2, other residents, or staff prior to the incident. R1 said it was an accident that he hit the staff. It was not an accident that I hit the other resident. R1 said he does not know his name (R2's). R1 said he had not had any problems with that resident before or after. R1 said he tries to harass me every now and then, by grunting at me, but I just ignore him and walk. I feel safe in the facility. I went to the hospital that night for hip pain, due to his walker hitting my left side or my kidney or something. I came back that night. No visible signs of injury were observed on R1. On 6/17/2025 at 12:45 PM, V5 (Certified Nursing Assistant-CNA) said she worked 6:00 PM-6:00 AM shift on 6/14/2025. V5 said staff were doing rounds for the residents. R1 kept yelling that he wanted to smoke and was hitting the walls down the hallway, in his room. R2 was sitting in the TV/Activity room in a chair. R1 kept walking to the nurse's desk yelling, We can smoke, it wasn't supposed to happen until Monday. R1 kept yelling. He went to the dining room/activity room with the television and started hitting the table chanting, We want to smoke. He came out of there and went to his room, hit the door, and was slamming things. R1 came back out of his room. V5 said she went down the hall to answer a resident's call light. As I came back out, I heard V4 (Registered Nurse/RN) yelling. R1 was standing over R2. R2 told him to be quiet. R1 hit R2 in the head. R2 stood up and hit R1 back. R1 hit R2 a couple times. V4 got in between R1 and R2. R1 still proceeded to hit R1 multiple times. R2 lost his balance and started falling. V5 said she and V4 caught R2 before he fell. V5 said R1 ran back to his room and stayed in his room until the police arrived. V5 said R1 has some behaviors at night, but not to the extent that he was ever aggressive towards other residents. V5 said he has yelled at staff. V5 said she was not aware of R1 swinging at any staff, or anything physical like that. On 6/17/2025 at 1:35 PM, V6 (CNA) said she saw the altercation. V6 said I was walking back from a resident's room and saw the nurse running to stop the fight. R2 was sitting down watching television, and R1 was behind the couches by the smoking door. R1 hit R2 in the head because R2 told him to be quiet. V6 said that is why R1 got mad and hit R2. V6 said R1 was hitting R2 in the face, and R2 was defending himself. I did not see it start. V6 said V12 (CNA) called 911. V6 said V4 split the residents up. V6 said it happened quick. It was kind of difficult to separate them, because they were going at it. V6 said V5 (CNA) was there too. V6 said she has not seen R1 hit another resident prior to that incident, adding that she was a new hire. V6 said R1 went to his room and R2 sat back down in the chair. V6 said she did not see any bleeding or bruising on either resident before they were sent out to the local hospital, or after they came back to the facility that night. On 6/17/2025 at 2:16 PM, V4 (RN) said on Saturday 6/14/2025. R2 was not the aggressor. He was very calm. V4 said R1 was very agitated. yelling, screaming, going back and forth from his room. V4 said she let R1 know that smoking hours were over and would resume the next morning. V4 said R1 was screaming profanities and punching and kicking the door and the wall in his room. V4 said R1 went to the TV area and was yelling anarchy, anarchy. V4 said R2 told R1 to please be quiet. V4 said she was trying to put stuff away quickly in the medication cart, lock it and make her way to the sitting area. V4 said she saw R1 hit R2. R2 got up and hit R1. V4 said she went over and separated them both. Staff were calling 911 while I was trying to break the fight up. V4 said she got elbowed in the shoulder by R1 while trying to break up the fight. V4 said she assessed both R1 and R2, and did not see any injuries on either resident. V4 said the paramedics assessed both residents. V4 said R2 was sent out to make sure there were no injuries. R1 was sent out due to aggressive behaviors. V4 said she was still on duty after they both came back and neither of them had any injuries. No new orders were given by the local hospital's emergency department doctor. Just to follow up with their doctor. V4 said R1 has been sent out to the local hospital before due to an incident involving behaviors with staff. Nothing physical. V4 said R2 has not had any aggressive behaviors that she is aware of, adding he is usually pretty quiet. On 6/17/2025 at 10:07 AM, V2 (Director of Nursing-DON) said she was at home when V10 (CNA) called her at 6:59 PM about the incident. V2 said she told her she was on her way. V2 said V4 called her around 7:32 PM to tell her there were residents in here being aggressive and fighting. V2 said V4 told her the police and emergency medical services had been called. V2 said she called V3 (Social Services Director-SSD) because she lived close to the facility and V3 told her she was already at the facility. V2 said V3 told her the police were already at the facility. V2 said when she arrived at the facility, V3 told her what happened. The nurse (V4) told V3 that R1 and R2 just started fighting and she tried to get in between them. she (V4) told staff to call 911. V2 said the police came and took both residents out of the facility. V2 said V4 said R1 was agitated earlier due to the facility taking away the last smoke break. He was punching the air, called her a racial slur, and refused to take his medications. V2 said she asked R1 what started the fight. He said that guy is an agitator, what he says and what he does. He agitates him and another resident. V2 said on 6/16/2025 she did see when R1 walked by R2, he (R2) did make a grunting/growling noise. V2 said when R1 first came back to the facility on 6/14/2025 he was on 1:1 supervision, then it was changed to 15-minute checks. V2 said the psychiatric Nurse Practitioner was notified of the incident, and an order for as needed Haldol was given because the hospital did not make any medication changes prior to sending him back to the facility on 6/14/2025. V2 said when R2 came back to the facility on 6/14/2025 he denied pain. V2 said R1 and R2 were kept separated after they returned to the facility on 6/14/2025. The facility's Incident Investigation dated 6/15/2025 showed R1 was the aggressor and hit R2. The investigation showed R1 had been very agitated due to missing a smoke break and was yelling, swearing, and punching the walls in his room and slamming doors. The investigation showed R1 observed having an altercation with another resident and punched the other resident several times. The investigation showed R1 also received punches from the other resident. 911 was called and staff were able to successfully break up the altercation. R1 taken to the hospital for evaluation. R1 and R2's background checks were reviewed. Both R1 and R2 had a hit on their background checks. R1 for property damage and domestic battery, and R2 for battery. The background checks showed R1 was listed as moderate risk. Requires closer supervision and more frequent observation than standard or routine. Should ascertain whether the level of supervision is sufficient. R2 was listed as a low risk. R1 and R2's care plans were reviewed showing interventions for behavior/aggression were in place. The 6/14/2025 local Police report was reviewed. The facility's one-on-one supervision and 15-minute checks were reviewed with no concerns. R1's 6/14/2025 After Visit Summary from the local hospital was reviewed showing the reason for R1's hospital visit was Behavioral Problem. R2's 6/14/2025 After Visit Summary from the local hospital showed Assault. Contusion of head. R1's progress notes for the last three months showed increased agitation towards V1 (Administrator) on 3/21/2025. Sent to a local hospital for evaluation. R1's admission Record, provided by the facility on 6/17/2025 showed he had diagnoses including, but not limited to, schizoaffective disorder, restlessness and agitation, and generalized anxiety disorder. R2's admission Record, provided by the facility on 6/17/2025 showed diagnoses including, but not limited to, paranoid schizophrenia, dementia, adjustment disorder with mixed anxiety and depressed mood, and shizoaffective disorder-bipolar type. The facility's policy and procedure titled Abuse, Neglect and Exploitation, with a revision date of 11/2024, showed Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking .

Based on interview and record review the facility failed to ensure a pressure injury was identified prior to becoming a stage three. This failure resulted in R31 developing a stage three pressure injury to his left ischium that had light serous drainage. This applies to 1 of 1 residents (R31) reviewed for pressure injuries in the sample of 18. The findings include: R31's Face sheet dated 3/5/25 shows R31 has diagnoses including, but not limited to: cerebral palsy, major depressive disorder, epilepsy, anxiety, schizoaffective disorder, paraplegia, hypokalemia, gastro-esophageal reflux disease (GERD), hyperkalemia, encephalopathy, hypertension, and hyperlipidemia. R31's Face sheet also shows that R31 was admitted to the facility on [DATE]. R31's Admission/Readmission Nursing Evaluation form dated 12/1/23 shows R31 requires dependence upon staff to shower/bathe, get dressed, move from a seated position to lying position, move from a lying position to a sitting position, and R31's skin was normal with no noted pressure injuries. R31's Braden Scale form dated 12/1/23 shows R31 had a score of 15, indicating R31 is at high risk of developing a pressure injury. R31's Braden Scale form states R31 does not have any stage 2, 3, or 4 pressure wounds present in the last 7 days and no pressure wounds have been resolved in the last 90 days. R31's Order Summary Report shows R31 has an order for daily skin check with a start date of 12/5/23. R31's Skin Only Progress Note dated 1/28/24 states, Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. No current skin issues noted at this time. R31's quarterly Braden Scale form dated 2/8/24 shows R31 had a score of 15. R31's Braden Scale form also states R31 does not have any stage 2, 3, or 4 pressure wounds present in the last 7 days and no pressure wounds have been resolved in the last 90 days. R31's Initial Wound Evaluation and Management Summary form dated 5/24/24 states, Patient present with a wound on his left ischium . Stage 3 pressure wound of the left ischium full thickness. Exudate: Light Serous . The measurements upon this initial examination were as follows: length of 1.2 centimeters (cm), width of 1.5 cm and a depth of 0.2 cm with a total surface area of 1.80 cm squared. The facility could not provide any other documentation between 2/8/24 and 5/24/24 indicating any skin abnormalities were found prior to 5/24/24. R31's Wound Evaluation and Management Summary form dated 2/28/25 shows R31's pressure wound of the left ischium is now a stage 4. The measurements upon this examination were as follows: length of 0.4 cm, width of 0.3 cm and a depth of 2.2 cm with a total surface area of 0.12 cm squared. On 3/3/25 at 12:13 PM and again at 1:08 PM, R31 was seen lying on his back with the head of the bed at an approximate 45-degree angle. On 3/5/25 at 10:51 AM, V17 Registered Nurse (RN) said R31 is dependent upon staff for all care. On 3/5/25, V3 (Infection Preventionist Nurse/RN) was attempted to be contacted by phone and was unable to be reached. On 3/5/25 at 1:54 PM, V2 (Director of Nursing) said nursing staff will complete a head-to-toe assessment upon admission and note any skin discrepancies. V2 also said nursing staff should at minimum complete a skin check at least weekly. Certified nursing assistants (CNAs) will complete a shower sheet and document any potential skin issues and bring the form to the nurse when completed. V2 said it is the expectation that staff should find skin concerns prior to it developing into a stage 3 pressure wound so the facility can provide treatment before it develops further. On 3/5/25 at 2:26 PM, V18 (Wound Doctor) said if the staff taking care of R31 during showering and incontinence care are paying attention and trying and looking at the skin, it should be easier to identify before a stage 3. V18 said the progression of the development of a stage 3 pressure wound is that the skin will first start to turn red. After the redness, the skin will become blanchable (skin that turns pale when pressure is applied to it and returns to normal color when pressure is released). The next phase would include the top layer of skin coming off. After the top layer of skin comes off, you can start to see the subcutaneous tissue below it start to show. When the subcutaneous layer shows, that is when you now have a stage 3 pressure wound. In a perfect world, the staff providing showers and incontinence care should be able to capture these stages as they occur.

Based on observation, interview, and record review the facility failed to ensure supplements were served and failed to obtain weekly weights for four of eight residents (R18, R24, R5, R34) reviewed for nutrition in the sample of 18. This failure resulted in R18 experiencing a significant weight loss. The findings include: 1. R18's Admission Record dated March 4, 2025 shows he was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, ataxia, dystonia, major depressive disorder, chronic pain syndrome, and cognitive communication deficit. R18's Order Summary Report dated March 4, 2025 shows a diet order started May 1, 2023 for general diet, double protein at breakfast and magic cup twice daily. An order for mighty shake four times a day was started on December 19, 2023. Monthly weights was entered to start January 4, 2024. R18's Weights Summary shows on January 9, 2025 R18 weighed 140.2 and on February 1, 2025 R18 weighed 123.7 pounds, which is a weight loss of 16.5 pounds or 11.8 % in one month. R18's Nutrition/Dietary noted dated February 8, 2025 shows, Resident with a weight loss of 16.5 pounds in one month or 11.8%. Body mass index is 18.3=underweight. Currently on a general regular diet with double protein at breakfast, shakes four times daily, magic cup twice a day .Suggest weekly weight x 4 to assure weight accuracy and three day calorie count. R18's Weights Summary shows that R18 was weighed on February 25, 2025 and February 26, 2025. There were no weekly weights documented for R18. On March 5, 2025 at 8:05 AM, R18 was sitting in the dining room eating breakfast. R18 did not have magic cup or a mighty shake with his meal. On March 5, 2025 at 10:37 AM, V7 Dietary Manager said R18 gets double protein. V7 said she did not know that R18 was supposed to get mighty shakes four times per day. On March 5, 2025 at 10:58 AM, V16 Dietitian said she has not seen or assessed R18 yet. V16 said she was notified of R18's weight loss and that R18 was on her list to see this week. R18's Care Plan initiated July 28, 2023 shows R18 has a nutritional problem or potential nutritional problem of low weight related to lack of nutrients and provide and serve supplements as ordered. 34490 2. On 3/3/25 at 12:30 PM, R24 was in her room eating lunch. R24 had a barbecue sandwich, coleslaw, bag of chips and a piece a cake for her meal. R24 did not have any yogurt with her meal. On 3/4/25 at 8:12 AM, R24 was in the dining room for breakfast. R24 was served cream of wheat, 3 pancakes, a sausage, milk and orange juice. R24 was not served yogurt. On 3/4/25 at 8:12 AM, V7 (Dietary Manager) said that all nutritional supplements that a resident is ordered to receive is on a list that is posted in the kitchen and should be provided during meals. V7 said that they do not have any residents with an order for super cereal (fortified cereal). On 3/4/25 at 8:44 AM, V7 said that R24 is supposed to get yogurt with every meal, but it wasn't put in the computer right so she has not been getting it. R24's Dietary Note dated 12/18/24 shows, Resident with weight loss of 22.8# in a month or 13%. Resident is on diuretics which may account for some of weight loss. Intakes recently decreased. Intakes 26 to 100%. Resident with set up and supervision at meals. Resident on a General regular texture diet with thin liquids, magic cup daily, yogurt at meals. Weight 149.5 # and BMI = 22. Suggest add super cereal and weekly weights R24's Weights and Vitals Summary printed on 3/4/25 shows that her weight was 172.3 pounds on 11/2/24 and on 12/3/24 she was 149.5 pounds (13% loss in 1 month). R24 was weighed again on 1/9/25, 2/16/25 and 2/25/25. R24's Physician's Order Sheet printed on 3/4/25 shows an order dated 4/11/23 for, General diet. Regular texture, Yogurt with meals .magic cup daily . There is no orders for weekly weights or supercereal. The facility provided Nutritional Supplement list printed 3/3/25 does not have R24 on the list to receive any nutritional supplements. R24's Meal Ticket shows that she likes hot cereal and yogurt. The meal ticket does not document any nutritional supplements that need to be provided. 47552 3. R5's Nutrition/Dietary note dated 2/8/25 written by V12 (Former Dietitian) recommended trying adding an appetite stimulant and increasing the daily oral nutrition supplement shake from once daily to BID (two times per day). R5's Order Summary Report dated 3/5/25 shows R5 is to receive an oral nutrition supplement shake once daily with a start date of 2/6/25. There are no additional orders showing supplementation was ever increased after V12's recommendations. On 3/5/25 at 10:56 AM, V16 (Registered Dietitian) said R5 experienced a significant weight change before V16 started working at the facility. V12's nutrition notes show the significant weight change was addressed at the time the weight change occurred. V16 said R5 has remained weight stable for about one month but V16 would hope that any recommendations made by V16 or other Dietitians would be followed and implemented. 40085 4. On 3/4/25 the morning breakfast service was observed between 8:10 AM and 8:35 AM. No residents including R34 were given any supplements with their trays. R34's 1/20/25 Dietary note written by V12 (former Dietician) shows that R34 had a significant weight loss of 13.7 lbs. 10% in 6 months and he should receive mighty shakes 2 times a day. R34's electronic medication administration summary shows that the mighty shakes should be given with breakfast at 8:00 AM and with dinner at 5:00 PM. A diet list of residents on nutritional supplements was provided during the breakfast service on 3/4/24 by V7 (Dietary Manager). The provided list shows R34 should receive mighty shakes twice a day. On 3/4/25 at 9:30 AM, R34 said, I have lost a lot of weight here, they used to give those shakes but I haven't gotten one in months. On 3/5/25 at 10:54 AM, V16 (Dietician) said I would hope residents get the supplements as ordered. The purpose of nutritional supplements is to prevent additional weight loss and for weight stabilization. The facility provided Weight Monitoring policy last revised on 10/2024 shows unintended weight loss may indicate a nutritional problem and the facility will implement and assess interventions to prevent and stabilize weight loss.

Based on interview and record review, the facility failed to offer the influenza vaccine at the start of influenza season for two of nine residents (R40, R4) reviewed for Influenza Vaccines in the sample of 18. This failure contributed to the facility experiencing an Influenza Outbreak and the hospitalization of R40 and R4. The findings include: 1. R40's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, anxiety disorder, major depressive disorder, bipolar disorder, and chronic pain. R40's MDS (Minimum Data Set) dated December 23, 2024 shows she is cognitively intact. R40's Progress Notes dated December 18, 2024 shows she was admitted to the local hospital with pneumonia and influenza A. R40's Hospital Records dated December 19, 2024 shows her admitting diagnoses were influenza A, pneumonia of right lower lobe due to infectious organism, and chronic obstructive pulmonary disorder exacerbation. R40 had new prescriptions for tamiflu (antiviral for influenza), prednisone (steroid), and levofloxacin (antibiotic). On March 5, 2025 at 11:40 AM, R40 said she did not remember what symptoms she was having when she got sent to the hospital. I was too out of it. R40 said she was not offered the influenza vaccine before she went to the hospital but would have taken the influenza vaccine if she was offered it. R40 said she received the influenza vaccine after she came back from the hospital. V19 RN (Registered Nurse) was nearby during this interview. V19 said she was the nurse that sent R40 to the hospital. V19 said she sent R40 to the hospital because R40 was having shortness of breath and coughing. V19 said the facility did not have the rapid result influenza tests. V19 said it was faster to send R40 to the hospital. V19 said R40 was diagnosed with influenza while at the hospital, but V19 suspected R40 had influenza while R40 was still at the facility. V19 said the facility usually administers the influenza vaccine in September, but V19 did not know why it was not administered until January this year. V19 said, I thought that was odd. R40's Vaccine Administration Record for the influenza vaccine shows that she signed the consent on December 30, 2024. The vaccine was administered to R40 on January 21, 2025. 2. R4's Admission Record dated March 4, 2025 shows she was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder, asthma, personality disorder, chronic obstructive pulmonary disease, acute and chronic respiratory failure, morbid obesity, and personal history of Covid-19. R4's Order Summary Report shows an order for may have annual flu vaccine with consent entered February 8, 2024. R4's local hospital records dated December 26, 2024 shows she was admitted to the hospital with influenza A. R4's Health Status Note dated December 29, 2024 shows, Contact and droplet isolation continues. Resident states she isn't feeling as bad as she did when she first went into the hospital. Resident states, 'I was feeling really bad before.' R4's Vaccine Administration Record-Immunization Consent Form 2024-2025 shows R4 signed the consent to received the influenza vaccine on December 30, 2024. The vaccine was administered on January 21, 2025. On March 5, 2025 at 11:33 AM, R4 said she had shortness of breath for about a week. R4 said she was sent to the hospital because it was not getting better. R4 said she got breathing treatments and steroids in the hospital. R4 said she got the influenza vaccine when she came back to the facility. R4 said the influenza vaccine was not offered before she went into the hospital. R4 said she would have taken the influenza vaccine prior to going to the hospital if the facility offered it. On March 4, 2025 at 12:56 AM, V2 DON (Director of Nursing) and V3 Infection Control Preventionist were interviewed together. V2 and V3 stated they both share the duties of the facilities Infection Control Program. V2 said she became the facility's DON in December 2024. V2 said the previous administrator was in charge of the immunizations. V2 said the influenza vaccine was given to the residents on January 21, 2025. V3 said the previous DON did not order the influenza vaccine at the beginning of the season. It fell through the cracks. V3 said the current administrator ordered the influenza vaccine that was administered in January 2025. V2 said the facility's influenza outbreak began December 13, 2024. V2 said there was a total of ten residents that had influenza. V2 DON said no residents were hospitalized with influenza. (R40 and R4 were hospitalized with influenza symptoms) On March 5, 2025 at 1:52 AM, V24 Director of Local Health Department said she got an email from the previous administrator at the facility reporting the influenza outbreak in December 2024. V24 said she assumed the facility gave their residents the influenza vaccine at the beginning of the influenza season in September/October due to the report of the influenza outbreak being in December. V24 said influenza vaccines can be given as early as September. V24 said that's when the influenza vaccine should be given, at the start of the season in September/October. V24 said there was no influenza vaccine shortage. In fact, we had a surplus of the influenza vaccine left over. V24 said. The facility's Influenza Congregate Setting Outbreak Log shows ten residents were positive for influenza from December 13, 2024-January 8, 2025. Only one resident was vaccinated with the influenza vaccine during the current influenza season, and that was when the resident was at a previous facility. R4's most recent vaccination date was 2023 and R40 was vaccinated January 27, 2024. The facility's Influenza Vaccination Policy revised January 2025 shows, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complication from influenza by offering out residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during the this period, or refuses to receive the vaccine. Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area.

Based on interview and record review the facility failed to assess and identify a change in condition for a resident after a fall. This failure resulted in a delay in identifying and obtaining treatment for R2's right hip fracture. This applies to 1 of 4 residents (R2) reviewed for injuries in the sample of 5. The findings include: R2's face sheet shows she has diagnoses including: Schizoaffective Disorder Bipolar Type, unspecified abnormalities of gait and mobility, unspecified dementia, and mild intellectual disabilities. R2's care plan shows she has altered mood and thought process relative to Bipolar disease and dementia, she is at risk for falls due to poor safety awareness and she requires staff assistance with her Activities of Daily Living (ADL's) including toileting and transfers. R2's Nursing Progress Notes includes a late entry documented by V15 (Registered Nurse/RN) that shows that R2 had a fall on 11/13/24 at 6:15 AM. R2 was in the dining room sitting and had a fall transferring herself from her wheelchair into a chair and fell on the floor. The Nursing Progress Note shows that staff assisted R2 to get off the floor and she was placed in a wheelchair and there was no skin concern noted at the time. The note additionally shows that R2 had been agitated at the time and nursing staff were attempting to calm her down. The next documentation or assessment in R2's Nursing Progress notes is on 11/14/24 at 5:46 PM, and it shows that R2 was not feeling well and remained in her room getting up out of bed into a wheelchair for a short period only. There is no documented assessment of R2's skin or any check from the fall on 11/13/24. On 11/15/24 at 2:53 AM, R2's Nursing Progress Notes documented by V14 (Licensed Practical Nurse/LPN) show that R2 was yelling out in pain with movement and one leg is shorter than the other and she was having right leg/hip pain. R2 was immediately sent to a local emergency room (ER) for evaluation and treatment. R2's hospital records show she was admitted to the hospital on 11/15/24 and diagnosed with a comminuted impacted right femoral neck (hip) fracture with swelling and a hematoma noted. R2 underwent a surgical procedure to repair her hip fracture. R2's hospital records show the facility had informed them that R2 had a fall on 11/11/24 but did not report to them fall on 11/13/24. R2's November 2024 Medication Administration Record (MAR) shows she received scheduled Tylenol for pain daily at 5:00 PM. R2's MAR has a pain scale assessment which shows on 11/13/24 her pain was a 5 but on 11/14/24 it is documented as a 0 on a 1-10 scale. On 11/18/24 at 10:10 AM, V15 (RN) said she was called to the dining room on 11/13/24 because R2 had a fall and was on the floor. V15 said she and another staff person whom she could not recall, lifted R2 up and put her in her wheelchair. V15 said she lifted up R2's skirt and looked at her skin but she did not see anything, and R2 was manic and agitated but did not complain of pain to her. V15 denied that anyone reported to her on 11/13/24 or 11/14/24 that R2 had begun complaining of her legs hurting. V15 said it is protocol to chart for 72 hours after a fall, and she thinks she checked R2 on 11/14/24 but did not document any body assessment. V15 said R2 is not someone who would be able to get herself off the floor without staff assistance unless she had something to hold on to and pull herself up. On 11/18/24 at 10:30 AM, R4 said he was in the dining room sitting near R2 when R2 had her fall on both days 11/11/24 and 11/13/24. R4 said R2 was mad and yelling out that day on 11/13/24 and did not want to sit in a wheelchair so she tried to transfer herself and fell . R4 said R2 fell on her side and landed on her hip. R4 said staff came immediately and helped her up into her wheelchair. On 11/18/24 at 10:50 AM, V6 (Certified Nursing Assistant/CNA) said she was caring for R2 on 11/13/24 after her fall until 6:00 PM. V6 said after the fall R2 was complaining of her legs hurt and she did not want to go to the dining room to eat because of it. V6 said she did not report R2's complaint to the nurse because it was typical for her, and she assumed it was because she was up in her wheelchair. On 11/18/24 at 12:36 PM, V16 (CNA) said she worked from midnight of 11/13/24 until 6:00 AM on 11/14/24 and cared for R2. V16 said R2 was still up in her wheelchair when she came on her shift. V16 said R2 would not let her put her to bed and she stayed in her chair overnight with her leg propped up on her bed. V16 did not see R2's hip or leg but R2 was complaining of her leg hurting. V16 said she and another CNA stood R2 briefly to change her underpants and sat her right back down. V16 said she did not tell the night nurse about R2 being up or complaining of her legs hurting because she assumed the nurse knew. V16 also said she was not aware that R2 had a fall on 11/13/24 or she would have went and told the nurse that R2 would not go to bed and her legs hurt. On 11/18/24 at 11:23 AM, V11 (CNA) said R2 was lackluster on 11/14/24 and she did not want to get out of bed. She was having trouble bearing weight when they transferred her, and she kept saying her legs hurt. V11 said R2 did not want to eat lunch and was whining during a transfer and having a hard time bearing weight. V11 said R2 was also incontinent at the dining table and that was not usual for her. V11 said she notified the day nurse V15 of the changes for R2 and her complaining of her leg hurting. V11 said she did not notice any bruising or issue with R2's hip. On 11/18/24 at 10:57 AM, V12 (CNA) said she worked overnight 11/14/24 into the morning of 11/15/24 and provided care to R2. V12 said she and another CNA took R2 to the bathroom and R2 was having a hard time standing so she got her into bed and pulled her pants down to look at her legs and hip and noticed her hip was not right it didn't seem to be in place, so she went and immediately got V14 (LPN) who sent R2 to the ER. On 11/18/24 at 1:09 PM, V14 (LPN) said she could hear R2 yell out when the CNAs were turning her so she went to the room. She assessed R2 and noticed that R2's right leg was rotated in, and she suspected R2 had a broken hip. V14 said she was not aware that R2 had a fall on 11/13/24 she was only aware of the fall on 11/11/24. V14 said after a fall the protocol is for the resident to be reassessed every shift for 72 hours. On 11/18/24 at 1:30 PM, V9 (R2's Physician) said he was notified that R2 had a fall on 11/13/24 but was not notified that she had a change in condition including trouble with weight bearing and complaining of leg pain. V9 said he would have had R2 sent to the ER for evaluation had he been notified sooner. V9 said a fall is consistent with the type of fracture R2 has. V9 said R2 could have been able to still transfer if she put the bulk of her weight on the other leg but this fracture would be painful. V9 said R2 complains of a lot of things and pain is a common complaint of hers. V9 said with no other clear evidence or reason it is likely R2 hip fracture is from her fall on 11/13/24. V9 also said it is likely she did not yet having any bruising to her hip so staff may not have seen any. V9 said he would expect the facility to follow protocol and if they are supposed to assess for 72 hours after a fall, they should be doing that. The facility provided Fall Prevention and Management Policy last reviewed on 1/2024 shows after a fall nurses should document on the resident for 3 days after to include physical assessments including range of motion, pain, vital signs, and any new interventions that will be implemented post fall. The same policy also states the Director of Nursing or designee will read the reports and nurses notes and make sure all supporting documentation is in the medical record.

Based on interview and record review the facility failed to treat a resident's pain as ordered by the physician. This applies to one of three residents (R1) in the sample of three reviewed for pain. This failure resulted in R1 saying that being without his pain medications affects him both physically and emotionally. R1 said he was feeling shaky and nauseated. The findings include: The facility face sheet shows R1 was admitted to the facility for diagnoses to include spinal stenosis, bipolar disorder, and depression. The facility assessment dated [DATE] shows R1 to be cognitively intact. The Physician Order Sheet for September 2024 for R1 shows an order for Norco oral tablet one tablet by mouth four times a day for back pain. On 9/12/24 at 9:40 AM, V3 (Registered Nurse/RN) said when she worked on Tuesday 9/3/24, R1 was out of his prescribed pain medication Norco. V3 said a new prescription was needed from the Physician in order to get the medication from the pharmacy. V3 said she began this process right away, but the faxes were not going through to the Physician. On 9/12/24 at 10:20 AM, V1 (Administrator) said when she came to work that Tuesday 9/3/24 and heard R1 was out of his pain medications and had been for a few days, she called the Physician's office herself to try and get the situation resolved. V1 said the faxes were not going through to the Physician's office. On 9/12/24 at 10:40 AM, V2 (Director of Nursing/DON) said R1 came to her on Tuesday 9/3/24 and told her he had been without his pain medications since Sunday 9/1/24. V2 said R1 appeared anxious and tired when he came to talk to her. V2 said she could not find any documentation that shows the nurses tried to get a refill of R1's pain medication until she came in on Tuesday 9/3/24. V2 said the nurses should be requesting the prescription from the Physician and getting the new order to the pharmacy before the resident runs out of a medication. V2 said there must be very poor communication between the nurses for this to have happened. On 9/12/24 at 11:30 AM, R1 said on the Friday before Labor Day he asked the nurse if he had enough Norco to get through the holiday weekend and was told he did. R1 said then on Sunday the nurse told him he had run out of Norco. R1 said on Tuesday he spoke with the DON and the Administrator and told them he had not had any of pain meds since Sunday, and they told him the nurses could get the medications out of the convenience box. R1 said he heard the DON tell V3 (RN) to get him a Norco from the convenience box, but no one ever did. None of the nurses offered to. R1 said being without his pain medications affects him both physically and emotionally. R1 said he was feeling shaky and nauseated by the time he finally got the pain medication on Wednesday. On 9/12/24 at 12:25 PM, V6 (RN) said she had given the last Norco to R1 on 9/1/24 at 5:00 PM and she was not sure if a refill had been requested so she passed the information on to the next shift. The controlled substance proof of use forms for R1's Norco dated 8/16/24 shows the last Norco was given on 9/1/24 at 5:00 PM. The controlled substance proof of use form dated 9/4/24 for R1 shows a dose of Norco was given at 11:58 PM to R1. R1 missed 12 doses of his prescribed pain medication. The nursing progress notes dated from 9/1/24 to 9/4/24 shows the Norco was not given due to the medication being on order. The care plan for R1 with a revision date of 4/8/24 shows R1 is prescribed pain medications due to back pain and the interventions include administer prescribed pain medications. The facility policy with a review date of 6/24/21 for medication administration shows medications shall be administered in a safe and timely manner as prescribed. The facility said they do not have a policy for pain when one was requested.

Based on observation, interview and record review, the facility failed to ensure a resident at high risk for elopement did not leave the facility unsupervised for 1 of 3 residents (R1) reviewed for elopement in the sample of 14. This failure resulted in an Immediate Jeopardy. The facility failed to ensure resident safety by timely and accurate documentation of resident monitoring for 14 of 14 residents (R1-14) reviewed for frequent monitoring (15-minute checks) in the sample of 14. The findings include: The Immediate Jeopardy began on 6/18/24 at 11:41 AM when R1 was not visually located in the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 6/28/24 at 8:46 AM. The surveyor confirmed by interview and record review that the immediacy was removed on 6/28/24, but non-compliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. 1. R1's face sheet showed a [AGE] year-old female with diagnosis of Alzheimer's Disease, delirium, vascular dementia, psychotic disorder, and major depressive disorder. R1's 6/23/23 care plan showed to monitor the resident every 15 minutes. R1's 10/5/23 social services note showed 9/2023 behaviors displayed included elopement, wandering, and exit seeking. R1's 2/2/24 and 5/2/24 elopement assessments showed she was at high risk for elopement. R1's 3/29/24 behavior note showed she exited the facility through the A wing door. R1's 5/2/24 cognitive assessment showed she had severe cognitive impairment. R1's 6/18/24 15-minute check log showed no checks from 12:58 AM-4:50 AM, 4:52 AM-9:30 AM, and 9:34 AM-11:25 AM. This record showed 11:26 AM as the last 15-minute check documented prior to R1's exit from the facility. R1's June 2024 behavior monitoring documentation showed she was checked once on 6/1, three times on 6/2, once on 6/3, three times on 6/4, twice on 6/5, twice on 6/6, twice on 6/7, once on 6/8 and wandering was noted, three times on 6/9 with wandering noted, once on 6/10, once on 6/11, twice on 6/12 with elopement/exit seeking behavior noted, three times on 6/13, twice on 6/14, twice on 6/15, once on 6/15, twice on 6/16 with worsened behaviors noted, once on 6/17, and once on 6/18/24. R1's last 6/18/24 documented check was at 11:26 AM (prior to return from the hospital). The local police department 6/18/24 report showed a call was received from a passerby at 12:03 PM. This report showed concern due to the heat and an elderly female walking eastbound on Highway 38 in front of (local restaurant). This report showed the passerby dropped the elderly female off at the police department and appeared disoriented and unaware of where she was. Due to the extreme heat for an unknown amount of time, the local fire department was called to the station. While speaking with the fire department the female was unable to provide any information as to her residence, telephone number, date of birth and claimed she called police but did not have a cell phone with her. The local fire department's 6/18/24 report showed they were dispatched to the police department at 12:38 PM and arrived at the local emergency room at 12:58 PM. This report showed R1 was found along Route 38 near (local restaurant) and suspicion for dementia and being lost was raised. R1 was dressed in a t-shirt, cardigan, and slippers. R1 was insistent she was in Aurora, had no personal effects, was speaking erratically and was confused. R1 was transported to the local community emergency room . R1's local emergency room record showed she was admitted on [DATE] at 1:04 PM with altered mental status. R1 was confused, alert, unsure of time and place, and gave two different names when asked who she was. This record showed she was found wandering on the side of the road. This record showed at 1:19 PM, staff from the facility presented at the bedside. At 1:39 PM, R1 was discharged back to the facility with staff. R1's 6/18/24 12:47 PM health status note (created 6/18/24 at 7:24 PM) showed R1 returned to the facility (was not discharged from ER until 1:39 PM) accompanied by staff. 15-minute checks to continue with upgrade to 1:1 if resident has increased exit seeking behaviors (i.e., stating she will leave to see family). Referrals made to memory care facilities due to this increased behavior by social services/management. There was no documentation in R1's record showing elopement on 6/18/24. The June 18, 2024, at 12:54 PM weather record showed a temperature of 91 degrees Fahrenheit, humidity level of 52% creating a heat index of at least 96 degrees Fahrenheit. An internet search showed (local restaurant) is 0.3 miles from the facility. Route 38 is a busy 4 lane undivided highway between Interstate 39 and Illinois Route 251. On 6/26/24, R1 was observed wandering in the facility. R1 was alert and oriented to person only. R1 was discharged from the facility at approximately 12:05 PM to a facility with a locked unit. On 6/26/24 at 8:45 AM, V8 (Registered Nurse/RN) said R1 constantly roams, is usually on 15-minute checks and a lot of times is a sitter (required 1:1 observation). R1 believes she owns the building and opens exit doors. On 6/26/24 at 8:50 AM, V9 (RN) said R1 has wandering as a baseline behavior and has dementia. V9 said on 6/18/24 about 12:40 PM, V12 (V9's family member) called her as she was working in the facility. She asked if we were missing a resident as she picked someone up by (local restaurant) because they looked confused and was walking around with a cardigan on. V12 told her the person said they were on their way to Aurora to see their dad. V9 said V12 told her she took R1 to the police department. V9 said she asked for a description and it matched R1. V9 said she notified V1 of the information. V9 said R1 was a high elopement risk and had gotten out of the facility multiple times. V9 said R1 thinks we're all in her house and doesn't know what we are doing there. On 6/26/24 at 8:59 AM, V10 (CNA) said she was assigned R1's hall on 6/18/24. V10 said she was passing room lunch meal trays to all the halls when a search for R1 was initiated. Passing room trays can take 20-45 minutes depending on what assistance the residents need. Whoever is in the dining room is responsible to ensure all residents come to meals and are accounted for when the CNA is passing room trays. I would still do the documentation (for 15-minute checks) even though I was passing trays. I saw R1 last at 12:00 PM in her room. It's everybody's responsibility to account for the residents. If R1 wasn't in the dining room, someone should have looked for her. On 6/26/24 at 9:07 AM, V4 (Business Office Manager/BOM) said on 6/18/24, she became aware R1 was not in the building around 12:30 PM during or after lunch. R1 had set door alarms off and tried to get out the door in the past. She says she's going to her parents' house in Aurora. V4 said she went to the police department around 12:30 PM and was told R1 was transferred to the local hospital. V4 said she went to the local hospital and brought R1 back to the facility. On 6/26/24 at 9:30 AM, V1 (Administrator) said on 6/18/24, R1 went out one of doors, the A wing door. It was hot and humid that day. There were temporary alarms on the doors. The facility's alarm vendor couldn't come to the facility until 6/19/24. They replaced the keypad on the front door and the fuse that operated the exit door alarm system. V6 (Maintenance Director) does weekly checks on the door alarms. R1 hasn't had exit seeking behaviors since I've been here. She talks about visiting her parents. I haven't known of her to attempt to leave the facility. An attempted elopement or elopement should be documented if you lose sight of the resident. R1 was on 15-minute checks when the elopement happened. When she returned to the facility, I had staff document their 15-minute checks on a paper log. R1 has been accepted to another facility which has a locked unit. She's being transferred there today. On 6/26/24 at 9:40 AM, exit door alarms were checked by V1. The temporary alarms on each door could be disengaged by moving a tab. On 6/26/24 at 10:58 AM, V5 (Dietary Manager) said lunch is served around noon and room trays are brought out at that time. On 6/26/24 at 11:47 AM, V6 (Maintenance Director) said on 6/11/24 he noticed the exit door to his shop wasn't working so he checked all the facility's exit doors. None of the door alarms were working except the door in the main dining room. V6 said he placed temporary door alarms on all exit doors on 6/11/24. V6 said he checks the door alarms weekly and he was not aware R1 had eloped on 6/18/24. The alarms must have been going off. On 6/26/24 at 12:05 PM, V11 (Certified Nursing Assistant/CNA) was passing room trays. On 6/26/24 at 12:12 PM, V11 (CNA) said it takes about 20-25 minutes to pass room trays. On 6/26/24 at 12:46 PM, V13 (head CNA) said if a door alarm is going off you should notify another person, go to the door, and check to see if anyone is outside. V13 said she worked 6/18/24. R1 looks out the front door and says she must get her dog or family members. V14 (CNA) worked 6/18/24 but she's on a plane right now. V15 (Registered Nurse/RN) worked too. On 6/26/24 at 12:50 PM, V10 (CNA) said nobody is assigned your resident checks when you are passing trays. Each is responsible for their own hall. I'm not sure what time they said R1 was missing. I did C wing head counts. On 6/26/24 at 12:58 PM, V1 (Administrator) said it takes about 20 minutes to walk to (local restaurant) from here. We don't really know what door R1 went out. On 6/26/24 at 1:24 PM, V7 (Activity Director) said it takes about 10 minutes to walk to the shopping center where (local restaurant) is located. V7 said on 6/18/24 before lunch R1 said she was looking for her mom and needed to get back to Aurora. R1 does that at least 3-4 times a month. I've seen her go out the front door before. On 6/26/24 at 2:20 PM, V13 (head CNA) said after lunch they began to do a head count. V13 can't remember what time it was but said they were cleaning the dining room. On 6/26/24 at 2:21 PM, V2 (Director of Nursing/DON) said whoever is assigned a resident's hall is responsible to do checks on those residents and document it at the time. If it's not documented, we can't prove it was done. If 15-minute checks are not done, a resident could be gone for an extended period, could cause harm and death. The DON and Administrator are responsible to ensure frequent resident checks are done. We received a phone call on 6/18/24 which prompted a resident head count. They were already looking for R1 since she didn't show up for lunch. Lunch starts around noon. It would take R1 5-7 minutes to walk to (local restaurant). I personally went to (Commercial Store) on 6/11/24 and purchased temporary door alarms. Two alarm packages were purchased, and each package contained four alarms. V6 installed them that day. The facility provided 6/11/24 (Commercial Store) receipt showed the alarms were purchased at 3:21 PM. On 6/26/24 at 2:30 PM, V1 said she did not contact any other alarm vendors. V1 said due to the bankruptcy we aren't supposed to add any new vendors. Corporate knew the alarms were down. We have a lack of equipment. There aren't enough tablets for staff to document their checks as they're being done. The CNAs word is the only proof I can provide that 15-minute checks are being done. On 6/26/24 at 2:59 PM, R5 said sometimes staff check on her every 15 minutes but not all the time. On 6/26/24 at 3:02 PM, R13 said no, staff don't check on him every 15 minutes. It's more like every 8 hours. On 6/26/24 at 3:03 PM, R6 said they (staff) check on me at night to make sure I'm still breathing. I could lay here for hours, and nobody comes in. On 6/26/24 at 3:06 PM, R8 said no, staff don't do 15-minute checks. They check in on me maybe every hour when I'm in my room. On 6/27/24 at 9:53 AM, V1 (Administrator) said the police were not notified of a missing resident. When the facility received a phone call at 12:46 PM, they became aware the resident was at the police station. The facility began a search for R1 on 6/18/24 at 12:15 PM when R1 could not be located to come to lunch. V1 confirmed there was no medical record evidence of R1's elopement on 6/18/24 or of an assessment upon her return. V1 said it was safe to say policies were not followed regarding door alarms and 15-minute checks. When the phone call was received there were still a couple of residents, including R1 that needed to be accounted for. The facility provided list of residents on 15-minute checks as of 6/26/24 at 10:16 AM included R1-R14. 2. R2's face sheet showed a [AGE] year-old male with diagnosis of dementia, traumatic brain injury, restlessness and agitation, chronic viral hepatitis C, adjustment disorder with anxiety, heart disease, hypertension, and epilepsy. R2's 2/27/24 care plan showed he had wandering behaviors and may demonstrate a risk for leaving the facility unattended/elopement related to impaired safety awareness. This care plan showed to monitor his location every 15 minutes. R2's 6/26/24 15-minute monitoring form (printed at 1:45 PM) showed he was checked at 3:26 AM, 3:27 AM, 4:56 AM, 8:48 AM, 8:50 AM, 9:28 AM, 9:50 AM, 10:33 AM, and 1:05 PM. 3. R3's face sheet showed a [AGE] year-old female with diagnosis of psychosis, altered mental status, history of physical and sexual abuse, dementia, and hypertension. R3's 6/23/23 care plan showed she is/has the potential to be inappropriate at times with actions and to monitor every 15 minutes. R3's 6/26/24 15-minute monitoring form (printed at 2:16 PM) showed she was checked at 1:46 AM, 1:47 AM, 4:12 AM, 4:13 AM, 4:54 AM, 8:47 AM, 8:48 AM, 9:28 AM, 9:50 AM, 10:33 AM, 1:04 PM, 1:05 PM, and 2:14 PM. 4. R4's face sheet showed a [AGE] year-old female with diagnosis of schizoaffective disorder, bipolar disorder, pervasive developmental disorder, autistic disorder, anxiety disorder, post-traumatic stress disorder, major depressive disorder, and psychotic disorder. R4's 5/26/23 care plan showed she is known/has history of inappropriate behavior of meeting men online, having them visit her in the facility, and engaging in sexual activity. A 5/26/23 care plan intervention showed to conduct 15-minute checks. R4's 6/28/24 15-minute check documentation (printed at 6/26/24 at 2:14 PM) showed entries for 3:26 AM, 3:27 AM, 4:46 AM, 8:48 AM, 8:50 AM, 9:28 AM, 9:50 AM, 10:33 AM, and 1:05 PM. 5. R5's face sheet showed a [AGE] year-old female with diagnosis of schizoaffective disorder, bipolar type, Picks disease, intellectual disabilities, pseudobulbar affect, psychosis, dementia, encephalopathy, anxiety disorder, and hypertension. R5's 8/18/23 care plan showed she suffered a fall and may be related to lack of safety awareness and poor balance. This care plan showed to monitor her every 15 minutes. R5's 6/26/24 15-minute check documentation (printed at 2:15 PM) showed entries for 1:31 AM, 4:05 AM, 4:43 AM, 5:00 AM, 6:08 AM, 6:59 AM, 7:00 AM, 8:21 AM, 8:30 AM, 9:10 AM, 9:23 AM, 9:32 AM, 9:48 AM, 10:40 AM, 11:11 AM,12:31 PM, 12:48 PM, 1:11 PM, 1:16 PM, 2:02 PM, and 2:15 PM. 6. R6's face sheet showed a [AGE] year-old female with diagnosis of anxiety disorder, insomnia, asthma, rheumatoid arthritis, personality disorder, post-traumatic stress disorder, morbid obesity, hypertension, and peripheral neuropathy. R6's 9/29/23 care plan showed she had risk factors for self-harm and to ensure her safety. This care plan showed R6 was to be supervised on 15-minute checks. R6's 6/26/24 15-minute safety check documentation (printed at 2:15 PM) showed entries for 1:38 AM, 1:39 AM, 4:12 AM, 4:53 AM, 6:08 AM, 6:09 AM, 6:59 AM, 7:00 AM, 8:22 AM, 8:30 AM, 9:10 AM, 9:23 AM, 9:32 AM, 9:48 AM, 10:40 AM, 11:11 AM, 12:32 PM, 12:48 PM, 1:11 PM, 1:16 PM, 2:02 PM, and 2:15 PM. 7. R7's face sheet showed a [AGE] year-old male with diagnosis of schizophrenia, hypertension, epilepsy, schizoaffective disorder, bipolar type, anxiety disorder, and psychosis. R7's 6/23/23 care plan showed he is or has potential to be inappropriate at times with communication and actions. This care plan showed to monitor him every 15 minutes. R7's 6/26/24 15-minute monitoring documentation (printed at 2:16 PM) showed entries for 1:35 AM, 4:08 AM, 4:50 AM, 6:10 AM, 7:01 AM, 8:28 AM, 8:31 AM, 9:11 AM, 9:24 AM, 9:32 AM, 9:48 AM, 10:41 AM, 11:12 AM, 12:39 PM, 12:40 PM, 12:49 PM, 1:12 PM, 1:16 PM, 2:04 PM, and 2:16 PM. 8. R8's face sheet showed a [AGE] year-old female with diagnosis of schizoaffective disorder, major depressive disorder, paranoid schizophrenia, type 2 diabetes, anxiety disorder, bipolar disorder, auditory hallucinations, and obesity. R8's 6/23/23 care plan showed she had impaired ability to understand boundaries and respect for personal property and to monitor her every 15 minutes. R8's 6/26/24 15-minute safety check documentation (printed at 2:17 PM) showed she was checked at 3:29 AM, 3:30 AM, 4:57 AM, 6:13 AM, 9:22 AM, 9:23 AM, 9:24 AM, 9:47 AM, 1:05 PM, and 1:06 PM. 9. R9's face sheet showed a [AGE] year-old female with diagnosis of type 2 diabetes, paranoid schizophrenia, morbid obesity, chronic obstructive pulmonary disease, dementia, mixed anxiety disorders, bipolar disorder, and major depressive disorder. R9's 6/23/23 care plan showed she was or had the potential to be inappropriate at times with communication and attire. This care plan showed to monitor her every 15 minutes. R9's 6/26/24 15-minute monitoring (printed at 2:17 PM) showed she was checked at 1:48 AM, 3:24 AM, 3:25 AM, 4:14 AM, 4:55 AM, 8:48 AM, 8:51 AM, 9:28 AM, 9:30 AM, 9:50 AM, 10:33 AM, 1:05 PM, and 2:16 PM. 10. R10's face sheet showed a [AGE] year-old male with diagnosis of polyosteoarthritis, major depressive disorder, hypertension, sepsis, dementia, anxiety disorder, cerebral infarction, and repeated falls. R10's 7/21/23 care plan showed he was at risk for falls and to check him every 15 minutes. R10's 15-minute safety check documentation (printed at 2:18 PM) showed he was checked at 1:34 AM, 1:35 PM, 4:07 AM, 4:08 AM, 4:49 AM, 4:50 AM, 6:09 AM, 6:59 AM, 7:00 AM, 8:23 AM, 8:30 AM, 9:10 AM, 9:24 AM, 9:32 AM, 9:48 AM, 10:40 AM, 10:41 AM, 11:11 AM, 11:12 AM, 12:34 PM, 12:35 PM, 12:48 PM, 1:11 PM, 1:16 PM, 2:03 PM, and 2:15 PM. 11. R11's face sheet showed a [AGE] year-old female with diagnosis of schizoaffective disorder, anxiety disorder, alcoholic polyneuropathy, homicidal ideations, chronic obstructive pulmonary disease, psychosis, and paranoid schizophrenia. R11's 6/23/23 care plan showed she was or had potential to be inappropriate at times with communication and actions. This care plan showed to monitor her every 15 minutes. R11's 6/26/24 15-minute safety check documentation (printed at 2:18 PM) showed she was checked at 1:31 AM, 1:32 AM, 4:06 AM, 4:44 AM, 4:45 AM, 6:09 AM, 7:00 AM, 8:24 AM, 8:30 AM, 9:10 AM, 9:24 AM, 9:32 AM, 9:48 AM, 10:41 AM, 11:12 AM, 12:36 PM, 12:48 PM, 1:11 PM, 1:16 PM, 2:03 PM, and 2:16 PM. 12. R12's face sheet showed a [AGE] year-old male with diagnosis of schizoaffective disorder, type 2 diabetes, hypertension, chronic obstructive pulmonary disease, bipolar disorder, Alzheimer's Disease, Parkinson's Disease, and major depressive disorder. R12's 6/23/23 care plan showed he had the potential to be inappropriate at times with communication and actions. This care plan showed to monitor him every 15 minutes. R12's 6/26/24 15-minute safety check documentation (printed at 2:19 PM) showed he was checked at 1:37 AM, 4:10 AM, 4:15 AM, 4:52 AM, 6:09 AM, 7:00 AM, 8:25 AM, 8:26 AM, 9:10 AM, 9:11 AM, 9:24 AM, 9:32 AM, 9:48 AM, 10:41 AM, 11:12 AM, 12:37 PM, 12:48 PM, 1:11 PM, 1:16 PM, 2:03 PM, and 2:16 PM. 13. R13's face sheet showed a [AGE] year-old male with diagnosis of paranoid schizophrenia, ataxia, osteoarthritis, cognitive communication deficit, type 2 diabetes, hypertension, anxiety disorder, personality disorder, and traumatic brain injury. R13's 6/23/23 care plan showed he had the potential to be inappropriate at times with communication and actions. This care plan showed to monitor him every 15 minutes. R13's 6/26/24 15-minute safety check documentation (printed at 2:20 PM) showed he was checked at 1:36 AM, 4:09 AM, 4:10 AM, 4:51 AM, 5:00 AM, 6:10 AM, 7:01 AM, 8:29 AM, 8:31 AM, 9:11 AM, 9:24 AM, 9:32 AM, 9:48 AM, 10:41 AM, 11:12 AM, 12:40 PM, 12:46 PM, 12:47 PM, 1:12 PM, 1:16 PM, 2:04 PM, 2:05 PM, and 2:16 PM. 14. R14's face sheet showed an [AGE] year-old female with diagnosis of schizophrenia, bipolar disorder, adjustment disorder, anxiety disorder, cerebral infarction, major depressive disorder, abnormalities of gait and mobility, impulse disorder, and conversion disorder. R14's 6/23/23 care plan showed she was a high fall risk and to do safety checks every 15 minutes. R14's 6/26/24 15-minute safety check documentation (printed at 2:20 PM) showed she was checked at 3:25 AM, 3:26 AM, 4:14 AM, 4:55 AM, 8:48 AM, 8:51 AM, 9:28 AM, 9:50 AM, 10:33 AM, 1:05 PM, 1:11 PM, and 1:12 PM. The facility's undated Resident Monitoring Policy showed the facility may initiate monitoring of residents as a nursing measure to assist in providing safety to residents that are identified to be a potential threat to self or others or an elopement risk. Initiate resident monitoring and document date, time, resident. Behavior, location and (as required) response to interventions. Continue resident monitoring until the Interdisciplinary Team (IDT) can determine the status of the resident and develop appropriate measures for intervention for the resident. The facility's 5/2021 Elopement/Missing Resident Policy and Procedure showed the facility will take reasonable precautions to prevent resident elopement. Notify law enforcement officials and request assistance if the resident is not located on the facility premises. The facility's undated Elopement Policy showed the facility will provide a secure environment in which residents incapable of responsibility for self are protected from wandering outside the facility unattended. If resident absent more than 20 minutes, notify law enforcement. The charge nurse shall complete an incident report, and document all observation, and occurrences in the medical record. The surveyor confirmed by interview and record review that the immediacy was removed on 6/28/24 when the facility took the following actions: 1.) All residents residing in the facility had Elopement Risk Assessment reviewed per the QA team. Those with a High Risk were verified to have their picture and identifiers completed and placed in the Elopement Binder maintained at the nurse's station. 2.) The facility QA team reviewed/revised the Plan of Care for each individual with a High-Risk Assessment. 3.) All staff in the facility are identified as responsible for resident's safety. 4.) All staff was in-serviced by the facility Administrator regarding the facility Door Alarm Policy and the responsibility of all staff to ensure the exit door alarms are activated at all times. 5.) All staff was in-serviced by the facility Administrator regarding the facility Elopement Policy/Procedures. 6.) All staff was in-serviced by the facility Administrator regarding Missing Resident Policy/Procedures. 7.) All staff was in-serviced by the facility Administrator regarding 15-minute check Policy/Procedures. 8.) Paper logs for 15-minute checks moving on residents on 15-minute checks and one on ones. 9.) During meal services a CNA not conducting hall trays will take over the 15-minute checks during the meal hall pass. 10.) CNAs in the dining rooms will chart the 15-minute checks while that resident is in the dining room. 11.) Facility maintenance personnel will continue to check door alarms weekly. 12.) Facility maintenance personnel will randomly throughout their shift monitor doors to ensure they are engaged. 13.) All staff will be educated during the orientation period of employment as to how to properly turn on and off exit door alarms and to those with elopement risk and location of the information. 14.) Director of Nursing or designee will be responsible for coordination the completion of QA audits to ensure ongoing performance improvement with 15-minute checks and documentation weekly for three months then evaluated by QAPI committee for further audit schedule as needed. 15.) Trends and/or concerns will be reported to the QAPI committee for review and identification of changes in monitoring based on outcomes. 16.) Staff will be in-serviced upon hire and annually to ensure continued compliance.

Based on interview and record review the facility failed to thoroughly assess a resident (R1) following an injury of unknown origin. This failure resulted in a delay in identifying and obtaining medical treatment for a clavicle fracture. This applies to 1 of 3 residents (R1) reviewed for resident injury in the sample of 4. The findings include: R1's face sheet shows she has diagnoses including Pick's Disease, Mental Disorder, Schizoaffective Disorder Bipolar Type, Mild Intellectual Disability, Anxiety Disorder, and Displaced Fracture of the Shaft of Right Clavicle. R1's active Care Plan shows the following: She has impaired cognition and altered mood and thought process with behavioral changes. R1 has a self-care deficit and requires staff assistance with her activities of daily living (ADL's) including toileting, transferring, and bathing. On 4/19/24 R1's care plan was updated to show R1 has a right mid clavicle fracture and requires her to wear a sling to her right arm and use a wheelchair for mobility. On 4/30/24 at 7:55 AM, R1 was sitting in a wheelchair in the dining area of the facility. She had her right arm in a sling. R1 told this surveyor she fell into the bathtub in her room and broke her arm. R1 said the injury was painful and her arm hurts. R1's shower sheet dated 4/12/24 completed by V7 (Certified Nursing Assistant/CNA) shows findings of bruising on her right shoulder. The body diagram on the form shows scribbled lines on the right chest above the clavicle to reflect the area where R1's bruising was. The shower sheet dated 4/12/24 was cosigned by V6 (Registered Nurse/RN). There is no documentation in R1's Electronic Medical Record (EMR) in the nursing progress notes or any assessment of a bruise or injury to R1's shoulder until 4/18/24. A nursing note completed on 4/18/24 by V6 shows R1 came to her and informed her that her shoulder hurt. When V6 examined R1's shoulder there was swelling, and yellowish bruising noted. The note shows R1 reported having a fall in her bathroom, over a week ago, getting herself up from her toilet and fell forward into her bathtub. R1's physician was contacted and an order for an X-ray was obtained. An X-ray report dated 4/18/24 shows R1 has a superior angulated comminuted oblique fracture of the mid right clavicle. R1's progress notes show R1 went out to an orthopedic follow up appointment on 4/19/24 and the Orthopedic follow up note for R1 shows R1 should wear a sling daily until follow up and cannot use her walker. On 4/30/24 at 8:15 AM, V5 (RN) said she was unable to recall the exact date, but she did notice a yellowish bruise on R1's right chest/shoulder area. She believes it was about a week prior to when it was discovered that R1 had a fractured clavicle (which was on 4/18/24). She said she at the time she saw the bruising she asked R1 what happened and R1 responded she fell in her bathroom; she asked her if it hurt and R1 said no. V5 denied seeing any bump or lump to R1's chest area. On 4/30/24 at 9:50 AM, she said when she looked at R1's bruising she didn't do a full assessment and she should have investigated it further. V5 said she is at the facility all the time and works a lot of shifts. On 4/30/24 at 1:50 PM, V5 clarified for this surveyor that she did not go back and assess R1's bruising any further because she knew it was there, and she did not document the injury in R1's EMR. Facility provided staffing schedules show V5 worked at the facility on the following dates: 4/12/24, 4/14/24, 4/15/24, 4/16/24, 4/17/24 and 4/18/24. On 4/30/24 at 9:40 AM, V6 (RN) said she was not aware that R1 had a bruise or an injury until 4/18/24 when it was reported to her. She then went to assess R1's shoulder and found a large yellowish fading bruise with a lump to the right chest/ clavicle region. R1 told V6 she had a fall a week ago in her room. V6 then called V3 (R1's Primary Care Physician) and obtained orders for an X-ray which showed R1 had a fractured clavicle. On 4/30/24 at 1:35 PM, this surveyor showed V6 R1's shower sheet dated 4/12/24 which was completed by V7 (CNA) that was signed off by her showing a large yellow bruise to R1's shoulder and written on the shower sheet was bruise on RT shoulder. V6 verified it was her signature on the sheet but said she did not go and assess the bruising to R1's shoulder. V6 said sometimes they just sign off on the shower sheets and she did not notice it said about R1 having a bruise. V6 said It's my fault I should have looked into it that day because the bump was probably worse, and I could have called for an X-ray sooner. V6 did not document anything in R1's EMR prior to 4/18/24 about the bruising/injury. On 4/30/24 at 1:30 PM, V7 (CNA) said she gave R1 a shower on 4/12/24 and noticed a large yellowish bruise on her right shoulder. V7 said she also could feel a slight lump on R1's shoulder. V7 said she cannot recall what nurse she told, but she did tell them about the bruise and lump, and they told her it was an old bruise from a fall. On 4/30/24 at 10:30 AM, V4 (Nurse Practitioner) said many factors can come into play but typically bruises start out as purple in color and then fade to yellow, and a yellowish bruise would be consistent with an injury 5-9 days old. V4 said at minimal staff should notify the residents physician, do a complete assessment, check for pain, and check for range of motion. V4 said a clavicle fracture is very painful and the primary treatment is to immobilize the arm. V4 said a clavicle fracture could be the result of a fall especially if the resident reports having a fall. On 4/30/24 at 12:05 PM, V3 (R1's Primary Care Physician) said he was not notified of any injury or fall for R1 until 4/18/24 when the facility nurse called him about bruising and swelling to R1's right shoulder. He said he ordered an X-ray that day and would have ordered one sooner had they called him about the bruising/injury before 4/18/24. V3 said the type of clavicle fracture R1 has is consistent with a fall on your side. He said a fading yellow bruise is also consistent with an injury a week ago and he describes it as a resolving bruise. V3 said an angulated (displaced) clavicle fracture is generally a painful fracture and the key is immobilization of the arm to decrease pain. V3 said the mechanism of the fracture would likely be from a fall and them not notifying him sooner is an issue. On 4/30/24 at 12:40 PM, V2 (Director of Nursing/DON) said a resident injury should be documented in the EMR in the nursing progress notes or assessments. V2 said when a resident injury is identified the nurses should do a head-to-toe assessment, assess for pain, and inform the doctor to obtain treatment orders. On 4/30/24 at 12:48 PM, V1 (Administrator) said she was shown the bruise and saw lump on R1's shoulder on 4/18/24. She thought something did not seem right, so she asked the nurse to call the physician for an X-ray order and when that came back it was identified that R1 had a fractured clavicle. V1 said when she investigated the incident R1 told her she had a fall in her bathroom, and she got herself up. The facility provided Abuse Prevention Policy revised 11/28/16 states, The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, other abnormalities, or injuries of unknown origin as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee.

Based on interview and record review the facility failed to obtain physician orders to ensure a resident received his pain medication. This failure resulted in R1 missing 41 days and 123 potential doses and experiencing uncontrolled pain. This applies to 1 of 3 residents (R1) reviewed for pain in the sample of 3. The findings include: R1's face sheet shows he was admitted to the facility on [DATE] with diagnoses including chronic embolism and thrombosis of the left lower extremity, bipolar disorder, depression, and chronic pain syndrome. R1's 1/4/24 Minimum Data Set shows he is cognitively intact with no memory impairments. R1's current care plan shows he has chronic pain due to medical conditions including spinal stenosis, and leg pain. Interventions to his care plan show pain medications should be administered as ordered and his physician should be notified of interventions not effective to manage pain. R1's care plan also shows he has a history of polysubstance abuse and drug seeking behaviors. On 2/28/24 at 8:17 AM, R1 said, I have chronic pain from a previous car accident that caused me to have back surgery and hardware in my back. I also developed blood clots in my left leg and had a stent put in that needs to now be removed. I have a lot of pain to my back and left leg into my groin area. The former Medical Director (V3) stopped seeing me in December and fired me from being his patient. Since then, I had no primary care physician, until yesterday, to prescribe my pain medication that was recommended by the pain clinic in January. The psychiatric Nurse Practitioner (V8) prescribed me Xanax to help with anxiety and withdrawal symptoms when my oxycodone was stopped. I told everyone I could I needed my pain medication ordered and would ask if they found me a new doctor yet, and I would hear from the Administrator (V1) we are working on it. R1 said I have pain every day and no pain medication to take beside Tylenol, and that doesn't even touch the pain. A Physician Progress Note for R1 completed by V3 on 12/18/23 with a date of service of 12/7/23 states, This will be our final visit with (R1). He continues to request more pain medication as, we have told him before, we will cover his pain medication until he is seen by the pain clinic as he and others in the facility had suspected malfeasance with regarding to handling of his pain medication and the medications of others. Although it is not proven, there may have been buying and selling of pain medication as well. Regardless, we tried to discuss this, and unfortunately, this was in a public location. (R1) became extremely agitated and repeatedly told me to, F*** off. He could not be reasoned with and seemed to be relieved that I had informed him I would no longer be providing his care and I did not think we could have a working relationship. We will not be seeing him in person again, I will certainly cover his medical issues until he finds a new physician or 30 days have elapsed. R1's nursing progress notes show the following: 1/4/24- 12:45 PM- Nursing Note shows R1 expressed concerns to V7 (Registered Nurse/RN) that his pain medication no longer had refills. V7 made a pain clinic appointment for R1 for 1/17/24. 1/8/24- 1:11 PM- Nursing Note shows R1 was complaining of body aches, nausea, and anxiety due to his pain medication prescription running out. Orders were received from V8 for Xanax to manage these symptoms. A pain consultation report completed on 1/17/24 by an outside pain management physician for R1 shows R1 has pain rated a 6/10 on the pain scale and described as throbbing and sharp with numbness and tingling. The symptoms worsen when R1 stands, walks, and lays in bed. The report shows R1 has pain from blot clots in his left leg and from a car accident resulting in back surgery in 2022. The recommendations include continue hydrocodone-acetaminophen 10-325 mg 1 tablet by mouth 3 times a day. R1's 1/17/24 Nursing Note shows the facility was aware and documented the recommendation for hydrocodone-acetaminophen to be ordered. R1's January 2024 medication administration record (MAR) shows his last dose of oxycodone-acetaminophen 10-325 milligrams (mg.) was given on 1/7/24. R1's MAR lists the medication is on hold from 1/9/24 through 1/27/24 and discontinued on 1/30/24. R1's February 2024 MAR and Physician Order Summary shows there were no active orders entered for the recommended hydrocodone-acetaminophen (Norco) until 2/27/24. Between 1/17/24 and 2/27/24 when the prescription was sent in for R1's pain medication, 41 days had passed, and he missed out on a possible 123 doses of Norco. On 2/28/24 at 9:20 AM, V5 (Registered Nurse/RN) said it is true that R1 was without a primary care physician (PCP) because V3 booted him and did not re-order his pain medications. V5 said since R1 did not have a new primary care physician there was no doctor to send the prescription for the recommended Norco to obtain the medication for R1. V5 said the facility has a new medical director who sent over the prescription for R1 just yesterday. On 2/28/24 at 9:25 AM, V6 (RN) said the facility administration was very well aware of R1 not having a PCP (Primary Care Physician) to issue the prescription for his pain medication. V6 said R1 complained of pain and constantly asked for his pain medication on schedule around the clock. On 2/28/24 at 10:53 AM, V2 (Director of Nursing/DON) said she has worked at the facility for about a month and was alerted a couple weeks after she started about the issue with R1 not having a PCP to prescribe his pain medication so she called the pain management company to see if they would send the prescription over but they would not order it because they just consult and give recommendations. On 2/28/24 at 11:23 AM, V3 was interviewed by phone and said he stopped seeing R1 due to an issue when R1 became belligerent telling him to F*** off. V3 said he repeatedly told the facility he won't just leave R1 hanging and will re-order his medications until they find him a new PCP within reason. V3 said he does not recall the facility contacting him to order R1's pain medication after his prescription ran out. V3 also said he also would have given the prescription for the pain medication that the pain clinic had recommended had the facility asked him. V3 said unfortunately R1 does have valid pain and will experience lifelong pain and without pain medications his pain level will increase, and withdrawal could happen if the medications are just stopped. V3 said he believes R1 does need the pain medication. On 2/28/24 at 12:50 PM, V1 (Administrator) said V3 is no longer the facility Medical Director. A new Medical Director (V9) took over the care of the residents including R1, and she was able to get him to send the prescription over for R1's pain medication on 2/27/24. On 2/28/24 at 1:45 PM, V7 (RN) said she did try to contact V3 to see if he would re-order R1's pain medication after his prescription ran out. She said she did not contact him after the pain clinic appointment because V3 had made it clear R1 was no longer his patient. V7 said she thinks most of the nursing staff at the facility dismiss R1's pain because they see him as a drug seeker, but she read his medical history and believes his pain is valid and he needs medication for it. V7 said she personally told the facility administration about R1 not having a prescription for his pain medication multiple times. On 2/28/24 at 2:10 PM, V8 (Psychiatric Nurse Practitioner) said she was aware of the concern with R1's pain medication running out because she was contacted about increased anxiety and some withdrawal concerns, so she gave orders for Xanax for these symptoms. V8 said she is not able to prescribe narcotics to residents that needs to be done by his PCP which he did not have at the time. The facility provided Pain Assessment and Management policy revised March 2015 shows the goal of pain management is to develop interventions consistent with the resident needs to help control pain. A physician should establish a treatment regimen and medications should be administered as ordered.

Based on interview and record review the facility failed to permit a resident to return to the facility after an acute hospitalization for 1 of 3 residents (R1) reviewed for discharge. The findings include: R1's electronic health record documents R1 had been residing at the facility since 7/28/2014. R1's 8/9/23 nursing note entered at 2:01 PM documents, Resident called [Mental Health Suicide Crisis Line] and stated she wanted to self-harm herself. Nurse did not know this until cops came in and stated that a resident had called. Resident did not show any self-harming signs or symptoms or nor did she state any discomfort or distress. Shortly, ambulance came as well, and she was transported via ambulance at around 7 PM. Vitals were all within normal range. At around 9:30 PM, a crisis worker [from acute mental health services] called stating that resident will remain at ER (emergency room ) until they find placement for her. Faxed over information to her (face sheet and admission sheet) told her info on POA (Power of Attorney). Told her that her parents are heavily involved in her care. [Mental Health Crisis worker] stated she would call them and tell them the situation and the conversation that went on when resident called the hotline. [V11] RN (Registered Nurse) stated this afternoon that resident will be going to Indiana for 5 days, and that most likely be transferred to [a long-term care facility near her mother]. Representative from [the long-term care facility near R1's mother] came in and [V11] told her [R1] was at hospital. Per [V11] the representative went to [the local acute care hospital] to interview resident. R1's acute behavioral care hospital documentation dated 8/31/23 showed, . 11:00 AM, Asking when she would be discharged . No other issues. R1's acute behavioral care hospital documentation dated 8/30/23 showed, 6:00 PM, [R1] is alert and oriented x 3. She can follow commands and make needs known. She had no behaviors . R1's complete medical record showed no documentation regarding R1's discharge from the facility aside from her note regarding being sent to the hospital. On 9/1/23 at 2:05 PM, V5 (Acute Behavioral Health Hospital Social Worker) said R1 came to their facility with suicidal ideation and was planning on discharging to [a long-term care facility near her parents]. V5 said she called the [long term care facility near R1's parents] and they said they had accepted her prior to her admission at their behavior health hospital but that they had changed their mind based off R1's hospitalization . V5 said she contacted the facility, and they told her she is beyond the 10-day bed hold and they were not taking her back. V5 said R1 is stable and has been cleared for return to the facility. V5 said she spoke with both V1 and V2 on the phone on Monday (8/28/23) and they said R1 had fired her doctor at the facility and does not have a bed there. On 9/5/23 at 12:35 PM, V4 (Social Services Director) said he does not typically get involved in resident discharges from the facility. V4 said if it is a discharge, they are aware of the MDS (Minimum Data Set) nurse would be taking care of that. V4 said R1 went to a psychiatric facility in Indiana, and he thought another facility was going to take R1 after that so she could be closer to her parents, but that facility decided not to take her. V4 said the other facility did not say why changed their mind on admitting R1. V4 said R1 was well beyond her 10-day bed hold when the hospital tried to send her back to the facility so they could not take her. V4 said, [R1] hasn't been happy here and fired her doctor. We thought maybe a fresh start would be good for her. Once a resident is out of the building it is out of our hands and goes straight through [V1] I was told we weren't taking her back. She didn't want [the facility physician] to take of her so she has to go someplace else. R1's 8/28/23 Behavior Health Hospital note showed, . 8/15 stable for discharge . Discharge Plan: social work will work on safe discharge. Pending placement?? . On 9/5/23 at 12:47 PM, V1 Administrator said R1 went out of the facility on 8/9/23 when she called 911 herself and said she wanted to be evaluated. V1 said the Social Services Director and the MDS nurse were working on getting her transferred out because she had fired her doctor at the facility . V1 said they were looking elsewhere because she could not go without having a doctor. V1 said they were in contact with the facility that R1 was going to be transferred to and the last she heard she had been accepted. V1 said the facility has not refused to take R1 back. V1 said they do have a 10-day bed hold policy and that if the facility is at full capacity, they can only hold the bed for 10 days but that if they send someone out and it takes more than 10 days to get them stabilized, they can make an agreement with the hospital to take them back. On 9/5/23 at 1:50 PM, V1 said she thinks she has pieced together what happened and that she was in the room for the conversation on the phone between V2 DON and V5 (the behavioral hospital social worker). V1 said she educated her staff now regarding the policy for taking residents back after a hospitalization . V1 said she educated her staff that they must accept the resident back if the facility is not at full capacity. V1 said she thinks this must have just been a miscommunication. The facility's policy and procedure titled Bed Hold Guarantee Policy with revision date of 8/1/17 showed, Upon leaving this facility for admission to a hospital or for a therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if: 1. The resident's condition is such that he/she is appropriate for the level of care provided by the facility, and 2. A Medicaid eligible resident was into in the hospital or on leave for more than 10 consecutive days; . If a resident in an Intermediate Care Facility leaves the facility for admission to the hospital and requires Skilled Care (Medicare) upon discharge, they will not be able to return to the Intermediate Care Facility. This facility strives to ensure that each Medicaid resident, who is discharged to an acute care setting or takes a therapeutic leave, has a bed reserved for his/her return. Beds shall be held for 10 days for hospitalization and therapeutic leave for Medicaid recipients .A Medicaid resident, whose hospitalization or therapeutic leave exceeds the 10-day bed-hold period, may return to their previous room if available or immediately upon the first availability of a bed in a semi-private room . If the facility determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with 42 CFR, Sec 483.15(c). The facility's undated Transfer and Discharge Policy and Procedure showed, It is the policy of [the facility] not to transfer or discharge a resident unless: 1. The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility .

Based on interview and record review the facility failed to provide consistent ongoing monitoring of oxygen saturation for a resident with a history of respiratory failure for 1 of 3 residents (R3) reviewed for respiratory care. This failure resulted in R3 experiencing respiratory distress requiring hospitalization and mechanical ventilation for breathing on 8/19/23 and on 8/31/23. The findings include: R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute on chronic respiratory failure with hypercapnia, acute on chronic diastolic congestive heart failure, essential hypertension, obstructive sleep apnea, acute on chronic respiratory failure with hypoxia, bipolar disorder, hyperlipidemia, asthma, morbid obesity, and schizophrenia. R3's facility assessment dated [DATE] showed she has no cognitive impairment and requires extensive assistance of staff for most cares. R3's July 2023 Physician Order sheet showed, Order Date: 6/27/23, Titrate O2 to keep sats at 90% via nasal cannula as needed for shortness of breath and low O2 sats. R3's August 2023 TAR (Treatment Administration Record) showed, Titrate O2 to keep sats at 90% via nasal cannula as needed for shortness of breath and low O2 sats. R3's Care Plan initiated 6/27/23 showed, Refusal of treatment. The resident is noncompliant with medical treatment . Educate the resident on importance of obtaining vital signs to ensure her health and safety . Monitor the resident's well-being every 15 minutes for signs and symptoms of distress . R3's Care Plan initiated 8/18/23 showed, Alteration in breathing pattern/oxygenation . Monitor O2 stats and report changes in lung sounds, breathing patterns, and LOC (level of consciousness). R3's Care Plan initiated 8/23/23 showed, Recent hospitalization for possible drug interaction. Decrease in oxygenation . Monitor for signs of distress. Monitor vital signs every shift, before and after smoking, and as needed . R3's 8/18/23 Behavior Note entered at 9:29 AM showed, Resident continues to refuse medications and continues to refuse to wear oxygen while in bed. Resident educated on the importance of following MD (physician) orders. Will continue to reapproach resident to give medications and provide treatments as ordered. Will continue plan of care. R3's 8/18/23 Nursing Note entered at 10:02 AM showed, Resident displays difficulty breathing as exhibited by pursed lip breathing, and use of abdominal muscles. Resident has a wet, productive cough. Resident has been refusing her medications frequently from this RN (Registered Nurse). BP (blood pressure) is 130/90 and O2 89% on RA (room air). Resident breath sounds are diminished in all lobes. Resident state she does not want to go to the hospital, MD notified Will continue current plan of care. R3's 8/18/23 Nursing Note entered at 5:42 PM showed, Resident found unresponsive when staff passing out dinner hall trays. RN assessed resident. Resident was in bed, with HOB elevated at 45-degree angle with O2 continuously at 4L per NC (nasal cannula). Resident appears to have apneic breathing. Pupils sluggish, but reactive. Resident nonresponsive to sternal rub, radial and pedal pulse weak but present Unable to obtain BP and O2 saturation prior to EMS (Emergency Medical Services) arrival . R3's electronic health record showed no evidence of ongoing monitoring between 10:02 AM and R3 being found unresponsive at 5:42 PM. R3's Acute Care Hospital Discharge documents showed, . admitted : 8/19/23, discharge date : 8/22/23, Primary Discharge Diagnosis: Acute on Chronic Hypoxic and Hypercapnic Respiratory Obstructive sleep apnea, Acute on chronic diastolic CHF (Congestive Heart Failure), NSTEMI (acute cardiac event) likely demand ischemia from hypoxia, AKI (Acute Kidney Injury), Pneumonia . Details of Hospital Stay, Presenting Problem/History of Present Illness: Unresponsiveness . Acute on Chronic Hypoxic and Hypercapnic Respiratory Obstructive sleep apnea, Required intubation (mechanical breathing support) . R3's 8/22/23 Nursing Note showed, Readmit to facility at 1800 (6:00 PM) today . Oxygen at 2L/NC to keep sats above 90% as soon as she arrived, she stated she wasn't going to wear the oxygen unless she wanted to . Will continue to monitor. R3's 8/31/23 Nursing Note entered at 11:20 AM showed, This nurse sent out resident. CNA (Certified Nursing Assistant) reported to nurse that resident was not her usual self. This nurse went to resident's room and noticed resident was very confused and did a set of vitals. Vitals were 127/92, pulse 100, RR 20, pulse ox 97% on 4L NC . When nurse asked resident questions, resident could not answer or had slurred speech. Called ambulance and called [acute care hospital] nurse to give report . R3's 8/31/23 Nursing Progress Note entered at 3:22 PM showed, Called [acute care hospital] for update on resident. They stated hospital transferred her to [higher acuity hospital]. She was intubated. RN stated CO2 was 108 and was retaining O2 [SIC] . R3's Acute Care Hospital documents showed on 8/31/23, . Acute on chronic respiratory failure with hypoxia/hypercapnia, Asthma with acute exacerbation, Acute on chronic diastolic heart failure, Obesity hypoventilation syndrome, Patient was intubated prior to transfer . Pulmonary/Critical Care Consultation Note . Ventilator Day 1. Mechanically ventilated as of 8/31/23 . Patient Status: . The patient suffers from life threatening illness and is clinically unstable . R3's electronic health record showed no evidence of monitoring R3 between 8/22/23 and her return to the acute care hospital on 8/31/23. On 9/5/23 at 1:23 PM, V6 CNA (Certified Nursing Assistant) said R3 would refuse to wear her oxygen because she did not like it. V6 said the last couple of weeks R3 has been asking her to put the oxygen on. V6 said it was like someone finally got through to her that she needed to use it. On 9/6/23 at 11:18 AM, V10 RN (Registered Nurse) said the day she sent R3 out (8/31/23) a CNA had alerted her that R3 was not acting right. V10 said she had gone into R3's room [ROOM NUMBER] times that day. V10 said R3 was usually on her call light throughout the morning but she wasn't that day. V10 said this wouldn't be abnormal for R3 if she had been up through the night. V10 said she got her equipment and went down to R3's room. V10 said when checked R3's vitals her oxygen saturation was 99% and it is never 99%. V10 said since she was not acting right, and her oxygen saturation was too high for her she wanted her to go to the hospital for evaluation. On 9/5/23 at 2:30 PM, V3 RN said the second time R3 was sent out she was intubated. V3 said she sent R3 out to the hospital the time before (8/18/23). V3 said R3 had been refusing to wear her oxygen that day. V3 said she had talked to R3 about what it means to be a full code and what she would have to do to her if she stopped breathing. V3 said R3 agreed to go lay down in her room. V3 said 3 or 4 hours later she had to send her out to the hospital. V3 said the nurses are supposed to check R3's oxygen saturation every shift. V3 said on the day she sent R3 out there was no time to get a set of vitals. On 9/6/23 at 4:04 PM, V2 DON (Director of Nursing) said she does not know much about R3's oxygen saturation levels. V2 said she knows the nurses do try to watch her oxygen and put it on. V2 said monitoring R3's oxygen saturations and vitals are very important for R3 because she has had to be intubated a couple times. R3 said when the nurses monitor the resident's oxygen saturations, they would document those findings in the vitals tab of the electronic record or the nursing progress notes. On 9/6/23 at 5:22 PM, V12 (Medical Director) said he has been providing care for R3 at the facility. V12 said he would expect the facility to monitor R3's oxygen saturation levels routinely. V12 said R3's oxygen saturation levels should be monitored every shift due to her ongoing respiratory issues to keep an eye on her current status. R3's weights and vitals tab showed R3's oxygen saturation was only documented twice between 8/22 and 9/5/23. R3's 9/5/23 Admission Summary showed, Resident returned to [long term care facility] . Staff to keep SpO2 above 88% .Resident to be closely monitored and is placed on 15-minute checks . The facility's policy with review date of 3/19 showed, Oxygen Therapy, Policy: Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress .

Based on observation, interview and record review the facility failed to provide initial assessments, treatments and preventative measures for two of four residents (R108 & R20) reviewed for pressure in the sample of 15. This failure resulted in a resident (R108) with a DTI (deep tissue injury) not being provided any offloading to her heels or treatment to her left heel after being seen by a wound care physician on 7/14/23. The findings include: 1. On 7/18/23 at 2:48 PM, R108 was asleep and laying on her side in bed. R108's legs were crossed and she did not have any offloading devices in place to her feet/heels. R108's left heel was visible and there was a quarter size black spot on her left heel. On 7/19/23 at 8:17 AM, R108 was laying in bed on her back. Her heels were resting on the mattress. V9 CNA (Certified Nursing Assistant) and V13 CNA were at the bedside to transfer R108 to her wheelchair. R108 had a quarter size black spot to her left heel. R108 stated she doesn't have boots or pillows placed under her heels to keep them off the mattress. V9 CNA stated, R108 has blankets she can put under her heels. The Re-Admission Summary dated 7/12/23 at 5:38 PM for R108 showed she arrived by stretcher, from the hospital to the facility. R108 was alert and oriented to person and place but was confused. R108 had a deep tissue injury to her left heel. The Skin/Wound Note dated 7/12/23 at 5:43 PM showed, Deep tissue injury noted to left heel. Will be referring resident to wound MD (medical doctor). No further concerns at this time. No other wound assessment was done to include the description or measurements of the wound. The Wound Care Physician documentation dated 7/14/23 for R108, that was not in her medical record, showed she had an unstageable DTI of the left heel that was pressure and measured 3.0 x 3.0 x not measurable in cm (centimeters). The dressing and treatment plan included the following: offload the wound; float heels in bed; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. Skin prep to the left heel daily. The Physician Orders dated July 2023 for R108 did not show any treatment orders for the DTI to her left heel. The TAR (Treatment Administration Record) dated July 2023 for R108 did not show any treatment or offloading of her left heel being completed since the doctor ordered it on 7/14/23. The treatment for skin prep to R108's heel wasn't added to her TAR until 7/19/23. The order to float heels while in bed to offset pressure and promote wound healing to the left heel DTI. Reposition every 2 hours was not added to R108's TAR until 7/19/23. On 7/19/23 at 1:02 PM, V4 RN (Registered Nurse) stated, the facility didn't have a wound care nurse but has a wound care doctor that comes in on Fridays at 5:00 AM and does wound rounds. V4 stated the wound doctor does the measurements, assessments and the documentation for wounds. V4 stated he puts the information and his orders in his notes and faxes them to the facility. V4 stated his notes are also accessible through V1 (Administrator) email. V4 stated the nurse that works on Friday enters the orders. No one else does wound assessments or measurements. Any resident in the facility with a wound is seen by the wound doctor. The floor nurse's do the treatments that are ordered and should be on the TAR. V4 stated she did not do a treatment for R108's ankle wound today. V4 stated there should be an order that goes on the treatment sheet so the nurse's know what treatment needs to be done. V4 stated she did not see an order for any treatment for R108; it was not on the treatment sheet. V4 stated no treatments have been done for R108's left heel. V4 stated R108's heels should be offloaded for prevention of wounds and for healing of the pressure area. On 7/20/23 at 10:05 AM, V2 DON (Director of Nursing) stated the last time she saw R108 was Saturday night (7/15/23) when she worked third shift. V2 stated she knew R108 had a wound to her left heel. V2 stated residents are seen weekly by the wound doctor on Friday mornings. V2 stated they get the doctor's assessments, measurements and orders from his website. V2 stated she thinks the wound doctor faxes his notes to the facility. V2 stated the wound doctor's treatment plan are orders and are to be entered into the electronic medical record as orders. V2 stated after the orders are entered it will cross over and show up on the resident's MAR and TAR so the orders can be completed. V2 stated its important to follow the doctor's so there is not further injury to the pressure ulcer and to help it heal. V2 stated she was not aware that the orders were not being done and stated they need to be followed. V2 stated staff should be encouraging offloading to help R108's DTI heal. On 07/19/23 at 1:10 PM, V4 went to R108's room and confirmed resident's heels were not offloaded and stated the resident had a DTI to her left heel. The Face Sheet dated 7/19/23 for R108 showed diagnoses including schizophrenia, bipolar disorder, hypertension, hyperlipidemia, asthma, morbid obesity, and insomnia. The MDS (Minimum Data Set) dated 6/14/23 for R108 showed no cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The Care Plan dated 6/27/23 for R108 did not show any plan in place regarding a DTI (deep tissue injury) to her heel. R108's Care Plan showed she will have no new open areas caused by pressure or friction for the next 90 days. There were no interventions for offloading, repositioning or treatment to her left heel DTI. The facility's Decubitus Care/Pressure Areas policy (1/2018) showed, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote healing of any pressure ulcer. Procedure: 1. Upon notification of skin breakdown, the QA form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. 2. The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. 3. Complete all areas of Treatment Administration Record or the Wound Documentation Record. Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician). Notify the physician for treatment orders. The physician's orders should include: type of treatment; frequency treatment is to be performed; how to cleanse, if needed; site of application; initiate physician order on treatment sheet. Documentation of the pressure area must occur upon identification and at least once each week on the TAR or Wound Documentation Form. The assessment must include: Characteristic (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc). Treatment and response to treatment. 39537 2. On 7/18/23 at 9:43 AM, R20 self-ambulated from her room to the activity room. R20's Face Sheet dated 7/19/23 showed diagnoses to include, but no limited to: schizoaffective disorder, irritable bowel syndrome, depression, mood disorder, anxiety, hypertension, emphysema, vascular dementia, generalized muscle weakness, and aphasia. R20's Nursing Home Discharge/Transfer Communication form dated 6/7/23 showed R20 had redness to her coccyx. R20's Braden Scale (a measure of potential for skin breakdown) dated 6/13/23 showed a score of 19 = Moderate Risk. R20's Progress Note dated 6/19/23 at 10:09 AM, showed R20 complained of pain to the right side of her bottom. The resident is alert and oriented. A Stage II pressure ulcer was noted on her right buttock. The resident is able to ambulate with walker to dining room. This note stated, Will consult wound doctor for further treatment. Will continue to monitor for progression of PI (pressure injury). This note did not contain a detailed assessment of R20's wound. There were no measurements or descriptions or the wound bed, peri-wound area, or drainage. R20's EMR did not contain any additional Skin Assessment from 6/19/23 - 6/29/23. (A complete wound assessment wasn't documented until R20 was seen by the wound doctor on 6/30/23). R20's Physician Order Sheet dated 7/19/23 showed an order for, Per Wound MD. Clean with wound cleanser. Place Xeroform on wound. Place Island gauze. Offload/reposition every 2 hours. Limit sitting time, no more than 60 minutes per meal. One time a day for Wound treatment (right bottom). The order was dated 6/20/23. The wound doctor's documentation was not available in the EMR. V1 (Administrator) had to print all wound documents. The first assessment completed by the wound doctor or R20's right, upper, medial buttock was dated 6/30/23 (11 days after the pressure ulcer was identified). This document showed R20 had a Stage 2 Pressure Ulcer measuring 1.4 x 2.4 x 0.2 cm. The wound duration was greater than 12 days. On 7/20/23 at 10:13 AM, V2 (DON - Director of Nursing) stated a new skin wound should be fully assessed and documented by the nurse working when the wound is found. V2 said a full assessment of the wound would answer all the questions the EMR asks in the EMR. The surveyor clarified that would include: the size of the wound, type of wound, wound appearance, peri-wound appearance, and presence of drainage. V2 replied, Yea, I guess. V2 said the full assessment of R20's wound should be entered in a progress note or Skin Assessment. R20 should have had an initial assessment completed that day (6/19/23). The initial assessment is an important tool to assist in the treatment plan. It helps the nurse determine if the wound is improving or deteriorating. V2 said their is no official Wound Care Nurse at the facility. V2 stated, [The EMR system] is very new and I don't think most of them (the nurses) know where to chart things yet. The facility's Decubitus Care/Pressure Areas Policy (revised 1/18) showed, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer . Procedure: 1. Upon notification of skin breakdown, the QA form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. 2. The pressure area will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. 3. Complete all areas of the Treatment Administration Record or Wound Documentation Record. i). Document size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician) . 5. Documentation of the pressure area must occur upon identification and at least once each week on the TAR or Wound Documentation Form. The assessment must include: i) Characteristic (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) .

Based on observation, interview, and record review the facility failed to supervise a resident with a history of elopement, and the facility failed to provide 1:1 monitoring for a resident. This failure resulted in R1 leaving the facility out of window on [DATE]. R1 was found approximately 3 hours later, by the side of the road, 9 miles from the facility with signs and symptoms of hypothermia. The immediate jeopardy began on [DATE]. V1 was notified of the Immediate Jeopardy on [DATE], at 9:00 AM related to R1's risk for R1's safety while R1 was gone. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level 2 due to the need to evaluate the effectiveness of staff monitoring of residents at risk for elopement. This applies to 1 of 3 residents (R1) reviewed for elopement in the sample of 3. The findings include: R1's profile face sheet documents R1 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] disorder, [CONDITION(S)] type. The [DATE] cognitive assessment documents R1 to be cognitively intact. The [DATE] community survival skills assessment shows R1 was not capable of an unsupervised outside pass. R1's nursing progress note for [DATE] at 7:45 AM, shows R1 punched a hole in the window and the wall, and the window appeared to be broken in R1's room. The nurse tried to speak with R1 and de-escalate R1 and R1 threw a glass of water at the nurse. The nurse documents she called 911 due to risk of injury to self and others, and R1 was transported to the local emergency room . At 9:30 AM, the notes show the nurse spoke with a crisis counselor and R1 was at risk of harming others. On [DATE] at 8:50 AM, V3 RN (Registered Nurse) said she was working on [DATE] when R1 began having what seemed to be an acute psychotic episode. She said R1 broke the window in R1's room and tore the dry wall off the wall. After R1 was at the emergency room , and no open beds could be found for inpatient care, R1 was returned to the facility and placed on 1:1 observation in R1's room. V3 said at times, R1 would sit at the nurses' station, or be in R1's room. V3 said when a resident is on 1:1 observation, someone sits in the doorway of their room with the door open for monitoring. The [DATE] crisis intake from the emergency department, shows R1 was delusional with impaired judgment and memory. The notes show R1 was being evaluated due to outbursts where R1 became aggressive and broke a window and began punching the wall. R1 shared that R1 felt staff at the facility do not want R1 back and R1 does not want to go back either. R1 repeated to the crisis worker R1 did not want to be in the facility. On [DATE] at 9:20 AM, V5 CNA (Certified Nursing Assistant) said she was assigned as R1's 1:1 today, and she was documenting R1's activity on a log. V5 said when a resident is on 1:1 the staff monitoring the resident must follow them wherever they go in the building. V5 said R1 could leave R1's room, but she would have to follow closely and have a visual of R1 at all times. V5 said she completes the 1:1 log with R1's location or what R1 is doing at 15-minute intervals. The completed forms are turned into the administrator. On [DATE] at 11:00 AM, V6 (Maintenance) said the window in R1's room opens up and down. R1 had broken the bottom pane of the window and it had to be boarded up for safety. V6 said he covered the window with ,d+[DATE]-inch plywood. R1's [DATE] nursing note at 12:40 AM, shows R1 came out of R1's room and pulled the fire alarm and eloped from the building. The fire department showed up and turned off the alarm and resident returned 30 minutes later laughing. R1 walked into R1's room where R1 was on constant monitor watch. On [DATE] at 4:10 PM, V7 CNA said R1 was already on a 1:1 because R1 was attempting to leave the building, and R1 was on 1:1 monitoring when R1 pulled the fire alarm. V7 said R1 walked out of R1's room and pulled the alarm, then R1 went outside through the door at the end of R1's hallway. V7 said R1 was outside for about 30 minutes and returned to R1's room. V7 said R1's window was covered with plywood at the time and remained intact. V7 said he sat outside R1's door in the hallway to watch R1 through the night. He said the door was open, and R1 would get up and close it if using the bathroom, then R1 would go back to bed. V7 said he stopped watching R1 at 6:00 AM, and R1 was in R1's bed when he left his shift. On [DATE] at 9:45 PM, V8 LPN (Licensed Practical Nurse) said she is the only nurse in the facility from 6:00 PM to 6:00 AM. She said R1 was on 1:1 monitoring when she arrived at the facility on [DATE] at 6:00 PM. She said R1 was on a 1:1 because the day before R1 had eloped from the building. She said during her shift the CNA was sitting outside of R1's door and had the door open. V8 said R1 pushed V7 out of the way and pulled the file alarm and exited the building. V8 said after the incident R1 returned to R1's room and V7 was watching R1. V8 said she saw R1 at 8:00 PM for R1's medication, and then did not see R1 again through the rest of her shift, 6:00 AM on [DATE]. V8 said R1 was on a 1:1 and V7 was watching R1. V8 said she did not know how or when R1 eloped from the facility. On [DATE] at 9:25 AM, R1 said the first time R1 left the building after pulling the fire alarm, R1 went out the front door, and was by the laundromat when a cop found R1 and returned R1 to the facility. R1 said R1 returned to R1's room, and waited about an hour, and broke the wood covering the window. R1 said R1 just gave it a good push and it broke out, and R1 climbed out and took off walking. R1 said nobody was watching R1, the staff were at the nurses' station watching movies like they do every night. R1 said R1 had on jeans, hiking shoes without socks, a T-shirt, and a winter coat. R1 said R1 did not have a hat or gloves for the cold temperatures, R1 just put R1's hands inside the coat pockets. R1 said R1 walked about ,d+[DATE] miles through the night until R1 became too cold and R1's legs were sore, and R1 laid down on the side of the road and fell asleep. R1 said R1 was there until someone woke R1 up and had called the ambulance. R1 said R1 had been telling the staff R1 wants to go to Ottawa, R1 wanted to leave. On [DATE] at 5:50 PM, V9 (Paramedic) said he responded to a call out of the fire department on [DATE] at 7:30 AM for a person found on the side of the road. V9 verified the person to be R1. V9 said he found R1 to be conscious, and very cold. R1 had stopped shivering, and that means R1 got pretty cold and was progressing through hypothermia. V9 said R1 reported to him that R1 had been walking a long time and was trying to get to Ottawa. V9 said R1 appeared to have been out in the cold for a lot longer than 1 hour. He said the location of where R1 was found, is about 9 miles from the facility. If average person walks about 3 miles per hour, R1 would have been walking for 3 hours, give or take. V9 said given R1's condition, R1 was out for about 3 hours in the 20-degree temperatures. The fire department patient care report documents R1 was approximately 9 miles from the facility at 7:30 AM. The weather report per timeanddate.com for [DATE] from midnight to 6:00 AM was a low of 19 degrees. The emergency room report for R1 shows R1 presented on [DATE] at 8:10 AM after (R1) was found laying on the ground, temperatures outside 20's Fahrenheit, after (R1) absconded from a local nursing home and was found a few miles away. R1 reported (R1) was tired of walking and couldn't stand anymore; (R1) did have a light coat and shoes on without socks; (R1's) temperature was registering low per EMS (Emergency Medical Services). On [DATE] at 9:30 AM, V1 (Administrator) said she was notified of a fire alarm going off in the facility about 1:00 AM, and R1 had gone outside. V1 said R1 was already on a 1:1 monitoring after R1 returned from the emergency roiagnom on [DATE]. V1 said V7 came in specifically to be 1:1 with R1 for the overnight shift. She said R1 had a history of pulling the fire alarm, and on [DATE] had punched a hole in the wall, and threw water at the nurse, and broke out R1's window. V1 said it was about 6:30 AM on [DATE] when staff discovered R1 was not in the facility. She said at about 6:15 AM at shift change the staff noticed the door alarms were not working. V1 said she initiated a fire watch, and staff were instructed to check all the doors and complete a head count of the residents and R1 was missing. V1 said it appeared R1 had busted out the window in R1's room. V1 said the staff were searching the building and driving around the neighborhood and town to see they could find R1. V1 said the police said they had found R1, and R1 was at the emergency room for evaluation. V1 said she does not know the location of where R1 was found, she believes R1 left the facility at 6:15 AM when the CNAs were changing shifts. When informed the location where R1 was found was approximately ,d+[DATE] miles from the facility, V1 stated she thought the average person such as R1 could walk/run the 9 miles in one hour. On [DATE] at 8:00 AM, V2 DON (Director of Nursing) said R1 remains on a 1:1 status. V2 said when a resident is on 1:1, the person watching the resident must keep eyes on them at all times, and if they leave their room, the staff will stay within ,d+[DATE] feet of them. V2 said R1 did not have a community pass to be out of the facility on R1's own due to R1's mental illness. V2 said on [DATE] R1 was discovered missing at 6:20 - 6:30 AM, R1 had climbed out R1's window. V2 said she was not sure who was supposed to relieve V7 at 6:00 AM, but someone should have been with R1 at all times. The staff should have changed shifts at R1's doorway. V2 said she believes R1 was found near a small town south of the facility, about ,d+[DATE] miles. V2 said R1 told her R1 had run 8 miles, and R1 was so proud of self. V2 said if a person were to walk that distance, it would take about 2.5 hours. V2 said she knows the weather was cold, probably less than 35 degrees out, and she was not sure exactly how long R1 had been outside. V2 said R1 had told her R1 would do it again if staff were not looking. On [DATE] at 8:15 AM, R1 said when R1 left the facility R1 had no cell phone. R1 stayed on paved roads, there was no streetlights, R1 walked all night in the dark. R1 stated R1 did not run at any time, R1 never really liked to run, and no one stopped to offer a ride. R1 said R1 had crossed over railroad tracks and bridges during R1's walk. R1 stated R1 escaped the facility 2 times in one night. Once when the alarm went off, and then after the alarm. Google maps shows 3 separate routes possible to the intersection where R1 was located. The directions show it would take a person over 2.5 hours to arrive at that location. The map shows the distance ranging from 8 miles to 8.6 miles. On [DATE] at 5:50 PM, V9 (Paramedic) said the potential for harm to R1 would have been the cold. His biggest concerns were with hypothermia- R1 was getting into the danger zone and had no one found R1 when they did, R1 probably could have died . V9 said where R1 was lying, on the edge of a country road, R1 could have been run over by cars passing R1 going 55 miles per hour. The facility's [DATE] policy for resident monitoring states it is the policy of the facility to initiate monitoring of residents as a nursing measure upon the clinical decision of the Charge Nurse and or Interdisciplinary Team to assist in providing safety to residents that are identified to be a potential threat to self or others or an elopement risk. 3. Initiate monitoring as indicated by need, 15-minute, 30-minute, 1-hour increments or one on one monitoring if determined necessary. 7. Continue monitoring the resident until the Interdisciplinary Team can determine the status of the resident and develop other appropriate measures for intervention determined by resident need. 8. Document all assessments, needs interventions and resident responses in the resident's medical record. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. On [DATE] beginning at 2:00 PM and ending at 3:00 PM, all staff were in-serviced on missing resident policy and procedure, elopement, elopement prevention, door alarm policy, monitoring residents 1:1 including documentation, behavior monitoring, and AMA (against medical advice) release of responsibility policy and procedure. 2. On [DATE] at 11:00 AM, social services completed an audit of residents of elopement risk. 3. The medical director has reviewed and approved the removal plan [DATE] at 9:40 AM. 4. As of [DATE] at 10:00 AM, all residents will be placed on an hourly rounding schedule where staff will complete a head count, unless a resident is on a different rounding schedule per their individual needs. 5. On [DATE] at 1:22 PM, the corporate compliance officer added definitions to the pre-existing resident monitoring sheets including hourly monitoring, 30-minute monitoring, 15-minute monitoring, and one to one monitoring to mirror the already existing company policy for resident monitoring. 6. Starting on [DATE] all staff will be educated on the new monitoring forms. The education be completed by [DATE].

Based on observation, interview, and record review the facility failed to protect a resident from physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of three. This failure resulted in R1 being physically assaulted twice on 10/27/21 and sustaining injuries including a closed head injury, left wrist injury, facial laceration, and nasal fracture. The findings include: On 10/28/21 at 8:19 AM, R1 was sitting on the bed in R1's room. R1 had a swollen nose, blood dripping from the right nare and staples under the right nare to R1's right upper lip. R1 had a red mark to the top of the right side of R1's head and bruising to the left side of the face. R1 stated, R2 went off on me. R2 said I stole (R2) pop, and (R2) went off on me in the room (resident's room). R2 cornered me and I couldn't get out. (R2) hit me eight times in the face and head. I yelled for help and no one would come. I crawled out of my room. The maintenance guy and housekeeper were in the hall and they told R2 to stop. I came back from the hospital and R2 attacked me in the living room. R2 hit me thirteen times. No one broke it up. I had to go outside to the smoking area. A whole bunch of staff were there. I was sent to the hospital again. Getting hit hurt a lot. A Nurse's Note dated 10/27/21 at 7:15 AM for R1 showed, R1 got into a physical altercation with roommate around 7:15 AM. R1 sent to ED (Emergency Department) for evaluation and treatment due to being on blood thinners. Resident moved to a different room. Resident returned at 8:20 AM with mild anxiety. As needed [MEDICATION(S)] given; will continue to monitor. On 10/28/21 at 11:56 AM, V13 (Housekeeping Supervisor) stated, It happened before 7:00 AM, it was 6:50 AM and I heard punching. I heard residents yell. The maintenance supervisor and I separated them. R2 said it was over stolen money. R2 had R1 against a wall. R1 went to the ground and crawled out of the room while we kept R2 busy. The hospital ER (emergency room ) Patient Visit Information dated 10/27/21 for R1's first visit to the ER showed R1 was seen for a head injury and left wrist injury with instructions for ice to his wrist, a wrist splint, Tylenol for pain and to return to the ER for new or worse symptoms. A Nurse's Note dated 10/27/21 at 10:20 AM for R1 showed, R1 got into another physical altercation with (R1's) ex-roommate around 9:30 AM. Authorities were called. Sent R1 to the ED for evaluation and treatment due to sustaining injuries to face. R1 has a laceration to left ear as well as a bruised, swollen nose. The hospital ER Patient Visit Information dated 10/27/21 for R1's second visit to the ER showed R1 was seen for a closed head injury, facial laceration, and nasal fracture with instructions to have the staples removed in seven days; return to the ER for vomiting, fever, swelling to the face, or as needed; Tylenol to be taken for pain; and to follow up with R1's provider this week. The hospital facial bone CT (computerized tomography) dated 10/27/21 for R1 showed, There is a comminuted nasal bone fracture. Conclusion: Comminuted fracture involving nasal bones. Fracture involving the anterior and inferior aspect of the nasal septum. Nasal septum is deviated significantly to the right. Mucosal thickening/inflammation/hemorrhage involving the middle and inferior nasal turbinates bilaterally, as well as along the course of the nasal septum. Soft tissue swelling over the upper lip, over the nasal and forehead. A Nurse's Note dated 10/27/21 at 1:00 PM for R1 showed, R1 returned to the facility with staples to upper lip and fractured nose. Pressure dressing applied to face/ear by ED. On 10/28/21 at 9:03 AM, V10 (Social Service Director) stated, I was in my office and I heard screaming. Someone was saying, Get of me, get off me. I saw R2 and R1 in the common area. R1 was in the chair. R2 was hitting R1. We all came in there and told R2 to get off R1. When I came in that morning my assistant said R2 accused R1 of stealing his money, they got into an argument and fight. I needed to talk to R2 about it, but we had morning meeting and I went there instead. After the morning meeting I was in my office putting papers together and that is when I heard the fight out here. I was told about the first incident; the second incident I was here. On 10/28/21 at 9:15 AM, V11 (Activity Aide) stated, I was in here (business office) and heard R2 talking about missing money, thirty-one dollars. I heard R2 yell, so I ran out there. R2 was behind the couch, stood up from the wheelchair and had R1 pinned on the couch. R2 was punching R1 in the head from behind. R1 was stuck and couldn't get up. When V12 (Business Office Manager) intervened, R1 got up and ran outside. R2 stopped when V12 yelled at him to stop. R1's nose and mouth were bleeding. The CNA's (Certified Nursing Assistant) were helping R1; R1 was sent to the hospital again. R2 has had behaviors before. On 10/28/21 at 9:26 AM, V12 (Business Office Manager) stated, I was not here for the first altercation. When I came in, I saw R2, and R2 told me not to look at him. R2 was agitated. I told R2 that I would discuss in the meeting on how to get his money back. R2 said, Nothing (curse word) ever gets done around here. R2 stated he had thirty-one dollars stolen from R2's wallet and went on his way. I heard yelling at the nurse's station and then R2 rolled past my office. I heard, This is what you get for stealing. I got up from my desk and walked out. I saw R2 wailing on R1. By the time I got over there, R2 was hitting R1. I yelled at R2 to stop. I grabbed R2's shirt to get R2 to stop and R2 did. R1 ran outside into the courtyard. V8 RN (Registered Nurse) said she knew it would happen again because R2 was so agitated. On 10/28/21 at 10:54 AM, V8 RN (Registered Nurse) stated, I was here for the altercation. I just started medication pass when V7 RN and I heard yelling. R1 and R2's room was on C hall. R1 and R2 were roommates. Somebody yelled to call 911 because R1 and R2 had just got into a fight. I called 911 and said we needed an ambulance and cops because R1 was on blood thinners. I didn't see anything. I was told what happened. R1 was on the floor in the hallway and R2 was in the bedroom sitting on the bed. R1 said, R2 just kept hitting me. When I asked R2 what happened (R2) said R1 took money and snacks or something. R1 went to the hospital. About 1.5 hours later, R1 came back with a closed head injury, bruise to (R1) head, and a swollen left wrist with a brace. R1 came to the desk and asked if R1 could sit in the living room. I said yes as long as they (R1 and R2) stayed apart. R2 came to the desk and said R1 had R2's money and was going to give it to another resident. I told R2 that he needed to talk to V1 (Administrator) because I don't have anything to do with money. R2 got loud with me and said, If you aren't going to do something; you guys aren't going to do anything about it. R2 went over to R1 who was sitting on the couch. R2 got behind R1, stood up from R2's wheelchair and started hitting R1. V11 and V12 came out of the business office towards R1, and I called 911. V12 got R2 off R1. V13 (Housekeeping Supervisor) came into the activity area and asked R2 to go to his room. R1 was outside bleeding. We wanted to get R1 away from R2. I went outside to assess R1, and R1 was bleeding pretty bad, so I sent R1 to the hospital. R1 looked very scared and said R1 wanted to press charges. R2 gets loud, yells and instigates situations with other residents. On 10/28/21 at 11:31 AM, V5 CNA (Certified Nursing Assistant) stated, I came in at 6:00 AM. I didn't see the first incident. For the second one I was at the nurse's station. I heard R2 state R1 was giving out money. R2 told the nurse if she wasn't going to do anything about it then (R2) was going to. V8 RN and V7 RN were at the nurse's station. I hear yelling and saw everyone go to the activity room. I saw R2 punching R1 and R1 ran to the back door, out onto the patio. I tried to go outside but R1 had R1's foot on the door to keep it closed. I had to scream for R1 to open it so I could see how bad R1 was hurt. R1 was bleeding from the nose, lip and ear. V5 CNA stated R2 was on every 15-minute checks after the first fight, but she didn't find a sheet to document every 15-minute checks. There was no documentation to show R2 had every 15-minute checks being done on 10/27/21 between the first fight and the second fight. On 10/28/21 at 1:36 PM, V7 RN stated, When R1 came back from the hospital (after first incident) R1 had a closed head injury and a swollen wrist per EMS (Emergency Medical Services). R2 was standing behind the paramedics and I gave them a heads up. EMS told R2 to leave. V1 came out and told R2 to move, R2 got an attitude and finally did. R1 was moved to another room. When R1 came back from the hospital R1's main priority was to find R1's phone charger. R2 was lurking around and not keeping R2's distance. R2 was very intrusive and in everyone else's business. R2 came up later and heard R1 and another resident talking about money. R2 lashed out and said, No one does anything in this place and if you don't take care of it; I am taking care of it myself. I didn't ask (R2) what (R2) meant. R2 wheeled from the front desk to the couch where R1 was sitting and started attacking R1 again. R1 ran out into the courtyard. R1 was pushing the door closed; R1 looked scared. R1 was afraid R2 was coming. R2 was punching R1, and R2 wasn't even looking at R1 but instead R2 was looking at everyone coming towards R2 as if R2 was saying it was our fault for not listening to R2. I feel we should have kept R2 and R1 completely distanced instead of letting R2 do whatever R2 wanted after the first incident happened. R2 was constantly lurking around R1 after the first fight. R2 has had incidents in the past of trying to get others riled up; R2 instigates things. On 10/28/21 at 2:41 PM V1 (Administrator) stated she was not at the facility for the first fight between R2 and R1. V1 stated that R2 was placed on every 15-minute checks. V1 stated staff should have filled out a form for every 15 minutes checks for R2. V1 stated she did not feel the facility could have done anything differently regarding the altercations between R1 and R2. The Nurse's Notes for R2 showed: On 10/27/21 at 7:15 AM R2 was in a physical altercation with his roommate. R2 accused R2's roommate of stealing. No injury noted. Another note with no date or time showed, R2 made physical contact with R2's ex-roommate again, unprovoked. No injury noted. The Identified Offender Information Form done by the facility for R2 showed on 6/15/21 a name-based background check was done and on 6/24/21 a fingerprint background check was done. The name-based background check done on 6/15/21 for R2 showed a HIT for convictions including domestic battery/bodily harm. The Identified Offender's Criminal Analysis Security Recommendation Report dated 7/21/21 for R2 showed the following risk assessment and security recommendation for R2, Moderate risk - The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal the need for closer observation or sustained visual monitoring on a time limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. R2's Care Plan dated 8/30/21 showed, Resident is known/has history of displaying inappropriate behavior and/or resisting care/services. R2 did not have a plan in place related to R2's history of being an identified offender with a moderate risk score. The Behavior Tracking Record dated October 2021 for R2 showed the facility was tracking Rejection of care, with 14 days of no tracking documented and no other behaviors being tracked. The MDS (Minimum Data Set) dated 9/13/21 for R2 showed R2 was alert, oriented and cognitively intact.

Based on observation, interview, and record review the facility failed to ensure a resident was supervised while showering which contributed to a resident (R8) falling in the shower and sustaining a femur(leg) fracture. The facility failed to ensure a resident(R16) was ambulated in a safe manner with a gait belt. This applies to 2 of 12 residents (R8, R16) reviewed for safety/supervision in the sample of 12. The findings include: 1. R8's Care Plan dated December 20, 2017 showed R8 has risk factors that require monitoring and intervention to reduce potential for self-injury due to her medical conditions that affect her balance and gait. The Care Plan showed Monitor (R8) for signs of fatigue during ambulation. R8's Occupational Therapy Plan of Care dated January 9, 2020 showed R8 needed supervision or touch assistance with verbal cueing during showering/bathing. R8's Fall Risk assessment dated [DATE] showed R8 was at high risk for falls. R8's resident assessment dated [DATE] showed R8 required limited assistance of one staff when showering/bathing. R8's Nurse's Notes dated June 30, 2021 showed R8 reported to staff that she had fallen on June 29, 2021 while in the shower. The Note showed that R8 complained of right knee and right ankle pain and is limping. Physician notified and new orders received .X-rays of right knee and right ankle ordered. R8's Nurse's Notes dated July 1, 2021 showed portable X-rays were completed in the facility on R8's right knee and right ankle. X-ray results showed a fractured right femur. R8 was sent to a local hospital for an evaluation of the injury. R8's X-ray report dated July 1, 2021 showed, Oblique fracture at the superior patellar pole. Fracture distal femur at the adductor tubercle . R8's fall incident report dated June 30, 2021 showed R8 was alone in the shower when she fell . On September 21, 2021 at 9:37 AM, R8 stated. I fell in the shower. I was by myself. I told the nurse. On September 21, 2021 at 10:51 AM, V1 Administrator stated, (R8) was in the shower by herself when she fell . She got herself up. She started limping and told the nurse she fell . We did X-rays on her here that showed she had a right femur fracture. She was sent to the hospital for an evaluation and returned to us the same day. I don't know if she was at risk for falls . On September 21, 2021 at 1:00 PM, V9 Physician stated, Although she (R8) is at a lower risk for falls, she still needs to be supervised when going to the bathroom and in the shower. 2. R16's Care Plan dated March 23, 2020 showed R16 has fall risk factors that require monitoring and intervention to reduce potential for self-injury .Use 1 to 2 assist as needed with a gait belt . The Care Plan showed R16 had diagnoses including history of falls, unsteadiness on feet, and difficulty in walking. On September 20, 2021 at 1:44 PM, R16 was walking down the hallway using a walker. V5 Physical Therapy Assistant was walking next to R16. No gait belt was in place around R16's waist. On September 21, 2021 at 9:01 AM, V6 Registered Nurse stated, (R16) is at risk for falls. All staff must use a gait belt when transferring or walking (R16). The facility's Ambulation Without Device policy dated September 2018 showed, Procedure: A. Place transfer belt around resident's waist, unless contraindicated .

Based on observation, interview, and record review the facility failed to supervise a cognitively impaired resident while outside the facility for 1 of 3 residents (R1) reviewed for supervision in the sample of 11. After R1 was left outside of the facility, in the sun, unsupervised, R1 was found unresponsive, red in the face, with a body temperature of 102 degrees Fahrenheit requiring 911 to be called. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/10/21 when R1 was found outside unattended and unresponsive. The Immediate Jeopardy was identified on 9/16/21. V1 Administrator was informed of the Immediate Jeopardy on 9/16/21. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/16/21 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Nurses Note dated 9/10/21 shows 4:30 PM, staff member alerted this nurse to a resident that needed assistance. This nurse assessed resident and called MD and 911 and sent to ER for Evaluation. The resident's temp was 102 and was lethargic. R1's emergency room Doctor's Progress Note dated 9/10/21 at 5:14 PM, shows R1 presents from nursing home with altered mental status. Was apparently found outside sitting in the sun for an unknown period of time. No one is sure how patient got outside since patient is non-ambulatory. Patient initially unresponsive and when stimulated awoke. The patient was hot and noted to have [CONDITION(S)] to chest and face. On paramedic's exam had fever of 102 degrees Fahrenheit .Patient initially had high temperature which came down on its own-may have been environmentally induced. Given intravenous hydration. Blood work shows evidence of dehydration. Based on patient's presentation and clinical findings she will need admission for heat related illness, altered mental status and urinary tract infection. R1's Face sheet shows R1 is [AGE] years old and has diagnoses of dementia, altered mental status, [CONDITION(S)] with delusions, metabolic [CONDITION(S)], and history of falling. R1's Minimum Data Set, dated dated dated [DATE] shows R1 is severely cognitively impaired and requires extensive assistance with activities of daily living. R1's Care Plan dated 6/16/21 shows R1 due to dementia, very difficult for resident to communicate needs, altered thought process and nonverbal resident has risk factors that require monitoring and intervention to reduce potential for self-injury encourage R1 to sit in areas well supervised by staff. On 9/14/21 at 9:30 AM, V2 Licensed Practical Nurse (LPN) said last Friday (9/10/21) around 4:30 PM, V11 Activity Aid brought R1 in from outside and to the nurse's station. V2 said R1 was in her wheelchair with her head back and was unresponsive. V2 said R1 only responded to sternal rub and her skin on her face and chest was red and hot to the touch. V2 stated R1's temperature was 102 degrees, I assumed from the heat, so we put ice packs and cold rags on her. I called the doctor and 911. There is conflicting stories as to what happened and how long she was outside. R2 said R3 pushed her outside, but R3 denied this. R1 does self-propel in the wheelchair and has tried to go out other doors in the past. I last saw R1 at lunch time for her noon medications and then didn't see her again until 4:30 PM when she was brought to me. R1 is still at the hospital, she was admitted with heat related altered mental status and a urinary tract infection. On 9/14/21 at 12:52 PM, V11 Activity Aid said at 4:15 PM during the resident smoke break, she found R1 outside in the patio area with her head back, face up to the sun and arms out to the side. V11 said R1's eyes were slightly open, and her face was red. V11 said R1 wasn't responding, and she brought her in to the nurse. V11 said she last saw R1 in the activity room around 2:10 PM. V11 said it was hot and sunny that day. On 9/14/21 at 12:49 PM, V10 Certified Nursing Assistant (CNA) stated when V11 brought R1 inside, she wasn't responding. It was really scary. She was really warm, so we started cooling her off with ice and wet washcloths. Her face, neck, and chest area was red. It looked like she had blisters. V10 said R1 was wearing a long sleeve shirt and sweatpants. V10 said it was hot outside that day. V10 said she remembers seeing R1 between 3:00 to 3:30 PM by an office in the far corner of the activity room but wasn't certain. On 9/14/21 at 12:40 PM, V12 Hospital emergency room Nurse said when R1 came to the ER she had a temperature of 101 degrees and was very red in the face, chest, and shoulders. V12 said the report from the paramedics was R1 was found outside, unattended in the full sun and unresponsive. Upon arrival, paramedics reported R1 had altered mental status and a temperature of 101 degrees. The facility reported that they think another resident pushed her out there and they were not sure how long she was outside. V12 said R1's skin was red like a sunburn, but not blistering. V12 said R1 was admitted with altered mental status, sunburn, and urinary tract infection. On 9/14/21 at 8:45 AM, R2 (who is cognitively intact per Minimum Data Set, dated dated dated [DATE]) said R1 was outside by herself and got too hot and was sent to the hospital. R2 said she saw R3 push R1 outside around 3:30 PM. R2 said now that door is locked. On 9/14/21 at 10:06 AM, R3 (who is cognitively intact per Minimum Data Set, dated dated dated [DATE]) said a few days ago R1 was outside in the sun and got heat stroke. R3 said he saw R1 outside at 1:30 PM and then when he went back outside for a smoke at 3:30 PM, she was still out there. R3 said it was hot out and R1 didn't look so well. R3 said if he was smarter, he should have said something. R3 said he did not know how R1 got out there. On 9/14/21 at 10:27 AM, R11 said she saw R1 outside at the 4 PM smoke break and R1 looked like she was sunburn. R11 said R1 looked like she was sleeping, she had her eyes closed. On 9/14/21 at 9:14 AM, R6 said you used to go out on the patio whenever you wanted. The door was not locked. On 9/14/21 at 9:16 AM, V3 Activity Director was outside on the patio with numerous residents who were smoking. The doorframe to the patio area had an alarm with a key sticking out of it. The patio area was a cement pad and was in full sun with no shade. V3 said the door was unlocked and the key was in the alarm, so the residents were able to come and go whenever they wanted before. V3 said residents were able to be outside without staff before last week. V3 said R1 came out on Friday and got sunburn and now the door is to be locked and staff has to be present. V3 said R1 is an elderly lady that has dementia and wouldn't know to come inside if she was too hot. On 9/14/21 at 9:46 AM, V5 CNA said R1 is confused and mentally would not know to come inside or be able to get herself inside. On 9/14/21 at 12:48 PM, V9 CNA said R1 has dementia and is confused. V9 said R1 can propel herself but R1 would not know to come inside if she was getting hot. V9 said she saw R1 in the activity room by an office in the corner around 3:00 PM when she went on her lunch break. On 9/14/21 at 1:43 PM, V2 LPN said due to R1's dementia and cognition, R1 wouldn't recognize she was getting over heated and know to come back inside. V2 said with how the door frame/threshold is and the cement area on the patio, R1 wouldn't even be able to get back inside by herself. V2 said R1 should be supervised. On 9/14/21 at 10:32 AM, V3 Activity Director said there was no activities in the activity room (the patio door is in the activity area) on Friday, so no staff were in that area to be able to see outside in the patio area. On 9/14/21 at 10:55 AM, V1 Administrator said she was notified by staff that R1 was found outside and sent to the hospital for heat issues. V1 said residents reported R1 was pushed outside by another resident but that resident denied it and they were not sure how R1 got outside. V1 said through staff interview, they think R1 was observed in the activity room prior to 3:30 PM but can't account for R1 after that time and are really not sure how long R1 was outside. V1 said at that time (Friday 9/10/21) the residents were able to go out on the patio when they wanted. The door was unlocked, and the key was in the alarm to disarm it. V1 said staff were only present outside with residents during smoke breaks and outdoor activities. On 9/15/21 at 1:20 PM, localconditions.com website shows on 9/10/21 at 2-4:00 PM, [NAME] Il temperature was 79-80 degrees with humidity at 37 %. On 9/14/21 at 2:55 PM, V13 Hospital Floor Nurse said she has been taking care of R1 at the hospital for the last few days. V13 said R1 was admitted for dehydration and a urinary tract infection. V13 said R1 has received intravenous fluids and antibiotics. V13 said the facility reported R1 was left outside, unattended for about 3 to 4 hours. V13 said when R1 got to the floor her skin on her face and neck was red like a sunburn. On 9/14/21 at 3:00 PM, R1 was in the hospital bed with her daughter at bedside. R1's skin on her face and neck was slightly pink as compared to her arms. R1 was mumbling and appeared confused. V14 (R1's daughter) stated the nursing home left her out in the heat for hours, she had a fever of 102 degrees and was not responsive. I don't want her to go back there! The facility was unable to provide a safety/supervision policy. The Immediate Jeopardy that began on 9/10/21 was removed and the deficient practice corrected 9/16/21 when the facility took the following actions to remove the immediacy and correct the noncompliance. The Administrator immediately ensured the alarmed doors were active and in working order on 9/10/2021 at 8:21 PM. The Administrator began in-servicing all staff on 09/10/2021 at 8:20 PM in regard to proper monitoring of residents, the door alarm policy, and the need for all residents to be monitored during their time outside. This education to be completed on 09/16/2021 at 12:00. The Medical Director reviewed the abatement plan on 9/16/2021. The IDT team will meet and discuss during morning meeting items related to: Fair weather outside safety for residents. Supervision of cognitively impaired residents in outdoor settings. The DON/designee (Administrator) will conduct rounds to monitor for compliance and safety related to residents being outside. These rounds will continue for four weeks and then will be followed by random review to maintain compliance. Ad hoc education will be given immediately to staff during such rounds. Assigned staff, including but not limited to activity or C.N.A. staff, will monitor residents while outside. Residents at high risk for heat related illness will be identified on the resident roster and made available to all staff to assist in proper monitoring. The resident roster with identified at risk residents will be made available to staff by 09/16/2021 at 4:00 PM. Nurse and/or Administrator will monitor weather conditions and give direction related to allowing residents outside.

Based on interview and record review the facility failed to ensure a resident was safely assisted from the facility van. The facility failed to ensure residents were supervised in common areas of the building resulting in physical altercations between residents. This failure resulted in R158 falling to the ground and sustaining multiple pelvic fractures. The facility failed to update a resident's comprehensive care plan following falls. This applies to 2 of 15 residents (R13 and R35) reviewed for safety and supervision in the sample of 15 and 1 resident (R158) outside the sample. The findings include: 1. The facility's incident report dated (MONTH) 4, (YEAR), showed on (MONTH) 31, (YEAR), R13 struck R158 with a closed fist. The residents were separated. There were no injuries to either resident. The facility's intervention was to keep the residents away from each other. R158's nurses note dated (MONTH) 31, (YEAR), showed at 6:30 PM, R158 was hit in the face and arm by a fell ow resident (R13) and was calling the police. R158 stated I was playing on my phone and he hit me in the face and on the arm. The local police arrived and spoke with the residents. R158's physician was called with a new order to keep the residents apart. R158's nurses note dated (MONTH) 19, (YEAR) at 6:20 PM, showed R158 was heard yelling in the community room at 3:45 PM. R158 was lying on the floor on her right side. R158 reported she was having pain in her tailbone and inner thighs. R158 was having difficulty trying to get up. R158 was transported to the local hospital by ambulance due to her pain and immobility. Another resident that had witnessed the incident reported that the perpetrator (R13) walked up to her and pushed her. At 9:30 PM, the local hospital was called for an update. R158 had multiple pelvic fractures. R158's hospital discharge summary dated (MONTH) 27, (YEAR), showed R158 was admitted to the hospital following a fall in a nursing facility resulting in multiple closed pelvic fractures with disruption of the pelvic bone. The facility's incident report dated (MONTH) 28, (YEAR) showed on (MONTH) 19, (YEAR), facility staff responded to a report of R13 shoving R158 to the floor. The residents were separated and assessed. The nurse on duty stated she heard R158 yelling at R13 in an angry tone then heard a commotion. The nurse observed R158 lying on the floor in pain. An ambulance was called an R158 was transferred to the local hospital. The new intervention to be put in place was to keep the residents away from each other. R158's care plan was reviewed for interventions related to the resident to resident altercation of (MONTH) 31st and (MONTH) 19, (YEAR). There were no interventions listed. On (MONTH) 7, (YEAR) at 2:11 PM, V2 (Director of Nurses) was asked if R13 and R158 were being supervised and kept apart. V2 stated, apparently not if he push her down. V2 stated there should have been interventions put in place after each incident. V2 was not aware of why the care plan was not updated. V2 stated it is important to keep the care plans updated so the staff know how to care for residents following falls and resident altercations. 2. R35's Minimum Data Set (MDS) dated (MONTH) 27, (YEAR) shows [DIAGNOSES REDACTED]. The MDS shows R35 is cognitively intact, and has no memory impairment. R35's (MONTH) 20, (YEAR) at 12:00 nurse note shows received report from DON (Director of Nursing) that patient fell backward in her wheelchair while out at an appointment and was sent to the ED (Emergency Department). On (MONTH) 7, (YEAR) at 8:37 AM, Z1 (Administrator) said the van driver notified him that R35 fell off the back of the lift, backwards, in her wheelchair. Z1 said R35 started moving while on the lift, tipped backwards and hit the ground. Z1 said R35 started spasming in her wheelchair, is a bigger woman, and tipped the chair over backward. On (MONTH) 7, (YEAR) at 10:08 AM, Z12 (Van Driver) said he was with R35 when she had her accident in the wheelchair. Z12 said he pushed R35 onto the facility van lift, locked her breaks, and turned around to operate the lift and saw her going over backwards. Z12 said the lift was up and R35 was suspended in the air 3-4 feet when she fell . Z12 said R35 flipped over backwards. I was in the van and then tried to grab the wheelchair. We both went over and fell on the ground. Someone call 911 who saw the accident. Z12 said he felt like somehow R35 got over center on the fulcrum. Z12 said R35 doesn't ride in her wheelchair because it is too big, and needs to ride in a facility wheelchair that is smaller. She was squeezed into a smaller chair. Z12 said there is 6-8 inch block that raises at the front and back of the ramp when it is in use. R35 went over the block at the back, and fell backwards in her chair, landing on her back. She fell about 3 feet from the ramp to the ground. On (MONTH) 7, (YEAR) at 10:33AM, R35 said she fell over backwards in her wheelchair off the facility van lift and landed on the back of her head. R35 said she was taken to the hospital by an ambulance from the parking lot. R35 said I thought I was gone when I fell , I hit my head so hard. R35 said she was going to get diabetic shoes, and she went in the facility van with Z12. R35 said they put her in a wheel chair that was too small for her because her wheelchair was too big for the van. R35 pointed to her wheelchair, and she was sitting in bariatric sized wheelchair. R35 said when they got to the store parking lot (Z12) came around, and unlocked the chair and moved her on the ramp out on the lift that extended off the back of the van. R35 said there is a hump the wheelchair has to go over to get out on the lift. R35 said (Z12) was in the van standing in front of her pushing her backwards and she was using her legs to help push over the bump because the chair wasn't moving. She said (Z12) was pushing her from the front, and she went straight over the back of the ramp. When he was pushing me out on the ramp I just kept going and flopped over backwards .he was right there and went over and landed on top of me on the ground. R35 said she has not gone in the facility van since she tipped over backwards off the ramp. At 11:33AM, Z12 turned the facility van on and activated the ramp and pointed to the raised back that stood about 8 inches in the air. The ramp was positioned 3-4 feet off the ground when it was extended off the back of the van. There was approximately a 2 inch incline from the facility van to the ramp. There was a raised area where the ramp met the facility van. Z12 said he was standing in front of R35 pushing her to the ramp when she fell . On (MONTH) 8, (YEAR) at 11:20 AM, Z1 (Administrator) and Z2 (Director of Nursing) said there was no formal investigation done or report of an investigation into the R35's fall from the facility van. Z1 said he talked to R35 and the van driver but no incident report was done. Z2 said there were no new interventions put into place since the fall. Z1 said the facility wheelchair that R35 used the day she fell had a maximum weight capacity of 275-300 pounds. The (MONTH) (YEAR) Monthly weight shows R35's weight as 319 pounds, and the January, (YEAR) form shows R35's weight as 319.7 pounds, almost 20 pounds higher than the maximum capacity weight for the wheelchair used to transport R35 on (MONTH) 20, (YEAR). R35's care plan dated (MONTH) 11, (YEAR) shows resident is morbidly obese. R35's Fall risk care plan reviewed on (MONTH) 30, (YEAR) does not have any interventions regarding the fall from the facility van.

Based on interview and record review, the facility failed to provide Cardio [MEDICAL CONDITION] resuscitation services according to standards of practice. R1 was found hanging from a scarf and without vital signs. The facility failed to establish an open airway and initiate artificial respirations immediately when they began CPR. No respirations were administered to R1 for a period of approximately 10 minutes. R1 later expired at the hospital due to [MEDICAL CONDITION]. The Immediate Jeopardy began on [DATE] at 5:50 PM, when R1 was found by her roommate hanging from a scarf and unresponsive, and later expired. E2 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:30 PM. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the effectiveness of any new policies, procedures, and training provided to the staff. This applies to 1 of 41 residents (R1) reviewed for care and services related to basic life support in the sample of 47. The findings include: R1's admission orders [REDACTED]. The facility's Advance Directive policy dated [DATE] shows it is the policy of the facility to honor resident's wishes as expressed in advance directives. If CPR (cardiopulmonary resuscitation) is indicated personnel shall administer CPR. The facility's incident timeline shows R3 (R1's roommate) found R1 hanging from her scarf on [DATE] at 5:50 PM. The facility was unable to provide a policy for CPR when requested. An Emergency Care Policy dated [DATE] was provided. R1's nurse's notes dated [DATE] at 7:00 PM, shows at 5:56 PM, E11 RN (Registered Nurse) was notified by R1's roommate that she wanted to show her something in her room. When E11 got to the room R1 was found hanging from a pipe in the ceiling by her scarf. R1's face was white and she was warm to the touch. On [DATE] at 9:00 AM, E11 RN (Registered Nurse) said R1's roommate (R3) came to the nurse's station and said I have something to show you. E11 and E9 RN walked with R3 down the hall toward R1's room. We got about half way there and R3 said I hope she is faking. E11 and E9 ran the rest of the way to the room and found R1with a knit scarf tied around her neck and looped around a pipe. R1's eyes were closed, her face was white, lips were white and she was not breathing. I tried lifting R1 as E9 called 911 and attempted to cut the scarf to release R1 from the pipe. E10 LPN (Licensed Practical Nurse) came into the room and tried to help me hold her up so E9 could cut the scarf. There was a chair nearby in the middle of the doorway with two coats on it. We lowered R1 to the chair and then the floor and E9 started chest compression while I went to get the ambu bag. At 11:40 AM, E11 said it was probably ,[DATE] minutes from the time we went to check on R1 until the time the ambu bag arrived to the room. At 10:25 AM, E9 said R1's roommate (R3) came to the medication cart and said she needed two nurses in her room. E9 and E11 proceeded to R1's room when R3 said I hope she is faking. E9 said they found R1 hanging from a pipe in the room. The television was very loud and she called 911 and threw the cell phone to E4 CNA (Certified Nursing Assistant) while she attempted to cut R1's scarf down with some scissors. E9 said there was no pulse or respirations and E10 started chest compressions. E9 said they struggled trying to cut R1 down and mouth to mouth respirations were not done. The CNA helped with chest compressions but no respirations were given until the ambu bag arrived in the room. The facility's undated timeline of events of [DATE] show the scarf was tied around the resident's neck very tight. At 10:45 AM, E10 said E11 and E9 got to the room about 20 seconds before me. E11 was trying to hold R1 up and E9 was trying to cut the scarf. I gave E9 my scissors to use. I helped E11 hold up R1. I started doing chest compressions and nobody was doing ventilations. E11 ran to get an ambu bag. R1 was still warm; there was no response from her. I was yelling her name thinking maybe it would jolt her back. At 3:15 PM, E10 said I attempted ventilations with the ambu bag and the air kept leaking out the sides. I moved her head and neck to try to get a good seal and air kept coming out the sides of the mask. I don't think we ever got the scarf off from around her neck. On [DATE] at 12:20 PM, E4 CNA said she was involved with resuscitation efforts on R1 along with E,[DATE]. When I got to R1's room she was hanging from the water pipe by a scarf around her neck. The three nurses were trying to cut her down. R1's feet were not on the floor. Nobody did mouth to mouth breathing. They were waiting for the bag thing I never saw before. I relieved E10 to do chest compressions and continued until the paramedics arrived. When E10 used the mask to help with breathing the air was going in the mouth and coming back out. The scarf was knotted on her neck pretty good while I was giving chest compressions. The local ambulance report shows the paramedics arrived to the patient at 6:07 PM. On [DATE] at 3:30 PM, Z3 local Fire Chief said the scarf was still around R1's neck when he arrived at the scene on [DATE]. Z3 said the facility was not attempting to remove the scarf. We called it to their attention, that if the scarf were removed it would help ventilation. The facility then removed the scarf. We did not have any problems ventilating the resident. Of course, the scarf was not tied around her neck at that time. The National Institutes of Health Medline Plus website shows CPR is a lifesaving procedure that is done when someone's breathing or heartbeat has stopped and involves rescue breathing, which provides oxygen to a person's lungs and chest compressions, which keep the person's blood circulating. Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only four minutes without oxygen, and death can occur as soon as four to six minutes later. The American Red Cross recommends to open the airway and begin CPR if there is no breathing after calling 911. On [DATE] at 11:45 AM, Z8 facility Medical Director said ,[DATE] minutes is a significant amount of time to delay ventilating a person who is not breathing. Just because you don't have an ambu bag doesn't mean you don't ventilate. R1's local emergency room record dated [DATE] shows R1 presented to the hospital at 6:21 PM and was pronounced dead at 6:24 PM. Through observation, interview, and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: A. All direct care staff received CPR training by [DATE]. B. All staff inservice training done with emphasis on having an open airway by [DATE]. C. Staff education on location of emergency supply carts was completed by [DATE]. The Administrator and the Director of Nursing shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of this plan of removal as of [DATE].

Based on observation, interview, and record review the facility neglected to follow their Abuse Prevention policy and procedure by not determining the cause and treating 34 residents suffering from a communicable rash from [DATE] to [DATE], 2013. This failure contributed to 39 of 54 residents experiencing pain, severe itching, mental anguish and [MEDICAL CONDITION] from a communicable rash. This applies to 39 of 56 residents (R1-R20, R23-R34, R,[DATE], R43, R46, and R56) reviewed for communicable skin eruptions in the sample of 56. The findings include: 1. Wound care Sheets were reviewed for all of the residents. The records show the rash has been ongoing since [DATE]. The monthly breakdown of rashes is as follows: June - 11 residents, July - 18 residents, August - 23 residents, [DATE] residents, and [DATE] - 32 residents were inflicted with the same itchy, red, raised rash. In [DATE] residents (R5, 21, 19, 25, 32, 33, 26, 3, 24, 23, 10, 7, 29, 34, 18, 4, 11, 14, 15, and R2) were treated with the Scabicide, [MEDICATION NAME]. The facility did not treat all of the residents or staff. The Centers for Disease Control recommends the following: "All patients or residents (symptomatic and asymptomatic) should be treated on the same day...All employees should be treated on the same day as the residents...(Table I: Recommended Actions and Rationale for Preventing the Transmission of Scabies in Healthcare and Residential Facilities). 2. R1's [DIAGNOSES REDACTED]. He has upper and lower extremity range of motion impairment. Nursing Notes show R1 had a red, raised rash from [DATE] to [DATE] (resident expired). The Nursing Notes document the resident's rash covered his entire body. The resident complained of itching. POS's for those months show the resident was treated with [MEDICATION NAME] ointment 0.1% twice daily (BID), Vaseline to Rash BID, Dermasmooth 0.1% oil BID for 2 weeks then off for 2 weeks. In October he received baths with Hibaclens daily, for 7 days. On [DATE], Z8 (Hospice Doctor) ordered skin scrapings to be done in an effort to determine the causative factor of the rash. On [DATE] at 4:00 PM, E2 (Director of Nursing) said Z9 (Medical Director) discontinued the order because he had no means of doing the skin scraping. Confidential interviewees said, " I would say at least 10 residents complain of itching on a daily basis. They are digging holes in their skin. (R1) was covered head to toe. He sat in bed scratching all day, until he passed away. (R1) also had Diabetic Ulcers on his foot. We reported it several times." (R1) broke my heart (crying). Oh my God, he was covered head to toe." During a confidential nurse interview it was stated, "I am ready to lose my mind. This rash is horrible. I am itching. I have the rash on my arms, breast, sides, and ankles. I don't know how the residents can stand it. Residents have died itching themselves. They (facility administration) aren't doing anything about the rashes. It will never get under control. (R1, 32, and 33) were covered with the rash up until they died . (R1) was the worst. A hospital History and Physical of [DATE] documents the following regarding R1: "Maculopapular rash all over his body..." On [DATE] at 6:00 PM, Z7 said, "When I saw him (R1) in the hospital on [DATE], I was shocked at his condition. His entire body was covered with sores. The poor man, the itching was awful. I had talked with the nursing staff at the facility several times regarding the itching. They put "boxing glove" appearing mitts on his hands so he wouldn't scratch. The facility was supposed to take him to a dermatologist. That never happened. At the hospital, the staff gowned and gloved every time they entered his room. They didn't know what the rash was either. The sores were oozing." On [DATE] and [DATE] confidential interviewees made the following statements. "There is no definitive [DIAGNOSES REDACTED]. They are very itchy and ooze a serous fluid. I got them mostly on my stomach and under my breasts. I would say at least 10 residents complain of itching on a daily basis. They are digging holes in their skin. (R1) was covered heat to toe. He sat in bed scratching all day, until he passed away. Not only the residents have the rash, employees have it too. We are worried about taking this home to our families. The staff wrote a letter to corporate about this rash, we never heard anything from them. The rashes started in June. I had it. I went to the doctor and was told I had Scabies. He gave me cream for it. I had the rash on my arms, neck, stomach, legs, under my bra, peri area...every where. Families would come to us crying because their loved ones were so miserable with the itching. We were all threatened by E9 (Registered Nurse - Corporate) that if we said anything about the rashes in the building, we would lose our jobs. I am ashamed I haven't spoken up. It's terrible when we have to make a choice, speak up or lose our jobs. The rash comes and goes. When I work for several days in succession, I have bites all over me. The bites itch horribly. When I am off for a few days, the rash subsides, then when I come back to work it starts all over again. You can't see anything biting, but sure do feel it. They have no idea what this is, but they keep bringing in more residents. I just itch and itch. I have been treated for [REDACTED]. I have scratched so much, I am bruised. The residents look very uncomfortable through out the building. I got the rash on my hands. My doctor treated me for Scabies. The rashes differ from each other. They are usually red papules, very itchy. (R32) has died . She was covered from her neck down to her feet, even the palms of her hands. Every night she would scratch and scratch, and scream out because of the severe itching. (R33) also had the rash when she died . It wasn't as bad as ( R32's). (R2) has been in the hospital. When he left here he was miserable. Even the palms of his hands had the rash. It's terrible when elderly people are in agony. This is the worse form of neglect I have ever seen. This is a Psychiatric facility. The residents behaviors have increased with the worsening of the rashes. They don't know what it is. At one point the facility was treated for [REDACTED]. At one point, about 20 residents were treated for [REDACTED]. The facility handed out Permethine ointment (scabies treatment) for any staff who wanted it. On [DATE] at 2:30 PM, a contracted staff member (confidential) said the outbreak of the rash goes back to [DATE]. The interviewee stated she has been treated by her physician twice for scabies. I have had to be off of work twice because of them. I had the rash on my arms, face, back, waist, inner thighs, calves, back of knees. The rash consisted of red raised blister-like bumps. They are very itchy." On [DATE] skin checks were conducted from 9:30 AM. to 11:30 AM. Thirty-Two residents (R4-R20, R,[DATE], R34, R,[DATE], R46, and R56) were found with some stage of the rash, ranging from bright red, raised papules to open wounds to light pink scattered red areas. The rashes ranged from in just one area of the body to the entire body. Many of the rashes were concentrated on the shoulders, arms, abdomen, back, legs and buttocks. The residents had many scratches on their skin and areas where the skin had been open and bleeding. Five closed resident records (R1-R3, R32 and R33) were reviewed, all were found to have the rash at time of discharge/death. On [DATE], during skin checks, the following comments were made from residents. R9 said she had itched since she arrived 1 month ago. R9 said, "It hurts. R10 said, I wake up scratching. Itches so bad I couldn't sleep last night.' R10 said he has had the rash for a couple of months. He said it gets better and then it reoccurs. R11 said, "Itches all over right now. Itches constantly. I complain but they don't give me anything for it. I can't focus on anything but the itching." R14 said, "It's uncomfortable. I am tired and worn out from scratching. I can't think about anything but the itching. Keeps me up at night. I've had it since July (2013)." R16 said, "Itching keeps me awake. There are days I want to rip my hair out of my head." R24 said, "It itches like hell!" R28 said, "The rash is painfully itchy. I was awake all night scratching (Resident crying). I'm out of my mind with all the itching." On [DATE], the facility sent (facsimile) a document showing all of the treatments tried, in an effort to treat the scabies-like rash. The only scabicide treatments used were the [MEDICATION NAME] and the Lindayn cream. The facility and staff were never 100% treated with the Scabicides. The other treatments were used to try to soothe the itching and inflammation. On [DATE] at 4:00 PM, E8 (regional Director) said, "We are really trying to clear this up. We know we have a problem." On [DATE] at 11:30 AM, Z9 (Medical Director) said, "We are not able to contain or cure it, we don't know what it is." The facility's Abuse Prevention Program ([DATE]) states, "Neglect is the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with Activities of Daily Living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident".

Based on observation, interview, and record review the facility failed to provide care and services to treat a resident with worsening diabetic ulcers. The facility also failed to provide care and services for residents suffering from communicable skin eruptions. This failure contributed to pain, severe itching, and mental anguish. This applies to 39 (R1-R20, R23-R34, R,[DATE], R43, R46, and R56) of 56 residents reviewed for communicable skin eruptions in the sample of 56. The findings include: 1. R1's [DIAGNOSES REDACTED]. He has upper and lower extremity range of motion impairment. Nursing Notes show R1 had a red, raised rash from [DATE] to [DATE] (resident expired [DATE]). The Nursing Notes document the resident's rash covered his entire body. The resident complained of itching. POS's for those months show the resident was treated with [MEDICATION NAME] ointment 0.1% twice daily (BID), Vaseline to Rash BID, Dermasmooth 0.1% oil BID for 2 weeks then off for 2 weeks. In October he received baths with Hibaclens daily, for 7 days. On [DATE], Z8 (Hospice Doctor) ordered skin scrapings to be done in an effort to determine the causative factor of the rash. On [DATE] at 4:00 PM, E2 (Director of Nursing) said Z9 (Medical Director) discontinued the order because he had no means of doing the skin scraping. Confidential interviewees said, " I would say at least 10 residents complain of itching on a daily basis. They are digging holes in their skin. (R1) was covered heat to toe. He sat in bed scratching all day, until he passed away. (R1) also had Diabetic Ulcers on his foot. We reported it several times. By the time he passed the ulcers took over his entire foot. Nothing was done for his. He got progressively worse. He complained of pain. (R1) broke my heart (crying). Oh my God, he was covered head to toe." During a confidential nurse interview it was stated, "I am ready to lose my mind. This rash is horrible. I am itching. I have the rash on my arms, breast, sides, and ankles. I don't know how the residents can stand it. Residents have died itching themselves. The facility keeps bringing new residents in. They aren't doing anything about the rashes. It will never get under control. (R1, 32, and 33) were covered with the rash up until they died . (R1) was the worst. (R1) had diabetic ulcers on his feet. His feet shouldn't have gotten like that if we would have had wound care specialists treat him. We could never get him to his scheduled appointments. Nursing documentation shows R1's diabetic ulcers had worsened. The nursing documentation is as follows: [DATE]: Rash to entire body... Complaining of itchiness... Diabetic foot sore to left big toe, black area near upper part of toe near toenail. Right big toe Diabetic foot sore black area near upper part of toe near toenail. Right outer foot black [MEDICAL CONDITION]. Wound clinic appointment scheduled per transportation." Nursing documentation of [DATE] is as follows: "...Red raised scabbed areas to entire body...itchy...Diabetic foot sores to left and right big toe and outer right foot and left inner heel. Wrapped with gauze...Bilateral feet red...painful to touch...PRN [MEDICATION NAME] (pain medication) given with some relief." A hospital History and Physical of [DATE] documents the following regarding R1: "Maculopapular rash all over his body, Multiple bilateral [MEDICAL CONDITION]." On [DATE] at 6:00 PM, Z7 said, "When I saw him (R1) in the hospital on [DATE], I was shocked at his condition. His entire body was covered with sores. The poor man, the itching was awful. I had talked with the nursing staff at the facility several times regarding the itching. They put "boxing glove" appearing mitts on his hands so he wouldn't scratch. The facility was supposed to take him to a dermatologist. That never happened. At the hospital, the staff gowned and gloved every time they entered his room. They didn't know what the rash was either." The interviewee said R1 was diabetic. She said his feet were full of diabetic ulcers. The bottom of his feet looked like raw hamburger. He had huge sores, other than the rash. The sores were oozing. 2. On [DATE] and [DATE] confidential interviewees made the following statements. "There is no definitive [DIAGNOSES REDACTED]. They are very itchy and ooze a serous fluid. I got them mostly on my stomach and under my breasts. I would say at least 10 residents complain of itching on a daily basis. They are digging holes in their skin. (R1) was covered heat to toe. He sat in bed scratching all day, until he passed away. Not only the residents have the rash, employees have it too. We are worried about taking this home to our families. The staff wrote a letter to corporate about this rash, we never heard anything from them. The rashes started in June. I had it. I went to the doctor and was told I had Scabies. He gave me cream for it. I had the rash on my arms, neck, stomach, legs, under my bra, peri area...every where. Families would come to us crying because their loved ones were so miserable with the itching. We were all threatened by E9 (Registered Nurse - Corporate) that if we said anything about the rashes in the building, we would lose our jobs. I am ashamed I haven't spoken up. It's terrible when we have to make a choice, speak up or lose our jobs. The rash comes and goes. When I work for several days in succession, I have bites all over me. The bites itch horribly. When I am off for a few days, the rash subsides, then when I come back to work it starts all over again. You can't see anything biting, but sure do feel it. They have no idea what this is, but they keep bringing in more residents. I just itch and itch. I have been treated for [REDACTED]. I have scratched so much, I am bruised. The residents look very uncomfortable through out the building. I got the rash on my hands. My doctor treated me for Scabies. The rashes differ from each other. They are usually red papules, very itchy. (R32) has died . She was covered from her neck down to her feet, even the palms of her hands. Every night she would scratch and scratch, and scream out because of the severe itching. (R33) also had the rash when she died . It wasn't as bad as ( R32's). (R2) has been in the hospital. When he left here he was miserable. Even the palms of his hands had the rash. It's terrible when elderly people are in agony. This is the worse form of neglect I have ever seen. This is a Psychiatric facility. The residents behaviors have increased with the worsening of the rashes. They don't know what it is. At one point the facility was treated for [REDACTED]. At one point, about 20 residents were treated for [REDACTED]. The facility handed out Permethine ointment (scabies treatment) for any staff who wanted it. On [DATE] at 2:30 PM, a contracted staff member (confidential) said the outbreak of the rash goes back to [DATE]. The interviewee stated she has been treated by her physician twice for scabies. I have had to be off of work twice because of them. I had the rash on my arms, face, back, waist, inner thighs, calves, back of knees. The rash consisted of red raised blister-like bumps. They are very itchy." On [DATE] skin checks were conducted. Twenty three residents ( R3, R5, R7-R14, R16, R18, R20, R23-R26, R28,R30,R35, R39, & R49) were found to have the red, raised, itchy rashy. The rashes ranged from in just one area of the body to the entire body. Many of the rashes were concentrated on the shoulders, arms, abdomen, back and legs. On [DATE] skin checks were conducted from 9:30 AM. to 11:30 AM. Thirty-Two residents (R4-R20, R,[DATE], R34, R,[DATE], R46, and R56) were found with some stage of the rash, ranging from bright red, raised papules to open wounds to light pink scattered red areas. Many of the residents had many scratches on their skin. Five closed resident records (R1-R3, R32 and R33) were reviewed, all were found to have the rash at time of discharge/death. On [DATE], during skin checks, the following comments were made from residents. R9 said she had itched since she arrived 1 month ago. R9 said, "It hurts. R10 said, I wake up scratching. Itches so bad I couldn't sleep last night.' R10 said he has had the rash for a couple of months. He said it gets better and then it reoccurs. R11 said, "Itches all over right now. Itches constantly. I complain but they don't give me anything for it. I can't focus on anything but the itching." R14 said, "It's uncomfortable. I am tired and worn out from scratching. I can't think about anything but the itching. Keeps me up at night. I've had it since July (2013)/." R16 asaid, "Itching keeps me awake. There are days I want to rip my hair out of my head." R24 said, "It itches like hell!" R28 said, "The rash is painfulliy itchy. I was awake all night scratching (Resident crying). I'm out of my mind with all the itching." On [DATE], the facility sent (facimille) a document showing all of the treatments tried, in an effort to treat the scabies-like rash. Hibacleans, [MEDICATION NAME], Vasoline, [MEDICATION NAME], Lindayn Cream, [MEDICATION NAME] Ointment, [MEDICATION NAME] cream, and [MEDICATION NAME]. The only scabicide treatments are the [MEDICATION NAME] and the Lindayn cream. The facility and staff were never all treated with the Scabicides. The other treatments were used to try to soothe the itching and inflamation. On [DATE] at 4:00 PM, E8 (Regional Director) said, "We are really trying to clear this up. We know we have a problem." On [DATE] at 11:30 AM, Z9 (Medical Director) said, "I don't have any concerns related to the treatment of [REDACTED]. You should help us to find out the cause. We don't have a specialist we can go to. We need help to identify what this rash is. Please arrange (people to assist us)."

Based on observation, interview, and record review the facility failed to have an effective infection control program and failed to implement interventions to prevent the spread of a communicable rash beginning [DATE] through [DATE]. This failure resulted in the spread of a communicable skin rash from 10 residents affected in [DATE] to 39 residents [DATE] resulting in pain and mental anguish for the residents. This applies to 39 of 56 residents (R1-R20, R23-R34, R,[DATE], R43, R46, and R56) reviewed for communicable skin eruptions in the sample of 56. The findings include: On [DATE] at 9:00 AM, E2 (Director of Nursing) said 24 out of 54 residents were experiencing some type of rash. E2 said she is not aware of any staff with the same type of rash. E2 said, "We have tried everything. We don't know what this rash is. I have been trying to get a Dermatologist in here to look at the residents. She said on [DATE], 20 residents (R2- R5, R7, R10 -12, R1 & 14, R18 & 19, R,[DATE], R29, R,[DATE], were treated for [REDACTED]. She said they gave out tubes of the [MEDICATION NAME] to any staff wanting it. E2 said, we bagged up all of their clothes (the residents treated). E2 said the housekeeping department had been working on deep cleaning all of the resident areas. On [DATE], 4 confidential interviewees said they had been treated for [REDACTED]. Wound care Sheets for all of the residents show the rash has been ongoing since [DATE]. The monthly breakdown of rashes is as follows: June - 11 residents, July - 18 residents, August - 23 residents, [DATE] residents, and [DATE] - 32 residents were inflicted with the same itchy, red, raised rash. In [DATE] residents (R5, 21, 19, 25, 32, 33, 26, 3, 24, 23, 10, 7, 29, 34, 18, 4, 11, 14, 15, and R2) were treated with the Scabicide, [MEDICATION NAME]. The facility did not treat all of the residents or staff. The Centers for Disease Control recommends the following: "All patients or residents (symptomatic and asymptomatic) should be treated on the same day...All employees should be treated on the same day as the residents...(Table I: Recommended Actions and Rationale for Preventing the Transmission of Scabies in Healthcare and Residential Facilities). 2. R1's [DIAGNOSES REDACTED]. He has upper and lower extremity range of motion impairment. Nursing Notes show R1 had a red, raised rash from [DATE] to [DATE] (resident expired). The Nursing Notes document the resident's rash covered his entire body. The resident complained of itching. POS's for those months show the resident was treated with [MEDICATION NAME] ointment 0.1% twice daily (BID), Vaseline to Rash BID, Dermasmooth 0.1% oil BID for 2 weeks then off for 2 weeks. In October he received baths with Hibaclens daily, for 7 days. On [DATE], Z8 (Hospice Doctor) ordered skin scrapings to be done in an effort to determine the causative factor of the rash. On [DATE] at 4:00 PM, E2 (Director of Nursing) said Z9 (Medical Director) discontinued the order because he had no means of doing the skin scraping. During a confidential nurse interview it was stated, "I am ready to lose my mind. This rash is horrible. I am itching. I have the rash on my arms, breast, sides, and ankles. I don't know how the residents can stand it. Residents have died itching themselves. They (facility administration) aren't doing anything about the rashes. It will never get under control. (R1, 32, and 33) were covered with the rash up until they died . (R1) was the worst. On [DATE] at 6:00 PM, Z7 said, "When I saw him (R1) in the hospital on [DATE], I was shocked at his condition. His entire body was covered with sores. The poor man, the itching was awful. I had talked with the nursing staff at the facility several times regarding the itching. They put "boxing glove" appearing mitts on his hands so he wouldn't scratch. The facility was supposed to take him to a dermatologist. That never happened. At the hospital, the staff gowned and gloved every time they entered his room. They didn't know what the rash was either. The sores were oozing." On [DATE] and [DATE] confidential interviewees made the following statements. "There is no definitive [DIAGNOSES REDACTED]. They are very itchy and ooze a serous fluid. I got them mostly on my stomach and under my breasts. I would say at least 10 residents complain of itching on a daily basis. They are digging holes in their skin. (R1) was covered heat to toe. He sat in bed scratching all day, until he passed away. Not only the residents have the rash, employees have it too. We are worried about taking this home to our families. The staff wrote a letter to corporate about this rash, we never heard anything from them. The rashes started in June. I had it. I went to the doctor and was told I had Scabies. He gave me cream for it. I had the rash on my arms, neck, stomach, legs, under my bra, peri area...every where. Families would come to us crying because their loved ones were so miserable with the itching. The rash comes and goes. When I work for several days in succession, I have bites all over me. The bites itch horribly. When I am off for a few days, the rash subsides, then when I come back to work it starts all over again. You can't see anything biting, but sure do feel it. They have no idea what this is, but they keep bringing in more residents. I just itch and itch. I have been treated for [REDACTED]. I have scratched so much, I am bruised. The residents look very uncomfortable through out the building. I got the rash on my hands. My doctor treated me for Scabies. The rashes differ from each other. They are usually red papules, very itchy. (R32) has died . She was covered from her neck down to her feet, even the palms of her hands. Every night she would scratch and scratch, and scream out because of the severe itching. (R33) also had the rash when she died . It wasn't as bad as ( R32's). (R2) has been in the hospital. When he left here he was miserable. Even the palms of his hands had the rash. It's terrible when elderly people are in agony. This is the worse form of neglect I have ever seen. This is a Psychiatric facility. The residents behaviors have increased with the worsening of the rashes. They don't know what it is. At one point the facility was treated for [REDACTED]. At one point, about 20 residents were treated for [REDACTED]. The facility handed out Permethine ointment (scabies treatment) for any staff who wanted it. On [DATE], the facility sent (facsimile) a document showing all of the treatments tried, in an effort to treat the scabies-like rash. The only scabicide treatments used were the [MEDICATION NAME] and the Lindayn cream. The facility and staff were never 100% treated with the Scabicides. The other treatments were used to try to soothe the itching and inflammation. On [DATE] skin checks were conducted from 9:30 AM. to 11:30 AM. Thirty-Two residents (R4-R20, R,[DATE], R34, R,[DATE], R46, and R56) were found with some stage of the rash, ranging from bright red, raised papules to open wounds to light pink scattered red areas. The rashes ranged from in just one area of the body to the entire body. Many of the rashes were concentrated on the shoulders, arms, abdomen, back, legs and buttocks. The residents had many scratches on their skin and areas where the skin had been open and bleeding. Five closed resident records (R1-R3, R32 and R33) were reviewed, all were found to have the rash at time of discharge/death. On [DATE], during skin checks, the following comments were made from residents. R9 said she had itched since she arrived 1 month ago. R9 said, "It hurts. R10 said, I wake up scratching. Itches so bad I couldn't sleep last night.' R10 said he has had the rash for a couple of months. He said it gets better and then it reoccurs. R11 said, "Itches all over right now. Itches constantly. I complain but they don't give me anything for it. I can't focus on anything but the itching." R14 said, "It's uncomfortable. I am tired and worn out from scratching. I can't think about anything but the itching. Keeps me up at night. I've had it since July (2013)/." R16 said, "Itching keeps me awake. There are days I want to rip my hair out of my head." R24 said, "It itches like hell!" R28 said, "The rash is painfully itchy. I was awake all night scratching (Resident crying). I'm out of my mind with all the itching." On [DATE] at 4:00 PM, E8 (Regional Director) said, "We are really trying to clear this up. We know we have a problem." On [DATE] at 11:30 AM, Z9 (Medical Director) said, "We are not able to contain or cure it, we don't know what it is." The facility's Infection Control Surveillance and Monitoring Policy and Procedure (undated) states, "It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with work practices and care of protective clothing and equipment is maintained. Procedure: ...Monitoring of the day to day operation of the Infection Control Program will be conducted by the DON (Director of Nursing). Included in these duties are: a. Investigation and implementation of controls to prevent infections in the facility. b. Determine and direct the correct procedures necessary for the prevention of infections. This shall be done on an individual basis, applying concepts of isolation per infection..."

Based on observation, interview, and record review the facility failed to be administered in a manner to assure each residents physical and mental well being by not actively obtaining resources to determine the cause of a communicable rash. This failure contributed to pain, severe itching, and mental anguish for 39 of 56 residents. This applies to 39 (R1-R20, R23-R34, R,[DATE], R43, R46, and R56) of 56 residents reviewed for communicable skin eruptions in the sample of 56. The findings include: On [DATE] at 9:00 AM, E2 (Director of Nursing) said 24 out of 54 residents were experiencing some type of rash. E2 said she is not aware of any staff with the same type of rash. E2 said, "We have tried everything. We don't know what this rash is. I have been trying to get a Dermatologist in here to look at the residents. She said on [DATE], 20 residents (R2- R5, R7, R10 -12, R1 & 14, R18 & 19, R,[DATE], R29, R,[DATE], were treated for [REDACTED]. She said they gave out tubes of the [MEDICATION NAME] to any staff wanting it. E2 said, we bagged up all of their clothes (the residents treated). E2 said the housekeeping department had been working on deep cleaning all of the resident areas. Wound care Sheets were reviewed for all of the residents. The records show the rash has been ongoing since [DATE]. The monthly breakdown of rashes is as follows: June - 11 residents, July - 18 residents, August - 23 residents, [DATE] residents, and [DATE] - 32 residents were inflicted with the same itchy, red, raised rash. In [DATE] residents (R5, 21, 19, 25, 32, 33, 26, 3, 24, 23, 10, 7, 29, 34, 18, 4, 11, 14, 15, and R2) were treated with the Scabicide, [MEDICATION NAME]. The facility did not treat all of the residents or staff. The Centers for Disease Control recommends the following: "All patients or residents (symptomatic and asymptomatic) should be treated on the same day...All employees should be treated on the same day as the residents...(Table I: Recommended Actions and Rationale for Preventing the Transmission of Scabies in Healthcare and Residential Facilities). Confidential interviewees said, " I would say at least 10 residents complain of itching on a daily basis. They are digging holes in their skin. (R1) was covered heat to toe. He sat in bed scratching all day, until he passed away. (R1) also had Diabetic Ulcers on his foot. We reported it several times. By the time he passed the ulcers took over his entire foot. Nothing was done for his. He got progressively worse. He complained of pain. (R1) broke my heart (crying). Oh my God, he was covered head to toe." During a confidential nurse interview it was stated, "I am ready to lose my mind. This rash is horrible. I am itching. I have the rash on my arms, breast, sides, and ankles. I don't know how the residents can stand it. Residents have died itching themselves. The facility keeps bringing new residents in. They aren't doing anything about the rashes. It will never get under control. (R1, 32, and 33) were covered with the rash up until they died . (R1) was the worst. A confidential interviewee stated, "We were all threatened by E9 (Registered Nurse - Corporate) that if we said anything about the rashes in the building, we would lose our jobs. I am ashamed I haven't spoken up. It's terrible when we have to make a choice, speak up or lose our jobs. The rash comes and goes. When I work for several days in succession, I have bites all over me. The bites itch horribly. When I am off for a few days, the rash subsides, then when I come back to work it starts all over again. You can't see anything biting, but sure do feel it. They have no idea what this is, but they keep bringing in more residents. I just itch and itch. On [DATE] skin checks were conducted from 9:30 AM. to 11:30 AM. Thirty-Three residents (R4-R20, R,[DATE], R34, R,[DATE], R46, and R56) were found with some stage of the rash, ranging from bright red, raised papules to open wounds to light pink scattered red areas. Many of the residents had many scratches on their skin. Five closed resident records (R1-R3, R32 and R33) were reviewed, all were found to have the rash at time of discharge/death. On [DATE], during skin checks, the following comments were made from residents. R9 said she had itched since she arrived 1 month ago. R9 said, "It hurts. R10 said, I wake up scratching. Itches so bad I couldn't sleep last night.' R10 said he has had the rash for a couple of months. He said it gets better and then it reoccurs. R11 said, "Itches all over right now. Itches constantly. I complain but they don't give me anything for it. I can't focus on anything but the itching." R14 said, "It's uncomfortable. I am tired and worn out from scratching. I can't think about anything but the itching. Keeps me up at night. I've had it since July (2013)/." R16 said, "Itching keeps me awake. There are days I want to rip my hair out of my head." R24 said, "It itches like hell!" R28 said, "The rash is painfully itchy. I was awake all night scratching (Resident crying). I'm out of my mind with all the itching." On [DATE], the facility sent (facsimile) a document showing all of the treatments tried, in an effort to treat the scabies-like rash. Hibacleans, [MEDICATION NAME], Vaseline, [MEDICATION NAME], Lindayn Cream, [MEDICATION NAME] Ointment, [MEDICATION NAME] cream, and [MEDICATION NAME]. The only scabicide treatments are the [MEDICATION NAME] and the Lindayn cream. The facility and staff were not all treated with the Scabicides. The other treatments help with the symptoms (itching and inflammation) but do not eradicated the organism. The Job Description for the Administrator states, "The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and the physical management of the facility, residents & equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulation. The Administrator will manage and conduct business of the facility in a manner that protects the facility license and certification at all times. The major goal of the Administrator is to provide and atmosphere in which residents may achieve their highest physical, mental and social well being." The Job Description of the Director of Nursing states, "The Director of Nursing is responsible for all aspects of the Nursing Department and of all nursing care required to achieve each residents greatest physical and mental well being. This entails organizing, directing and overseeing the planning of care, delivery of care, physician orders, therapist and other consultant orders and recommendations, and the supervision of nursing personnel..."

Based on observation, interview, and record review the facility failed to have the Medical Director involved in the coordination of medical care for residents suffering with a communicable skin rash from 6/1/2013 to 10/25/2013. This failure resulted in the spread of an itchy, painful rash spreading to a total of 39 residents causing mental angush. This applies to 39 of 56 residents (R1-R20, R23-R34, R36-39, R43, R46, and R56) reviewed for communicable skin eruptions in the sample of 56 The findings include: On 10/18/2013 at 9:00 AM, E2 (Director of Nursing) said 24 out of 54 residents were experiencing some type of rash. E2 said she is not aware of any staff with the same type of rash. E2 said, "We have tried everything. We don't know what this rash is. I have been trying to get a Dermatologist in here to look at the residents. She said on 8/18/2013, 20 residents (R2- R5, R7, R10 -12, R1 & 14, R18 & 19, R23-26, R29, R32-34, were treated for [REDACTED]. She said they gave out tubes of the [MEDICATION NAME] to any staff wanting it. E2 said, we bagged up all of their clothes (the residents treated). E2 said the housekeeping department had been working on deep cleaning all of the resident areas. Wound care Sheets were reviewed for all of the residents. The records show the rash has been ongoing since June 1, 2013. The monthly breakdown of rashes is as follows: June - 11 residents, July - 18 residents, August - 23 residents, September 26 residents, and October 2013 - 32 residents were inflicted with the same itchy, red, raised rash. In August 2013, 20 residents (R5, 21, 19, 25, 32, 33, 26, 3, 24, 23, 10, 7, 29, 34, 18, 4, 11, 14, 15, and R2) were treated with the Scabicide, [MEDICATION NAME]. The facility did not treat all of the residents or staff. The Centers for Disease Control recommends the following: "All patients or residents (symptomatic and asymptomatic) should be treated on the same day...All employees should be treated on the same day as the residents...(Table I: Recommended Actions and Rationale for Preventing the Transmission of Scabies in Healthcare and Residential Facilities). On 10/25/2013, skin checks were conducted from 9:30 AM. to 11:30 AM. Thirty-Two residents (R4-R20, R23-31, R34, R36-39, R46, and R56) were found with some stage of the rash, ranging from bright red, raised papules to open wounds to light pink scattered red areas. Many of the residents had many scratches on their skin. Five closed resident records (R1-R3, R32 and R33) were reviewed, all were found to have the rash at time of discharge/death. On 10/11/2013, Z8 (Hospice Doctor) ordered skin scrapings to be done on all of his residents with the rash. On 9/18/2013 at 4:00 PM, E2 (Director of Nursing) said Z9 (Medical Director) discontinued the order because he had no means of doing the skin scraping. On 11/1/2013 at 11:30 AM, Z9 (Medical Director) said, "I don't have any concerns related to the treatment of [REDACTED]. You should help us to find out the cause. We don't have a specialist we can go to. We need help to identify what this rash is. Please arrange (people to assist us)." The facility did not provide a job description for Medical Director. A copy of the Medical Director contract was provided. Within the contract, it is stated, "Section 3.02 Physician shall guide, approve, and help oversee the development, implementation and monitoring/evaluation of Facility's resident care policies and procedure in the following areas:...(b) The integrated delivery of care and services, such as medical, nursing, pharmacy, social, rehabilitative and dietary services, which includes clinical assessments, analysis of assessment findings, care planning including preventive care, care plan monitoring and modification, infection control (including isolation or special care), transfers to other settings, and discharge planning; (c) The use and availability of ancillary services such as x-ray and laboratory; (d) The availability, qualifications, and clinical functions of staff necessary to meet resident care needs;..."

Based on observation, interview, and record review the facility's Quality Assurance Committee failed to to develop, implement and correct an escalating skin problem that resulted in a communicable skin rash affecting an increasing the number of residents from June 1, 2013 through October 25, 2013. This failure resulted in the spread of infectious skin eruptions beginning with 10 residents, and effecting 39 residents by October 25, 2013. This applies to 39 (R1-R20, R23-R34, R36-39, R43, R46, and R56) of 56 residents reviewed for communicable skin eruptions in the sample of 56. The findings include: On 10/25/2013, skin checks were conducted from 9:30 AM. to 11:30 AM. Thirty-Two residents (R4-R20, R23-31, R34, R36-39, R46, and R56) were found with some stage of the rash, ranging from bright red, raised papules to open wounds to light pink scattered red areas. Many of the residents had many scratches on their skin. Five closed resident records (R1-R3, R32 and R33) were reviewed, all were found to have the rash at time of discharge/death. Wound care Sheets for all of the residents showed the rash has been ongoing since June 2013. The monthly breakdown of rashes is as follows: June - 11 residents, July - 18 residents, August - 23 residents, September 26 residents, and October 2013 - 32 residents were inflicted with the same itchy, red, raised rash. In August 2013, 20 residents (R5, 21, 19, 25, 32, 33, 26, 3, 24, 23, 10, 7, 29, 34, 18, 4, 11, 14, 15, and R2) were treated with the Scabicide, [MEDICATION NAME]. The facility did not treat all of the residents or staff. The Centers for Disease Control recommends the following: "All patients or residents (symptomatic and asymptomatic) should be treated on the same day...All employees should be treated on the same day as the residents...(Table I: Recommended Actions and Rationale for Preventing the Transmission of Scabies in Healthcare and Residential Facilities). On 11/1/2013 at 11:30 AM, Z9 (Medical Director) said, "I don't have any concerns related to the treatment of [REDACTED]. Z9 said the rashes were discussed in the July 2013 Quality Assurance Committee (QA) meeting. The facility presented 2 (5/23/13 & 8/15/13) QA Sign-in Sheets. On 8-15-2013 a physician was not present at the meeting. The facility did not provide documentation showing the committee's development and implementation of interventions and the evaluation of the success of the tried interventions. The facility did not provide a Quality Assurance Policy and Procedure.

Based on interview and record review, the facilty failed to keep residents from being verbally, mentally and/or physically abused by E6. This failure resulted in R48 becoming upset after being yelled at and treated rudely. This is for 3 residents (R22, R45, R48) in the supplemental sample reviewed for abuse and neglect. The findings include: 1. A grievance/complaint report was submitted by R48 on 1/28/13. In the report, R48 documents returning to the facility after a trip (out to eat, get a hair cut and look at medical id bracelets) with another resident on 1/26/13. R48 stated, "We returned on time but E6(Licensed Practical Nurse - LPN) ripped into me. He asked if he could talk to me in private away from (another resident). (The other resident) left. E6 spoke to me loudly at my room door. He did not enter and make it private, but chose to let the whole hallway hear if they wanted to listen. He asked why I didn't wear my mask in public and how I was contaminating my world. He let me know [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) was serious. At (previous facility)[MEDICAL CONDITION] meant isolated rooms and laundry. Residents walked around and ate with everyone else as normal. He called me stupid. That wasn't good enough, I was completely ignorant. I didn't reply much but stated I would do better wearing my mask. I am an educated person but not in medical science. If it was so detrimental, why didn't they approach the issue earlier. I felt awkward, confused, bad, stupid, ignorant and sad. Good job E6, I sure wouldn't treat anyone that way. It makes me tear up just to write this down. It would be hard for me (R48) to open up with my feelings since I feel hurt by a bully." On 6/19/13 at 8:55am, E2 said "E6 raised his voice and R48 took it as he was "coming at her". On 6/19/13 at 2:45pm E1 (Administrator) said, "In this case, I did not interview anyone else. It wasn't abuse, just customer service." The facility's incident investigation form dated 2/19/13 at 1pm documents, "Resident (R48) had issue with male nurse E6. Investigation showed resident was person using inappropriate words to nurse, not nurse to resident." There was no summary of the investigation to describe the "issue" R48 had with E6. There was no documentation of interviews with E6, other staff or residents. The nurse's notes dated 1/28/13 at 10am document, R48 is alert and oriented x 3. The MDS of 5/9/13 assessed R48 as cognitively intact with no memory problems. The facility ' s Abuse Prevention Program (11/11/11) showed, " Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation; Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability; Physical abuse includes hitting, slapping, pinching, and controlling behavior through corporal punishment. 2. A note written by E22 (Registered Nurse - RN) (no date) showed, "While I was giving R45 her medications, she told me that yesterday E6 (Licensed Practical Nurse - LPN) shook her by her shoulders and told her to "shut up" and stop pulling the call light. I notified E2 (Director of Nursing - DON) and E1 (Administrator) at 6:30pm on 1/31/13." The facility's "First and Final Report " dated 2/3/13 showed, "Date Incident Reported: 1/31/13 at 7:00pm; Type of Incident: Alleged physical abuse onto a resident; Resident: R45. Resident's Diagnosis: [REDACTED].; Conclusion: The abuse allegation against E22 is not valid. " The Abuse/Neglect Incident Investigation Form dated 2/1/13 showed, "On 1/30/13 at 7:00pm I entered the room of R45. She was awake and yelling for medication. I gave R45 her pills and eye drops." On 6/18/13 at 12:15pm, E8 (Assistant Director of Nursing - ADON) stated she would be able to tell if a staff member was abusing a resident by, "Bruises, skin issues and a change in resident behavior but we have residents that have behaviors." E8 stated she would remove staff from the building immediately if another staff member told her that a staff member was abusing a resident. On 6/18/13 at 3:00pm, E6 (Licensed Practical Nurse - LPN) was interviewed about abuse and stated a resident would "speak out, verbalize" if a staff member was abusing a resident. E6 stated if staff is accused of abusing a resident the staff is removed from the floor, sent home and an investigation is done; A body check is done and witnesses are interviewed. 3. The facility's "Alleged physical abuse investigation" dated 6/4/13 showed, "R22 stated that E6 (LPN) had thrown him into his bed in the early morning of 6/4/13. E6 sequestered in nursing station office until investigation is completed. " On 6/19/13 at 8:50am, E2 (Director of Nursing - DON) stated, "There was an allegation of abuse 2-3 weeks ago against E6. R22, out of the blue, came up the hall and said, "You (E6) are the one that threw me down in bed last night." They (E1 - Adminstrator, E8 - Assistant Director of Nursing & E4 - Social Services) asked E6 to stay off that hallway and away from R22. E6 was not sent home he stayed and worked." The Abuse/Neglect Incident Investigation Form dated 6/4/13 at 5:05pm, written by E23 (Certified Nursing Assistant - CNA) showed, "R22 told the administrator along with E23 (Certified Nursing Assistant - CNA) that E6 threw him into bed around 4:00am on 6/4/13. R22 just decided to report it late. " The Abuse/Neglect Incident Investigation Form dated 6/4/13 at 5:05pm showed R22 was asked why he reported it so late ? R22 stated, "I have no answer." The facility's Resident Interview form dated 6/4/13 at 5:05 pm, written by E1 (Administrator) regarding R22 showed, "A nurse pushed me into bed and cussed at me. He has a beard. He pushed me into my bed this morning." R22 pointed to E6 as the nurse that was involved. R22's Incident Investigation form for Abuse/Neglect dated 6/4/13 at 5:10pm showed "re-interview" at the top of the form and R22 stated, "All staff are treating me well but E6." The Psychiatric Follow - Up Evaluation form dated 5/29/13 for R22 showed, "No aggression, agitation or hallucinations. R22 said he is dealing with his [MEDICAL CONDITION] [DIAGNOSES REDACTED]." The Care Plan dated 6/6/13 for R22 showed, "R22 is known/has history of displaying inappropriate behavior and/or resisting care/services; agitated with family related to nursing home placement." The Nurse's Notes dated 6/10/13 for R22 showed, "Ecchymosis to right lower arm noted 3.5 x 6.5cm. R22 was not aware of the bruising and can't recall a time of occurrence." 4. Confidential interviews were conducted while on site during the survey between 6/17/13 - 6/19/13. Resident comments regarding staff treatment included the following statements: 1. We have no input what so ever, (regarding changes) they just tell us the way it is. 2. Weekend and night staff have a different routine from day shift. It's a skeleton crew. 3. E6 (LPN) has a cold manner, with no resident rapport. 4. E6 is not accessible, he likes to hide, we have to find him, often in the therapy room. 5. E6 likes to goof off and rough house with nurses. 6. If I ask for medications, he always tells me it's not time yet. 7. I missed 14 of my 28 doses of my medication during the evening shift because I was afraid to ask for it. I don't want to tick him off, he does not like to be told by a resident. 8. E6 sets up the medications at the cart, and tells the residents it is their responsibility to get their own meds. 9. He responds in a sharp, snap, bark voice when you ask for something. 10. They give showers (to residents) whenever they want to, even during the night. They wake residents up and take them into the shower room. 11. E6 made a scene last night (in my room) he talked very loud with a disgusted with you attitude. 12. E6 has been known to go off before. I have heard him in the lunch room, busts out in a loud voice. He stated, "If they pick on us, we can pick on them." 13. Heard E6 tell a resident "I will force you to return to your room".